Practice Guidelines for the Treatment of Lyme Disease
Clinical Infectious Diseases
Executive Summary Tick bites and prophylaxis. The best currently available method for preventing infection with Borrelia burgdorferi is to avoid vector tick exposure. If exposure to Ixodes scapularis or Ixodes pacificus ticks is unavoidable, measures recommended to reduce the risk of infection include using both protective clothing and tick repellents, checking the entire body for ticks daily, and promptly removing attached ticks, before transmission of B. burgdoiferi can occur (A-III [see
... ur (A-III [see tables 1 and 2 for recommendation categories, indicated in parentheses throughout this text]). Routine use of either antimicrobial prophylaxis (E-I) or serological tests (D-III) after a tick bite is not recommended. Some experts recommend antibiotic therapy for patients bitten by I. scapularis ticks that are estimated to have been attached for >48 h (on the basis of the degree of engorgement of the tick with blood), in conjunction with epidemiological information regarding the prevalence of tick-transmitted infection (C-III). However, accurate determinations of species of tick and degree of engorgement are not routinely possible, and data are insufficient to demonstrate efficacy of antimicrobial therapy in this setting. Persons who remove attached ticks should be monitored closely for signs and symptoms of tick-borne diseases for up to 30 days and specifically for the occurrence of a skin lesion at the site of the tick bite (which may suggest Lyme disease) or a temperature >38?C (which may suggest human granulo- Category Definition A Good evidence to support a recommendation for use B Moderate evidence to support a recommendation for use C Poor evidence to support a recommendation for or against use D Moderate evidence to support a recommendation against use E Good evidence to support a recommendation against use NOTE. Table is adapted from . age of 50 mg/kg/d, divided into 3 doses per day (maximum, 500 mg/dose), or doxycycline (for those aged >8 years) at a dosage of 1-2 mg/kg twice per day (maximum, 100 mg/dose) (B-II). Cefuroxime axetil, at a dosage of 30 mg/kg/d, divided into 2 doses daily (maximum, 500 mg/dose), is an acceptable alternative agent (B-III). Macrolide antibiotics are not recommended as first-line therapy for early Lyme disease (E-I). When used, they should be reserved for patients who are intolerant of amoxicillin, doxycycline, and cefuroxime axetil. Possible regimens for adults are as follows: azithromycin, 500 mg orally daily for 7-10 days; erythromycin, 500 mg orally 4 times daily for 14-21 days; and clarithromycin, 500 mg orally twice daily for 14-21 days. Possible dosages for children are the following: azithromycin, 10 mg/kg/d (maximum, 500 mg/d); erythromycin, 12.5 mg/kg 4 times daily (maximum, 500 mg/dose); and clarithromycin, 7.5 mg/kg twice daily (maximum, 500 mg/dose). Patients treated with macrolides should be closely followed. Ceftriaxone (2 g iv daily), although effective, is not superior to oral agents and is not recommended as a first-line agent for treatment of Lyme disease in the absence of neurological involvement or third-degree atrioventricular heart block (E-I).