Full Recommendations For The Prevention Diagnosis And Treatment Of Lyme Disease
I. Which measures should be used to prevent tick bites and tick-borne infections?
Personal Protective Measures
Summary of the Evidence
Rationale for Recommendation
Although there is little systematic evidence supporting some of these measures for the prevention of Lyme disease, they may offer potential benefits with little effort, risk, or cost.
Properly designed studies performed with human subjects under realistic conditions are required to test the efficacy of personal protection measures. Similarly, research is needed to inform how to motivate the adoption and continued use of best practice personal protection measures.
Repellents to Prevent Tick Bites
Summary of the Evidence
In laboratory and field experiments involving human subjects, the use of DEET, picaridin, IR3535, oil of lemon eucalyptus , p-methane-3,8-diol , 2-undecanone, and permethrin reduced the number of ticks detected crawling on or attached to subjects compared with controls . Other commercially available products, including botanical agents and essential oils cannot be recommended due to insufficient evidence.
Antibiotics Can Prevent Lyme Disease
B O S T O N, June 12, 2001 — For the first time, doctors have shown that aquick dose of antibiotics can ward off Lyme disease after a tickbite, but they caution against overusing the treatment.
Some physicians already give antibiotics to people who arebitten by deer ticks, the bugs that spread Lyme disease. However,many experts oppose this, because there has been no clear evidencethe treatment actually prevents the disease, even thoughantibiotics can clear up Lyme disease once it occurs.
Now there is proof the approach works. A study conducted in NewYork’s Westchester County, where Lyme disease is common, found thatjust two pills of doxycycline are highly effective if given withinthree days of a bite.
“Ours is the first study to show that Lyme disease can beprevented after a tick bite,” said the study’s chief author, Dr.Robert B. Nadelman of New York Medical College in Valhalla, N.Y.
The study, to be published in the July 12 issue of the NewEngland Journal of Medicine, was released on the journal’s Web siteearly today because of its importance.
About 15,000 cases of Lyme disease are reported annually in theUnited States, mostly in the Northeast from Maine to Maryland theMidwest in Wisconsin and Minnesota, and the West in northernCalifornia and Oregon.
Tick Bites Rarely Lead to Infection
Still, Nadelman said it may make sense to treat people if theyare bitten by a blood-filled nymphal stage deer tick in an areawhere Lyme disease is common.
Clinical Questions And Evidence Review
An initial list of relevant clinical questions for these guidelines was created by the whole panel for review and discussion. The final set of clinical questions was approved by the entire committee. All outcomes of interest were identified a priori and explicitly rated for their relative importance for decision making. Each clinical question was assigned to a pair of panelists.
Evidence summaries for each question were prepared by the technical team from Tufts Medical Center. The risk of bias was assessed by the technical review team using the Cochrane risk of bias tool for randomized controlled trials , the Newcastle-Ottawa scale for nonrandomized studies and QUADAS-2 tool for diagnostic test accuracy studies . The certainty in the evidence was initially determined for each critical and important outcome, and then for each recommendation using the GRADE approach for rating the confidence in the evidence . Evidence profile tables and quality of evidence were reviewed by the guideline methodologists . The summaries of evidence were discussed and reviewed by all committee members and edited as appropriate. The final evidence summaries were presented to the whole panel for deliberation and drafting of recommendations. Literature search strategies, PRISMA flow diagrams detailing the search results, data extraction and evidence profiles tables, and additional data, such as meta-analysis results when appropriate, can be found in the supplementary materials .
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Racial Differences In Incidence
Lyme disease is reported primarily in whites, although it occurs in individuals of all races. No genetic explanation is known for this the disparity most likely stems from social or environmental factors and possibly to the fact that erythema migrans is more difficult to diagnose in dark-skinned individuals.
Disclosure And Management Of Potential Conflicts Of Interest
The Lyme conflict of interest review group consisting of 2 representatives from IDSA, AAN, and ACR were responsible for reviewing, evaluating, and approving all disclosures. All members of the expert panel complied with the consensus IDSA/AAN/ACR process for reviewing and managing conflicts of interest, which required disclosure of any financial, intellectual, or other interest that might be construed as constituting an actual, potential, or apparent conflict, regardless of relevancy to the guideline topic. Thus, to provide transparency, IDSA/AAN/ACR required full disclosure of all relationships. The assessment of disclosed relationships for possible COI by the IDSA/AAN/ACR review group was based on the relative weight of the financial relationship and the relevance of the relationship . For more information on allowable and prohibited relationships, please review Table 1 and Table 2. In addition, the IDSA/AAN/ACR adhered to Section 7 of the Council for Medical Specialty SocietiesââCode for Interactions with Companiesâ . The COI review group ensured that the majority of the panel and each cochair was without potential relevant conflicts . Each of the cochairs and all members of the technical team were determined to be unconflicted. See the notes section for disclosures reported to IDSA/AAN/ACR.
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Borrelia Burgdorferi Infectious Cycle
The infectious cycle of B burgdorferi involves colonization, infection of Ixodes ticks, and then transmission to broad a range of mammalian hosts, including humans. Variation in environmental and host conditions promotes different gene expression and changes in the composition of the membrane proteins of the spirochete. This adaptation is a critical step in the pathogenesis and transmission of Lyme disease.
The Ixodes tick progresses through four stages of development: egg, larva, nymph, and adult . Only larvae, nymphs, and adult female ticks require blood meals, and only ticks in the nymphal and adult stages can transmit B burgdorferi.
The life cycle of Ixodes ticks spans 2 years . The adult lays eggs in the spring, and the larvae emerge in the summer. The larvae feed once, in late summer, on any of a wide variety of small animals . The following spring, the larvae emerge as nymphs. Nymphs feed once, in the spring and summer. The white-footed mouse is the preferred feeding source of nymphs, but other animals apparently suffice. Nymphs molt into adults the following fall and feed once on a larger animal, with the white-tailed deer being the preferred host.
Ticks carry B burgdorferi organisms in their midgut. The bacteria are introduced into the skin by a bite from an infected tick, and disease is transmitted to humans as the spirochete is translocated from the gut to the salivary glands and then to the person at the site of the bite.
Awareness Of Lyme Disease
1.1.1 Be aware that:
the bacteria that cause Lyme disease are transmitted by the bite of an infected tick
ticks are mainly found in grassy and wooded areas, including urban gardens and parks
tick bites may not always be noticed
infected ticks are found throughout the UK and Ireland, and although some areas appear to have a higher prevalence of infected ticks, prevalence data are incomplete
particularly high-risk areas are the South of England and Scottish Highlands but infection can occur in many areas
Lyme disease may be more prevalent in parts of central, eastern and northern Europe and parts of Asia, the US and Canada.
1.1.2 Be aware that most tick bites do not transmit Lyme disease and that prompt, correct removal of the tick reduces the risk of transmission.
1.1.3 Give people advice about:
where ticks are commonly found
the importance of prompt, correct tick removal and how to do this
covering exposed skin and using insect repellents that protect against ticks
how to check themselves and their children for ticks on the skin
sources of information on Lyme disease, such as Public Health England’s resources and guidance on Lyme disease and organisations providing information and support, such as patient charities.
For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on awareness of Lyme disease.
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Trial Design And Study Characteristics
Table summarizes the study design of the four randomized, double-blind, placebo-controlled trials included for analysis. All four trials were conducted in areas where Lyme disease is endemic and all trials enrolled patients with an Ixodes scapularis tick bite within the preceding 72 h. In all four trials, the blinding of patients was performed by giving them identical-appearing tablets, capsules or liquid suspensions. The success of patient blinding was assessed in only one study. In all four trials, physicians were reported to be blinded to the treatment allocation. However, no trial reported how physician blinding was assessed. Two trials assessed patient compliance: the first measured patient compliance by assessing the antimicrobial activity of patient urine and the other asked subjects to swallow the single-dose regimen under direct observation by study personnel.
All of the four clinical trials used the development of erythema migrans or symptoms of extracutaneous Lyme disease as their primary outcome for statistical analysis. All trials measured serum antibodies against B. burgdorferiat presentation and upon follow-up. Only two trials, confirmed equivocal or positive results with immunoblot assays.
Dosage, duration and types of antibiotics tested varied among trials. In three trials, a 10 day course of treatment was administered. In the other trial, subjects were given two 100 mg capsules of doxycycline as a single dose.
Data Sources And Study Selection
To identify controlled trials on antibiotic prophylaxis for Lyme disease published after our prior meta-analysis, we searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials from 1 January 1995 to 1 April 2009 using the keyword combination and , without language restrictions. We retrieved full-length texts of all articles potentially pertaining to Lyme disease chemoprophylaxis after a review of titles and abstracts from our search. References of obtained articles were reviewed to identify additional studies for retrieval. To minimize publication bias, we searched for unpublished trials in the metaRegister of Controlled Trials and in the NIH registry using the search term Lyme disease.
We applied similar eligibility criteria to the retrieved articles as in our prior meta-analysis. Trials were included if their patients were randomly allocated to a treatment or placebo group, enrolled within 72 h following an Ixodes tick bite and had no clinical evidence of Lyme disease at enrolment. We did not restrict trials based on the antibiotics used, age of the patients enrolled, length of patient follow-up or the outcomes observed.
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Treatment For Erythema Migrans
People treated with appropriate antibiotics in the early stages of Lyme disease usually recover rapidly and completely. Early diagnosis and proper antibiotic treatment of Lyme disease can help prevent late Lyme disease.
Treatment regimens listed in the following table are for the erythema migrans rash, the most common manifestation of early Lyme disease. These regimens may need to be adjusted depending on a persons age, medical history, underlying health conditions, pregnancy status, or allergies. Consult an infectious disease specialist regarding individual patient treatment decisions.
|100 mg, twice per day orally||N/A|
|500 mg, three times per day orally||N/A|
|500 mg, twice per day orally||N/A|
|4.4 mg/kg per day orally, divided into 2 doses||100 mg per dose|
|50 mg/kg per day orally, divided into 3 doses||500 mg per dose|
|30 mg/kg per day orally, divided into 2 doses||500 mg per dose|
*When different durations of antibiotics are shown to be effective for the treatment of Lyme disease, the shorter duration is preferred to minimize unnecessary antibiotics that might result in adverse effects, including infectious diarrhea and antimicrobial resistance.
NOTE: For people intolerant of amoxicillin, doxycycline, and cefuroxime, the macrolide azithromycin may be used, although it is less effective. People treated with azithromycin should be closely monitored to ensure that symptoms resolve.
Should I Remove A Tick And How
Yes, remove a tick. But do not manhandle the tick by squeezing it, putting Vaseline over it, or holding a hot match to it, as this may increase the chance of transmitting disease.
The tick should be removed with fine pointed tweezers. Grasp it from the side where it meets the skin, and, using steady gentle pressure, gently pull in the opposite direction from which it embedded, until the tick is released. Expect to see the skin tent as you gently pull. Place the tick in a lidded container or zip-lock bag. Wash and disinfect the bite site, your hands, and your tweezers. Avoid handling the tick.
If you use a tick removal device like a tick scoop or tick key, follow the directions given on the package for safe and effective use.
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When Is Antibiotic Prophylaxis Indicated In The Prevention Of Lyme Disease
Routine prophylaxis after a recognized tick bite is not recommended. A guideline from the Infectious Disease Society of America recommends prophylactic antibiotic therapy for adults and children older than 8 years, using a single 200-mg dose of doxycycline only if all of the following criteria are met :
The attached tick can be reliably recognized as a nymphal or adult Ixodes scapularis
The tick has been attached for at least 36 hours, as determined by the degree of engorgement of the tick or certainty about the time of exposure to the tick
Prophylaxis can be started within 72 hours of the time the tick was removed
The local rate of infection of these ticks with Borrelia burgdorferi is at least 20%
Doxycycline treatment is not contraindicated
The species of tick is important because non-Ixodes ticks , although they can contain the organism, are highly unlikely to cause disease. The one clinically relevant exception may be bites by Amblyomma americanum in the central and southern midwestern United States, but few data exist on treating these tick bites prophylactically.
Feder HM Jr. Lyme disease in children. Infect Dis Clin North Am. 2008 Jun. 22:315-26, vii. .
Centers for Disease Control and Prevention. Lyme Disease: Diagnosis and Testing. CDC. Available at . November 20, 2019 Accessed: March 30, 2021.
Edlow JA. Erythema migrans. Med Clin North Am. 2002 Mar. 86:239-60. .
Program Allows S Kingstown Pharmacy To Offer Drug For Tick Bites Meeting Strict Criteria
SOUTH KINGSTOWN A family-owned pharmacy in this seaside town recently began dispensing antibiotics to people without prescriptions to reduce the risk of developing Lyme disease.
Green Line Apothecary announced in late June that it is offering the single 200-mg prophylactic dose of doxycycline to adults within 72 hours of a deer tick bite if they meet the U.S. Centers for Disease Control and Preventions criteria for infection risk.
Proponents of the program reportedly the first of its kind in the country say it serves an important public health need by expanding timely access to treatment that could prevent more people from developing the potentially debilitating disease. And they hope it will become a national model.
But experts caution that expanding access to antibiotics to prevent Lyme disease may do more harm than good. Most people who will get the preventative treatment, they say, would likely never have developed Lyme disease. For those who are infected, some doctors worry a prophylactic dose may not be enough to prevent the patient from getting sick. And misuse or overuse of antibiotics can contribute to another major public health problem: antibiotic resistance.
The pharmacy program follows passage of legislation by the Rhode Island General Assembly in 2016 that expands pharmacists role to include initiation of drug therapies under so-called collaborative practice agreements.
“If we can prevent it for anybody,” she said, the effort will be a success.
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Empiric Antibiotic Prophylaxis For Patients With Tick Bites
Am Fam Physician. 2006 Mar 1 73:774-776.
to the editor: I was happy to see the article on the diagnosis of Lyme disease1 in the July 15, 2005, issue of American Family Physician. Although the article1 correctly makes reference to coinfection with human granulocytic ehrlichiosis, it incorrectly identifies the causative organism as Babesia microti . This distinction is a critical one because the treatments for these infections are different. Although ehrlichiosis , like Lyme disease, can be treated with doxycycline , babesiosis is an intracellular parasite treated with antiprotozoal medications in addition to traditional antibiotics .
Further, the article states that empiric antibiotic prophylaxis is not recommended for patients who seek care after a tick bite but who are asymptomatic.1 A recent randomized controlled trial2 demonstrates that a single 200-mg dose of doxycycline, if administered within the first 72 hours after a likely exposure, will prevent approximately 90 percent of the cases of Lyme disease. For physicians, such as myself, who practice in endemic areas, this is a very good option. Because the clinical symptoms of Lyme disease do not appear until well after this three-day window, it is imperative that patients and physicians be aware of this valuable prevention technique. I use this option in my own practice and have found that it decreases the incidence of Lyme disease significantly and gives my patients a much-needed sense of security.