Management

The drug of choice for Lyme disease is doxycycline; alternatively amoxicillin, azithromycin or ceftriaxone can be used, see figure 5. Please note that azithromycin does not cross the blood brain barrier so ceftriaxone or doxycycline is often preferred, unless contraindicated.

Although there is no difference in cure rate between these antibiotics, a single daily dose of doxycycline is likely to be easier to adhere to for patients than more frequent antibiotic regimens. Treatment is continued for at least 21 days.

All children under 18 with erythema migrans and additional symptoms should be discussed with an Infectious Diseases specialist.

Ask female patients if they might be pregnant before offering antibiotic treatment for Lyme disease as this will affect your antibiotic choice.

If symptoms worsen during treatment, assess for an allergic reaction to the antibiotic. Be aware that a Jarisch-Herxheimer reaction may cause an exacerbation of symptoms but does not usually warrant stopping treatment.

Learning Bite:

A Jarisch-Herxheimer reaction is a systemic reaction thought to be caused by the release of cytokines when antibiotics kill large numbers of bacteria. Symptoms include a worsening of fever, muscle pains and headache. The reaction can start between 1 and 12 hours after commencement of antibiotic therapy but can also occur later. It can last for a few hours or 1-2 days. The reaction is self-limiting and usually resolves within 24-48 hours. It was originally reported in the treatment of syphilis but has been documented in tick-borne diseases including Lyme disease, leptospirosis and relapsing fever.

Despite treatment the symptoms of Lyme disease may take months or even years to resolve for a number of reasons:

• The symptoms are caused by alternative diagnosis
• The patient has become re-infected
• There has been a treatment failure
• Symptoms relate to an immune reaction or organ damage

Given the risk of treatment failure, a second (different) antibiotic course should be considered in patients with on-going symptoms despite an initial course of antibiotics.

Consider discussion with a national reference laboratory or referral to a specialist appropriate to the patients symptoms, if they are ongoing after two courses of antibiotics for Lyme disease. Do not routinely offer further antibiotics.

It should be explained to patients with ongoing symptoms following appropriate treatment for Lyme disease that:

• Continuing symptoms may not mean they still have an active infection
• Even after treatment, symptoms may take months or even years to resolve
• Permanent damage from the infection may result in some symptoms
• It is not possible to diagnose active infection using the existing testing methods – an alternative diagnosis may explain their symptoms

Consider the need to support patients with on-going symptoms after treatment for Lyme disease by referral to other services e.g referral to adult social care for a care and support needs assessment or communication with a child or young persons school or higher education regarding graded return to activity as appropriate.

Figure 5: Lyme disease: Antibiotic choices – see here for the BMJ infographic