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NICE suggest that (1):

Emergency referral

  • follow usual clinical practice for emergency referrals, for example, in people with symptoms that suggest central nervous system infection, uveitis or cardiac complications such as complete heart block, even if Lyme disease is suspected

Specialist advice

  • discuss the diagnosis and management of Lyme disease in children and young people under 18 years with a specialist, unless they have a single erythema migrans lesion and no other symptoms
    • choose a specialist appropriate for the child or young person's symptoms dependent on availability, for example, a paediatrician, paediatric infectious disease specialist or a paediatric neurologist

  • if an adult with Lyme disease has focal symptoms, consider a discussion with or referral to a specialist, without delaying treatment
    • choose a specialist appropriate for the person's symptoms, for example, an adult infection specialist, rheumatologist or neurologist.

Treatment depends on the stage of the disease.

Early disease (stage I):

  • treatment is with oral antibiotics - recommended for people presenting with erythema migrans without evidence of neurological or cardiac manifestations (1,2)
    • doxycycline 100 mg bd for 21 days (range 10–21 days) contraindicated in children aged under twelve years and for pregnant and breastfeeding women (2)
    • first alternative for adults amoxicillin 1g tds for 21 days (1)
    • second alternative for adults oral azithromycin 500 mg daily for 17 days (1)

Early disseminated infection (stage II):

  • this stage of the disease is characterised by neurological, cardiac and ocular manifestations.
  • the carditis is generally self-limiting but may be complicated by life-threatening features such as third degree heart block. These must be managed as if they were due to any other aetiology. The carditis must also be treated with high dose IV antibiotics, e.g. ceftriaxone.
  • neurological complications, e.g. Bannwarth's syndrome, are also treated with high dose IV antibiotics.
  • severe ocular manifestations also require parenteral antibiotic therapy.
  • effective antibiotic therapy of early disease generally prevents late disease.

Late disease (stage III) is generally with high dose IV antibiotics, e.g. ceftriaxone.

NICE have suggested antibiotic treatment for Lyme disease in adults and young people (aged 12 and over) according to symptoms

Lyme disease without focal symptoms

Clinical features Treatment First Alternative Second Alternative
Erythema migrans and/or Non-focal symptoms

Oral doxycycline:

100 mg twice per day or 200 mg once per day for 21 days

Oral amoxicillin:

1 g 3 times per day for 21 days

Oral azithromycin:

500 mg daily for 17 days

Lyme disease with focal symptoms

Clinical features Treatment First Alternative Second Alternative
Lyme disease affecting the cranial nerves or peripheral nervous system

Oral doxycycline:

100 mg twice per day or 200 mg once per day for 21 days

Oral amoxicillin:

1 g 3 times per day for 21 days

-

Lyme disease affecting the central nervous system

Intravenous ceftriaxone:

2 g twice per day or 4 g once per day for 21 days (when an oral switch is being considered, use doxycycline)

Oral doxycycline:

200 mg twice per day or 400 mg once per day for 21 days

-
Lyme disease arthritis

Oral doxycycline:

100 mg twice per day or 200 mg once per day for 28 days

Oral amoxicillin:

1 g 3 times per day for 28 days

Intravenous ceftriaxone:

2 g once per day for 28 days

Acrodermatitis chronica atrophicans

Oral doxycycline:

100 mg twice per day or 200 mg once per day for 28 days

Oral amoxicillin:

1 g 3 times per day for 28 days

Intravenous ceftriaxone:

2 g once per day for 28 days

Lyme carditis

Oral doxycycline:

100 mg twice per day or 200 mg once per day for 21 days

Intravenous ceftriaxone:

2 g once per day for 21 days

-
Lyme carditis and haemodynamically unstable

Intravenous ceftriaxone:

2 g once per day for 21 days (when an oral switch is being considered, use doxycycline)

- -
  • For Lyme disease suspected during pregnancy, use appropriate antibiotics for stage of pregnancy
  • Do not use azithromycin to treat people with cardiac abnormalities associated with Lyme disease because of its effect on QT interval.

Erythromycin is not recommended for the treatment of Lyme borreliosis (LB) due to its high failure rate (4).

Reference:

Last edited 05/2018 and last reviewed 09/2019

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