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Chapter 152: Lyme Disease

Chinmoy Bhate; Robert A. Schwartz

LYME DISEASE

Therapeutic Approach

Lyme disease is a multisystem tick-borne spirochetal infection.1 Cutaneous disease is characterized by an expansile erythematous patch, often with central clearing, known as erythema chronicum migrans (ECM). Multiple stages of disease may exist; antibiotic therapy is typically tailored to extent of infection.2,3 Early-stage disease, consisting of ECM, is generally treated with oral antibiotics. Later-stage disease, with dissemination or neurologic symptoms, may require intravenous therapy. See Table 152-1.

Table 152-1Lyme Disease Treatment Table
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Table 152-1 Lyme Disease Treatment Table
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MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Systemic Therapy      
Doxycycline ECM or early stage Antimicrobial 100 mg PO BID × 10-20 d Contraindicated in pregnancy, avoid ages <8 yo; photosensitivity, GI upset, esophagitis, headache None, other than as relevant to workup of infection IA4-7
  Arthritis   100 mg PO BID × 28-30 d IB8
  LCC or ACAc   100 mg PO BID × 14-28 d, potentially longer for ACA III for LCC9, IIB for ACA10
  C1d   100 mg PO BID × 14-21 d IV3,11-12
  Ne   100 mg PO BID × 14-21 d IB13-14
  Pf   200 mg PO, single dose IB for P15

Amoxicillin

(preferable for children <8 y)

 ECM or early stage Antimicrobial Adults: 500 mg PO BID × 10-20 d Hypersensitivity, GI upset None, other than as relevant to workup of infection IA4,16
      Children: 50 mg/kg/d PO, divided into three doses × 10-20 d IB17
  Arthritis   Adults: 500 mg PO BID × 28-30 d IB8
      Children: 50 mg/kg/d PO, divided into 3 doses × 28-30 d III18
  LCC or ACA   Adults: 500 mg PO BID × 14-28 d

III for LCC,9,19

IV for ACA3
      Children: 50 mg/kg/d PO, divided into 3 doses × 14-28 d

IV for LCC,3,17

IV for ACA3
  C1   Adults: 500 mg PO BID × 14-21 d IV3
      Children: 50 mg/kg/d PO, divided into 3 doses × 14-21 d IV3

Cefuroxime axetil

(potential alternative for children)

 ECM or early stagea Antimicrobial Adults: 500 mg PO BID × 10-20 d Jarisch-Herxheimer reaction, GI upset None, other than as relevant to workup of infection IA4
      Children: 20 or 30 mg/kg/d, divided into 2 doses × 10-20 d IB17
  Arthritis   Adults: 500 mg PO BID × 28 d IV3
      Children: 20 or 30 mg/kg/d, divided into 2 doses × 10-20 d IV3
  LCC or ACA   Adults: 500 mg PO BID × 14-28 d IV3
 

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