Patient education: Lyme disease treatment (Beyond the Basics)

LYME DISEASE OVERVIEW — Lyme disease is the most common tick-borne illness in the United States and Europe. Lyme disease is caused by an infection with the bacteria Borrelia burgdorferi, which are carried by deer ticks. The bacteria are transmitted when a tick bites a person.

In most people, treatment with antibiotics is very effective at eliminating symptoms, preventing complications of the disease, and curing the infection. Some symptoms improve rapidly with this treatment, whereas other symptoms gradually improve over weeks to months.

This topic review discusses the treatment of Lyme disease. Separate topic reviews discuss what to do after a tick bite to prevent Lyme disease and the symptoms and diagnosis of Lyme disease. (See "Patient education: What to do after a tick bite to prevent Lyme disease (Beyond the Basics)" and "Patient education: Lyme disease symptoms and diagnosis (Beyond the Basics)" and "Patient education: Lyme disease prevention (Beyond the Basics)".)

More detailed information about Lyme disease is available by subscription. (See "Epidemiology of Lyme disease" and "Clinical manifestations of Lyme disease in adults" and "Diagnosis of Lyme disease" and "Evaluation of a tick bite for possible Lyme disease" and "Treatment of Lyme disease" and "Prevention of Lyme disease".)

LYME DISEASE TREATMENT

General principles — Antibiotics are the primary treatment for Lyme disease, and the vast majority of patients recover after antibiotic treatment. The recommended treatment for Lyme disease varies depending upon the stage of disease and the types of symptoms. The rate of recovery may also vary depending upon the specific symptoms and recovery may take weeks to months after finishing antibiotic treatment.

In about 10 to 15 percent of individuals with early Lyme disease, substances released by the dying bacteria cause a brief worsening of symptoms (called a Jarisch-Herxheimer reaction). This reaction occurs within 24 hours after starting antibiotics, continues for a day or so, and then resolves. Antibiotic therapy should not be stopped if this reaction develops, but should instead continue as originally planned.

There is no evidence that the Lyme bacteria are resistant to any of the antibiotics commonly used to treat the infection. In rare cases, additional therapy beyond the recommended doses may be used for brief periods of time (typically one month). However there is no evidence that additional treatment with any antibiotic results in improvement of slowly resolving symptoms. (See "Treatment of Lyme disease".)

Early localized Lyme disease — Early localized Lyme disease (the erythema migrans rash, with or without flu-like symptoms) is treated with oral antibiotics, usually doxycycline, amoxicillin, or cefuroxime, taken daily. Doxycycline is given for 10 to 21 days, and amoxicillin and cefuroxime are given for 14 to 21 days.

Antibiotics prevent worsening of the disease and may decrease the duration and severity of symptoms. (See "Musculoskeletal manifestations of Lyme disease".)

Early disseminated Lyme disease — When Lyme disease is recognized after it has moved from the tick bite site to other locations, the recommended treatments may be either oral or intravenous antibiotics. Oral antibiotics are used for cases that are considered less serious. These include cases of multiple skin lesions, nerve involvement (such as facial palsy) in which the symptoms are limited to nerves that do not involve the brain or spinal cord, and mild cases of inflammation of the heart (typically causing slight delays in conduction of electrical signals from one part of the heart to the other). For cases of nerve involvement such as facial palsy, a spinal tap may be required to test the cerebrospinal fluid (CSF) for evidence of infection before deciding whether to treat with oral or intravenous antibiotics.

More serious manifestations including meningitis (inflammation of the lining of the brain and spinal cord) and more advanced forms of heart block with moderate to severe delays in conduction are sometimes treated with intravenous therapy. For meningitis, the entire course of antibiotics is often given intravenously. For heart block, patients are generally given intravenous antibiotics initially and monitored in the hospital; in addition, a temporary pacemaker may be required for patients with complete heart block resulting in a very slow heartbeat. When the heart block has improved, patients are often changed to oral antibiotics. For patients with multiple symptoms, the treatment used is dictated by the most serious manifestation. Treatment with intravenous antibiotics is typically recommended for 10 to 28 days (most commonly 14 days).

Intravenous (IV) therapy is usually started in a healthcare provider's office or emergency department. It can be continued at home and monitored by a visiting or home health nurse. Patients receiving home intravenous therapy should watch for symptoms of infection or inflammation at the site of the IV line (pain, redness, and swelling) and symptoms of blood clots in the vein (pain and swelling in the arm or armpit). Because of the risks associated with intravenous antibiotics, some clinicians may choose to use oral antibiotics even for more serious manifestations of disease in some patients where the risk of intravenous therapy is elevated.

It has not been proven that the use of intravenous antibiotics results in faster or more complete improvement of symptoms, even in severe cases of meningitis and heart block. In European cases of Lyme disease, oral antibiotics appear to be equivalent to intravenous antibiotics for meningitis, and an increasing number of providers in the United States are starting to use oral doxycycline to treat meningitis.

Late Lyme disease — Manifestations of late Lyme disease include arthritis and neurologic conditions.

In most individuals, the arthritis of late Lyme disease resolves with oral antibiotic therapy given for 28 days; intravenous antibiotics are recommended only if the arthritis does not improve with oral treatment. However, in some adults and children, arthritis persists after antibiotic therapy.

Arthritis that lingers after antibiotic therapy may require therapies used for other types of arthritis and/or synovectomy (surgical removal of the joint lining). More information about these treatments is discussed separately. (See "Patient education: Osteoarthritis treatment (Beyond the Basics)".)

Neurologic conditions associated with late Lyme disease are treated with intravenous antibiotics, usually ceftriaxone or cefotaxime, given daily for two to four weeks.

Post-Lyme disease syndromes — In some people, symptoms such as headache, fatigue, and joint pain do not resolve immediately after treatment is completed. In addition, some patients develop pain or fatigue after a gap of several weeks to months after antibiotic treatment of Lyme disease. These symptoms usually resolve gradually over time. Taking more antibiotics does not improve symptoms or shorten the course of post-Lyme symptoms.

Chronic Lyme disease is another term that is used to describe symptoms of pain, fatigue, and difficulty thinking clearly that occur after antibiotic treatment of Lyme disease. There are currently no strict criteria for defining chronic Lyme disease, and no evidence that antibiotics beyond the currently recommended amounts improve symptoms. Because the symptoms are often non-specific and can overlap with many other diseases, it is important to ensure that there are no other potential causes of the symptoms that may be more amenable to therapy.

CAN I GET LYME DISEASE AGAIN? — If you had early Lyme disease and were treated, it is possible to become reinfected if you are bitten by another infected tick. However, Lyme antibodies (proteins your immune system makes to fight the bacteria) are likely to remain in your blood for years, even after treatment; as a result, it can be hard for doctors to know whether a positive blood test means you have been reinfected. Therefore, they typically diagnose reinfection if you get a new rash that is typical for Lyme disease after a possible exposure to deer ticks. If you were treated for late Lyme disease, reinfection is very unlikely, since people with late Lyme disease develop a stronger and longer-lasting antibody response.

ARE ANTIBIOTICS NECESSARY AFTER A TICK BITE? — Several factors must be taken into consideration when deciding if antibiotic treatment is necessary after a tick bite to prevent Lyme disease. (See "Patient education: What to do after a tick bite to prevent Lyme disease (Beyond the Basics)" and "Evaluation of a tick bite for possible Lyme disease".)

PREVENTING LYME DISEASE — You can take steps to prevent infection with Lyme disease. This is discussed in a separate article. (See "Patient education: Lyme disease prevention (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Lyme disease (The Basics)
Patient education: Rocky Mountain spotted fever (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: What to do after a tick bite to prevent Lyme disease (Beyond the Basics)
Patient education: Lyme disease symptoms and diagnosis (Beyond the Basics)
Patient education: Lyme disease prevention (Beyond the Basics)
Patient education: Osteoarthritis treatment (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Clinical manifestations of Lyme disease in adults
Diagnosis of Lyme disease
Evaluation of a tick bite for possible Lyme disease
Lyme carditis
Epidemiology of Lyme disease
Musculoskeletal manifestations of Lyme disease
Prevention of Lyme disease
Treatment of Lyme disease

The following organizations also provide reliable health information.

●National Library of Medicine

     (www.nlm.nih.gov/medlineplus/lymedisease.html, available in Spanish)

●National Institute of Allergy and Infectious Diseases

     (https://www.niaid.nih.gov/diseases-conditions/lyme-disease)

●A review of Chronic Lyme Disease

(https://www.niaid.nih.gov/diseases-conditions/chronic-lyme-disease)

●Center for Disease Control and Prevention

     (www.cdc.gov/ncidod/dvbid/lyme/)

●American Lyme Disease Foundation, Inc.

     (http://aldf.com/lyme-disease/, available in Spanish)

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