Treatment

Treatment Guidelines

• The optimal treatment regimen for the management of known tick bites, EM rashes and persistent disease has not yet been determined. Accordingly, it is too early to standardize restrictive protocols. However, ILADS does make recommendations for each of these clinical situations

  • ILADS recommends against the use of a single 200 mg dose of doxycycline for the prevention of Lyme disease. Not only is it unlikely to be highly efficacious, in the human trial failed therapy led to a seronegative disease state.  

  • Based on animal studies, ILADS recommends that known blacklegged tick bites be treated with 20 days of doxycycline (barring any contraindications).

  • Given the low success rates in trials treating EM rashes for 20 or fewer days, ILADS recommends that patients receive 4-6 weeks of doxycycline, amoxicillin or cefuroxime. A minimum of 21 days of azithromycin is also acceptable, especially in Europe. All patients should be reassessed at the end of their initial therapy and, when necessary, antibiotic therapy should be extended.

  • ILADS recommends that patients with persistent symptoms and signs of Lyme disease be evaluated for other potential causes before instituting additional antibiotic therapy.

  • ILADS recommends antibiotic retreatment when a chronic Lyme infection is judged to be a possible cause of the ongoing manifestations and the patient has an impaired quality of life.

Clinical Judgment and Shared Decision-Making

• Given the number of clinical variables that must be managed and the heterogeneity within the patient population, clinical judgment is crucial to the provision of patient-centered care.

• Based on the GRADE model, ILADS recommends that patient goals and values regarding treatment options be identified and strongly considered during a shared decision-making process.

Reconciling Divergent Guidelines

• Conflicting guidelines most often result when evidence is weak; when developers differ in their underlying values, approach to evidence reviews, synthesis or interpretation; and/or when developers have varying assumptions about intervention benefits and harms.

• The differences by clinical situation between the ILADS and IDSA treatment recommendations are reconciled in Supplementary Appendix I.