Late Lyme Disease Treatment
Lyme arthritis – Lyme arthritis can usually be treated successfully with antimicrobial agents administered orally. Doxycycline (100 mg twice per day) , amoxicillin (500 mg 3 times per day), or cefuroxime axetil (500 mg twice per day) for 28 days is recommended for adult patients without clinical evidence of neurologic disease.
For children, amoxicillin (50 mg/kg per day in 3 divided doses [maximum of 500 mg per dose]) (B-I), cefuroxime axetil (30 mg/kg per day in 2 divided doses [maximum of 500 mg per dose]) (B-III), or, if the patient is ⩾8 years of age, doxycycline (4 mg/kg per day in 2 divided doses [maximum of 100 mg per dose]) (B-I) is recommended. Oral antibiotics are easier to administer than intravenous antibiotics, are associated with fewer serious complications, and are considerably less expensive.
Neurologic evaluation, that may include lumbar puncture, should be performed for patients in whom there is a clinical suspicion of neurologic involvement. Adult patients with arthritis and objective evidence of neurologic disease should receive parenteral therapy with ceftriaxone for 2–4 weeks. Cefotaxime or penicillin G administered parenterally is an acceptable alternative. For children, intravenous ceftriaxone or intravenous cefotaxime is recommended; penicillin G administered intravenously is an alternative.
For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of ceftriaxone. A second 4-week course of oral antibiotic therapy is favored by panel members for the patient whose arthritis has substantively improved, but has not yet completely resolved, reserving intravenous antibiotic therapy for those patients whose arthritis failed to improve at all or worsened.
Adult patients with late neurologic disease affecting the central or peripheral nervous system should be treated with intravenous ceftriaxone for 2 to 4 weeks (B-II). Cefotaxime or penicillin G administered intravenously is an alternative. Response to treatment is usually slow and may be incomplete. Re-treatment is not recommended unless relapse is shown by reliable objective measures.
Acrodermatitis chronica atrophicans. Available data indicate that acrodermatitis chronica atrophicans may be treated with a 21-day course of the same antibiotics (doxycycline, amoxicillin, and cefuroxime axetil) used to treat patients with erythema migrans (see above). A controlled study is warranted to compare oral with parenteral antibiotic therapy for the treatment of acrodermatitis chronica atrophicans.
Coinfection – Coinfection with B. microti or A. phagocytophilum or both may occur in patients with early Lyme disease (usually in patients with erythema migrans) in geographic areas where these pathogens are endemic. Coinfection should be considered in patients who present with more-severe initial symptoms than are commonly observed with Lyme disease alone, especially in those who have high-grade fever for >48 h, despite receiving antibiotic therapy appropriate for Lyme disease, or who have unexplained leukopenia, thrombocytopenia, or anemiaCoinfection might also be considered in the situation in which there has been resolution of the erythema migrans skin lesion but either no improvement or worsening of viral infection–like symptoms