eMedicine Specialties > Ophthalmology > Infectious Disease

Lyme Disease: Treatment & Medication

Author: Gerald W Zaidman, MD, Professor of Clinical Ophthalmology, New York Medical College; Chief of Cornea Service; Director, Department of Ophthalmology, Westchester Medical Center
Contributor Information and Disclosures

Updated: Aug 26, 2009

Treatment

Medical Care

All patients with stage 1 Lyme disease should be treated with any one of the following oral antibiotics for 2-3 weeks: tetracycline 500 mg 4 times a day, doxycycline 100 mg 2 times a day, phenoxymethyl penicillin 500 mg 4 times a day, or amoxicillin 500 mg 3-4 times a day.

Children, pregnant women, patients who cannot tolerate tetracycline, and patients who are allergic to penicillin may be given erythromycin 500 mg 4 times a day.

The later stages of Lyme disease can be treated with oral antibiotics, but these patients usually need 30 days of therapy. Patients with severe disease (eg, meningitis, neuroborreliosis, carditis) require parenteral therapy with beta-lactam antibiotics, such as 14-21 days of one of the following: intravenous penicillin G 3-4 million units every 4 hours, intravenous ceftriaxone 2 g/d in divided doses, parenteral penicillin and ceftriaxone in combination, or roxithromycin and cotrimoxazole in combination.

Combination therapy may be worthwhile in patients who do not respond to monotherapy. Physicians should observe patients closely for possible Jarisch-Herxheimer reactions after the institution of therapy; this allergic/inflammatory response may manifest in the skin, mucous membranes, viscera, or nervous system.

Stage 1 conjunctivitis and photophobia require no therapy. Stage 2 Bell palsy is self-limited but requires supportive therapy to prevent the complications of exposure keratitis. Keratitis and episcleritis benefit from topical corticosteroids, usually a short course of prednisolone acetate 1% or fluorometholone 0.1%.

A treatment regimen for severe neuro-ophthalmic disease (involving the optic nerve) or posterior segment disease (eg, pars planitis, vitreitis) has not been established. Oral corticosteroids without concomitant antibiotics should not be used. The best approach for these patients might be a therapeutic antibiotic trial, in which patients can receive 2-3 weeks of intravenous penicillin or ceftriaxone. If patients respond to treatment, the trial is successful, ocular Lyme disease is diagnosed, and no further therapy is needed. Recurrences of Lyme uveitis, once adequate intravenous therapy has been given, can be treated with judicious corticosteroids.

Medication

The goal of pharmacotherapy is to prevent complications, to reduce morbidity, and to eradicate the infection.

Antibiotics

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

Tetracycline (Sumycin)

Treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Two different dosing regimens exist depending on whether the patient has early or late Lyme disease.

Doxycycline (Bio-Tab, Doryx, Vibramycin, Doxy, Vibra-Tabs)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Penicillin V potassium (Veetids, Robicillin VK, V-Cillin K)

Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached, and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.

Amoxicillin (Trimox, Amoxil, Biomox)

Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria.

Erythromycin (EES, E-Mycin, Eryc, Erythrocin, Ery-Tab)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, one half total daily dose may be taken q12h. For more severe infections, double the dose. Primarily used when patient is allergic to penicillin.

Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. Reserved as a parenteral agent in severe cases of the later stages of Lyme disease.

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. Reserved for use in severe cases of the later stages of Lyme disease. Can be combined with IV penicillin in patients that do not respond to monotherapy.

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.

Prednisolone acetate 1% (Pred Forte)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Useful in cases of Lyme keratitis.

Fluorometholone 0.1% (Flarex, Fluor-Op, FML, FML-Forte)

Suppresses migration of polymorphonuclear leukocytes and reverses capillary permeability.

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