Antibiotic therapy for Lyme disease in a population-based cohort

Evidence-based guidelines for the management of Lyme disease

This report, completed in November 2003, is intended to serve as a resource for physicians, public health officials and organizations involved in the evaluation and treatment of Lyme disease.

Diagnosis, treatment, and prevention of Lyme disease in children

The approaches to diagnosing and treating Lyme disease (LD) have been improved and refined as a result of basic and clinical research, and considerable practical experience. In addition, there have been recent studies that have allowed improvements in the ability to prevent infection with Borrelia burgdorferi. This paper will review the relevant literature and address recent developments in the diagnosis, treatment, and prevention of LD. Issues specifically related to the management of children will be identified. Controversies regarding treatment approaches will be examined in some detail. Understanding the clinical manifestations, or stage, of LD is crucial when approaching both diagnosis and treatment. Early localized disease is best diagnosed by recognizing the characteristic skin lesion, erythema migrans. Early disease will frequently, but not always, be accompanied by a detectable antibody response, particularly IgM antibody to the spirochete. Late disease, chiefly arthritis, is generally associated with high levels of IgG antibody. Western blot technology allows confirmation of enzyme immunoassay results and is especially useful when the latter is in the low or equivocal range. Early localized disease responds well to oral antibacterial therapy. Early disseminated disease, often associated with neurologic findings, may require parenteral therapy. The arthritis associated with LD frequently responds to oral antibacterials, but some refractory cases may require intravenous therapy, and occasionally surgery. Doxycycline is the oral antibacterial of choice, while amoxicillin and cefuroxime axetil are alternatives that may be preferred in young children. Owing to its long half-life and once daily dose administration, intravenous ceftriaxone has become the accepted standard for parenteral therapy. Tick avoidance has long been the mainstay for preventing LD. Antibacterial prophylaxis, using doxycycline, for tick bites has been shown to be an effective approach to prevention, but its relevance to pediatrics is uncertain. Vaccines designed to prevent infection have also been developed.

Management of tick bites and early Lyme disease: a survey of Connecticut physicians

Practice guidelines have been published for the treatment of Lyme disease (LD). These guidelines have been challenged as inadequate. Two common LD management problems are antibiotic prophylaxis of deer tick bites (deer ticks may carry Borrelia burgdorferi, the spirochete that causes LD) and antibiotic treatment of erythema migrans, the pathognomonic rash of LD. A 1-page questionnaire was sent to a 13% (573/4300) sample of Connecticut physicians to define how they treat deer tick bites and erythema migrans. Questionnaires were returned by 320 (56%) of 573 physicians. Questionnaires were analyzed for the 267 physicians who saw patients with LD. Seventy (26%) of the 267 surveyed physicians prescribed antibiotic prophylaxis for patients with tick bites. B burgdorferi serology was ordered by 31% of physicians for patients with tick bites. Most surveyed physicians treated erythema migrans with doxycycline or amoxicillin for a mean of 21 days. Serology was ordered by 49% of physicians for patients with erythema migrans. Most physicians did not use prophylaxis for patients with deer tick bites. In addition, most of the physicians surveyed followed established guidelines for treating patients with erythema migrans. However, many of the physicians surveyed do serologic testing for patients with tick bites and/or erythema migrans. Serologic testing for these patients is usually not necessary.