eMedicine Specialties > Ophthalmology > Infectious Disease
Lyme Disease: Treatment & Medication
Updated: Aug 26, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
Adult
Early: 500 mg PO qid for 2-3 wk
Late: 500 mg PO qid for 30 d
Pediatric
Not established; discuss with ID expert
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; 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 drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
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.
Adult
Early: 100 mg PO bid for 2-3 wk
Late: 100 mg PO bid for 30 d
Pediatric
Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; 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 drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
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.
Adult
Early: 500 mg PO qid for 2-3 wk
Late: 500 mg PO qid for 30 d
Pediatric
Not established
Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently
Documented hypersensitivity
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
Caution in renal impairment
Amoxicillin (Trimox, Amoxil, Biomox)
Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria.
Adult
Early: 500 mg PO tid/qid for 2-3 wk
Late: 500 mg PO tid/qid for 30 d
Pediatric
Not established
Reduces efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
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.
Adult
Early: 500 mg PO qid for 2-3 wk
Late: 500 mg PO qid for 30 d
Pediatric
Not established
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
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.
Adult
3-4 million U IV qid for 14 d
Pediatric
Not established
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
Documented hypersensitivity
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
Caution in impaired renal function
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.
Adult
2 g/d IV in divided doses for 14 d
Pediatric
Not established
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in women who are breastfeeding and allergic to penicillin
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.
Adult
1 gtt in affected eye(s) tid/qid
Pediatric
Not established
Effects may decrease in patients taking phenytoin, barbiturates, and rifampin
Documented hypersensitivity; viral, fungal, or tubercular infections
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
Caution in hypertension; known to cause cataract formation with chronic use; in prolonged use, withdraw treatment by gradually decreasing frequency of applications to avoid adrenal insufficiency
Fluorometholone 0.1% (Flarex, Fluor-Op, FML, FML-Forte)
Suppresses migration of polymorphonuclear leukocytes and reverses capillary permeability.
Adult
Ointment: Apply q4h in severe cases; qd/tid in mild-to-moderate cases
Solution: 1-2 gtt into conjunctival sac q1h during day; q2h at night until favorable response obtained, then 1 gtt q4h
Pediatric
<2 years: Not established
>2 years: Administer as in adults
None reported
Documented hypersensitivity; herpes simplex, keratitis, viral and fungal diseases of the ocular structure
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
Prolonged use may result in elevated intraocular pressure or glaucoma
More on Lyme Disease |
| Overview: Lyme Disease |
| Differential Diagnoses & Workup: Lyme Disease |
 Treatment & Medication: Lyme Disease |
| Follow-up: Lyme Disease |
| References |
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Further Reading
Keywords
Lyme disease, borreliosis, Lyme borreliosis, ticks, tick bite, tick-borne disease, tick-borne illness, infection, Borrelia burgdorferi, B burgdorferi, ocular Lyme disease, Lyme uveitis, arthropod-related disease, spirochetal disorder, ocular manifestations of Lyme disease
