eMedicine Specialties > Neurology > Neurological Infections

Lyme Disease: Treatment & Medication

Author: Augusto A Miravalle, MD, Fellow, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School
Coauthor(s): R Philip Kinkel, MD, FAAN, Associate Professor of Neurology, Harvard Medical School; Director, Multiple Sclerosis Center, Beth Israel Deaconess Medical Center; Consultant Neurologist, Children's Hospital of Boston
Contributor Information and Disclosures

Updated: Jul 23, 2009

Treatment

Medical Care

  • The goals of treatment are to cure B burgdorferi infection, to speed the resolution of the clinical manifestations, and to prevent complications.
    • The antibiotic regimen is based on the stage of disease, the clinical manifestations, and the patient's characteristics.
    • The selection of pharmacologic modality should always be based on the patient's allergies, age, and concomitant medical conditions.
    • Of great importance, doxycycline is contraindicated in patients younger than 8 years and in pregnant women.
    • Doxycycline, amoxicillin, or cefuroxime axetil for 10-14 days is indicated for early localized or early disseminated disease associated with erythema migrans in the absence of neurologic involvement or third-degree heart block. This regimen is also recommended for patients with cranial nerve palsy with normal CSF findings and those with borrelial lymphocytoma.
    • Cefuroxime axetil is effective; however, because of its cost, it is reserved for patients unable to take amoxicillin or doxycycline.
    • Of note, data from a recent clinical trial indicate that 10-day treatment with doxycycline was as effective as 20-day treatment with doxycycline in patients with erythema migrans.
    • LD arthritis without neurological disease may be treated with the drugs listed above for 28 days. The preferred duration of the oral regimen for ACA is 21 days.
    • Macrolides are alternatives agents but are used only when the first-line agents are not tolerated or are contraindicated.
  • Neurologic LD in patients aged at least 8 years is effectively treated with a 2-week course of parenteral penicillin, ceftriaxone, or cefotaxime.8,9
  • Oral doxycycline is as efficacious as parenteral antibiotics in patients who have Lyme-associated meningitis, facial nerve palsy, or radiculitis.8
  • Evidence from 3 trials suggested a lack of benefit from prolonged antibiotic treatment of what is known as post-Lyme syndrome (symptoms persisting or recurring after appropriate treatment in the absence of evidence of ongoing infection).9
  • Prophylactic antibiotics are not recommended in pregnant women.10
  • Antibiotic treatment of pregnant patients is restricted to those who have a reliable clinical diagnosis of LD.10

Consultations

  • Consultation with a rheumatologist may be appropriate in patients with persistent arthritic sequelae despite conventional antimicrobial therapy.
  • Consultation with a neurologist is recommended in patients with persistent or chronic manifestations of LD, such as chronic fatigue syndrome.

Medication

The goals of pharmacotherapy are to reduce morbidity, prevent complications, and eradicate the infection.

Antibiotic

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.


Doxycycline (Doryx, Vibramycin)

Inhibits protein synthesis by binding to 30S and possibly 50S ribosomal subunit of susceptible microorganisms. DOC for early localized or early disseminated disease without neurologic disease or third-degree heart block. Particularly recommended if concomitant ehrlichiosis suspected.

Adult

100 mg PO bid; 200-400 mg/d PO/IV in 2 divided doses may be adequate for meningitis or radiculopathy in patients intolerant to first-line therapies

Pediatric

<8 years: Not recommended
>8 years: 1-2 mg/kg PO bid; not to exceed 100 mg bid

Antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate decrease bioavailability; can increase hypoprothrombinemic effects of anticoagulants; can decrease effects of oral contraceptives, causing breakthrough bleeding and increasing risk of pregnancy

Documented hypersensitivity; children <8 y; pregnancy; severe hepatic dysfunction

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider determinations of drug serum levels with prolonged therapy; if used during tooth development (last half of pregnancy through age 8 y), can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines


Amoxicillin (Amoxil, Trimox)

First-line agent and therapeutic alternative to doxycycline for early localized or early disseminated disease without neurologic disease or third-degree heart block. May be used in patients with beta-lactam allergy, pregnancy, and children <8 y.

Adult

500 mg PO tid

Pediatric

50 mg/kg/d PO divided tid; not to exceed 500 mg/dose

May decrease efficacy of oral contraceptives; disulfiram and probenecid can increase levels; allopurinol may increase incidence of rash

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Superinfections may occur; adjust dose in renal impairment


Cefuroxime axetil (Ceftin)

Second-generation cephalosporin; inhibits cell-wall synthesis. Alternative therapy for early localized or early disseminated disease; not first-line because of cost.

Adult

500 mg PO bid

Pediatric

30 mg/kg/d PO divided bid; not to exceed 500 mg/dose

Alcohol consumed within 72 h after may cause disulfiramlike reaction; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity of potent diuretics such as loop diuretics; aminoglycosides increase nephrotoxic potential

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer half dose if CrCl 10-30 mL/min and quarter dose if CrCl <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy


Clarithromycin (Biaxin)

Macrolide antibiotic; inhibits protein synthesis by binding to 50S ribosomal subunit. Not first-line therapy; alternative in patients intolerant of doxycycline, amoxicillin, and cefuroxime.

Adult

500 mg PO bid

Pediatric

15 mg/kg/d PO divided bid; not to exceed 500 mg/dose

Fluconazole and pimozide increase toxicity; rifabutin and rifampin decrease effects and increase adverse GI effects; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; may increase plasma levels of certain benzodiazepines, prolonging CNS depression; disopyramide causes arrhythmias and increase in QTc intervals; omeprazole may increase plasma levels of both; coadministration with ranitidine or bismuth citrate not recommended with CrCl <25 mL/min (give half dose or increase dosing interval if CrCl <30 mL/min)

Documented hypersensitivity; coadministration of pimozide

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Diarrhea may indicate pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies; may increase risk of torsades de pointes when coadministered with other agents that can prolong QT interval


Ceftriaxone (Rocephin)

Third-generation cephalosporin; inhibits bacterial cell-wall synthesis. DOC in patients requiring parenteral therapy.

Adult

2 g IV qd

Pediatric

75-100 mg/kg/d IV/IM; not to exceed 2 g/d

Probenecid may increase levels; ethacrynic acid, furosemide, or aminoglycosides may increase nephrotoxicity

Documented hypersensitivity; hyperbilirubinemic neonates

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in suspected hypersensitivity to penicillin; dose reduction required in combined hepatic and renal disease; do not use in neonates with hyperbilirubinemia


Penicillin G (Pfizerpen)

Penicillin antibiotic; inhibits cell-wall synthesis. Alternative to ceftriaxone in patients requiring parenteral therapy.

Adult

3-4 million U IV q4h

Pediatric

200,000-400,000 U/kg/d IV in divided doses q4h; not to exceed 18-24 million U/d

Probenecid can increase effects; tetracyclines can decrease effects

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in history of penicillin or cephalosporin hypersensitivity, atopic predisposition (eg, asthma), impaired renal function, or preexisting seizure disorder


Cefotaxime (Claforan)

Third-generation cephalosporin; inhibits bacterial cell-wall synthesis. Alternative to ceftriaxone in patients requiring parenteral therapy.

Adult

2g IV q8h

Pediatric

150-200 mg/kg/d IV divided in 3-4 doses/d; not to exceed 6 g/d

Probenecid may decrease clearance; furosemide or aminoglycosides may increase nephrotoxic potential

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in previous hypersensitivity to penicillins or cephalosporins; adjust dose in severe renal impairment; associated with severe colitis


Azithromycin (Zithromax)

Macrolide antibiotic; inhibits protein synthesis by binding to 50S ribosomal subunit. Not first-line therapy; alternative in patients intolerant of doxycycline, amoxicillin, and cefuroxime. Recommended duration 7-10 d.

Adult

500 mg PO qd

Pediatric

10 mg/kg/d PO; not to exceed 500 mg/d

May increase levels of tacrolimus, phenytoin, ergot alkaloids, alfentanil, bromocriptine, cyclosporine, digoxin, disopyramide, and triazolam; changes or responses to carbamazepine, theophylline, or warfarin not observed, but caution advised; nelfinavir may increase serum levels; aluminum- and magnesium-containing antacids may decrease peak levels

Documented hypersensitivity to azithromycin or other macrolide antibiotics; concurrent pimozide

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hepatic or renal dysfunction; pseudomembranous colitis reported; caution in patients at risk of prolonged cardiac repolarization (may increase QT interval)


Erythromycin (E.E.S., Ery-Tab)

Macrolide antibiotic; inhibits protein synthesis by binding to 50S ribosomal subunit. Not first-line therapy; alternative in patients intolerant to doxycycline, amoxicillin, and cefuroxime.

Adult

500 mg PO qid

Pediatric

12.5 mg/kg PO qid; not to exceed 500 mg/dose

May increase risk of torsades de pointes when coadministered with agents that can prolong QT interval; may increase levels or effects of benzodiazepines, calcium channel blockers, cyclosporine, mirtazapine, nateglinide, nefazodone, quinidine, sildenafil, tacrolimus, venlafaxine, and other CYP3A4 substrates; may decrease levels of zafirlukast and effect of clindamycin and lincomycin; aminoglutethimide, carbamazepine, nafcillin, nevirapine, phenobarbital, phenytoin, rifampin, and other CYP3A4 inducers may decrease levels

Documented hypersensitivity to erythromycin or macrolide antibiotics; preexisting liver disease, concomitant ergot derivatives, pimozide, or cisapride

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hepatic dysfunction; pseudomembranous colitis reported; caution in patients at risk of prolonged cardiac repolarization (may increase QT interval)

More on Lyme Disease

Overview: Lyme Disease
Differential Diagnoses & Workup: Lyme Disease
Treatment & Medication: Lyme Disease
Follow-up: Lyme Disease
Multimedia: Lyme Disease
References
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Further Reading

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Keywords

Lyme arthritis, Lyme borreliosis, Garin-Boujadoux-Bannwarth syndrome, Garin-Bujadoux-Bannwarth syndrome, Bannwarth syndrome, Borrelia burgdorferi sensu lato, B burgdorferi sensu lato, Borrelia burgdorferi sensu stricto, B burgdorferi sensu stricto, Ixodes ricinus, I ricinus, Borrelia garinii, B garinii, Borrelia afzelii, B afzelii ticks, tick-borne disease, Lyme disease

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Contributor Information and Disclosures

Author

Augusto A Miravalle, MD, Fellow, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School
Augusto A Miravalle, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

R Philip Kinkel, MD, FAAN, Associate Professor of Neurology, Harvard Medical School; Director, Multiple Sclerosis Center, Beth Israel Deaconess Medical Center; Consultant Neurologist, Children's Hospital of Boston
R Philip Kinkel, MD, FAAN is a member of the following medical societies: American Academy of Neurology and Consortium of Multiple Sclerosis Centers
Disclosure: Nothing to disclose.

Medical Editor

Aashit K Shah, MD, Associate Professor of Neurology, Wayne State University; Program Director, Clinical Neurophysiology Fellowship, Department of Neurology, Detroit Medical Center
Aashit K Shah, MD is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, and American Epilepsy Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Michael K Racke, MD, Professor of Neurology and Molecular Virology, Immunology, and Medical Genetics, Chairman of Neurology, Chief of Neurology Service, Ohio State University Medical Center
Michael K Racke, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association for the Advancement of Science, American Association of Immunologists, and American Neurological Association
Disclosure: Teva Neuroscience Consulting fee Consulting; Peptimmune Inc. Consulting fee Consulting; Bristol Myers Squibb Consulting fee Consulting; EMD Serono Honoraria Speaking and teaching

 
 
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