Diagnostic Testing Of Asymptomatic Patients Following Tick Bites
We recommend against testing asymptomatic patients for exposure to B. burgdorferi following an Ixodes spp. tick bite .
Summary of The Evidence.
Following the removal of an Ixodes spp. tick, asymptomatic patients would have negative serologic tests for B. burgdorferi unless the patient had a prior infection. Notably, the background seroprevalence of B. burgdorferi in a highly endemic Lyme disease area was 5% in the mid-1990s and is now even higher, even doubled, in some Lyme disease endemic regions . Although follow-up testing 46 weeks after the tick bite could detect an asymptomatic seroconversion, we recommend against testing as there is insufficient evidence that patients with asymptomatic seropositivity should receive antibiotic therapy.
Rationale for Recommendation.
Serologic testing of asymptomatic patients following a tick bite does not help with treatment decisions. There is currently insufficient evidence that asymptomatic patients with positive serologic tests should receive antibiotic therapy. Available data suggest that patients with asymptomatic seropositivity are much less likely to develop disseminated Lyme disease than are untreated patients with erythema migrans . Moreover, a positive serologic test for Lyme disease near the time of a tick bite most likely represents past exposure or a false positive, as a newly acquired infection would not yet have prompted antibody generation.
Iv Antibiotic Regimen: Cephalosporin Plus Azole Plus Liposomal Cinnamon Clove And Oregano
- ceftriaxone 2 gm IV 2 times a day for 4 days on and 3 days off
- tinidazole 500 mg taken orally 1 pill 2-3 times a day for 4 days on and 3 days off in 7-day cycles
- liposomal cinnamon, clove, and oregano capsules 1 pill 2 times a day
- Various antibiotics can be used as IV. I use this one most commonly because it is the easiest to administer and one of the lowest cost IV regimens. The ceftriaxone is given in a syringe and injected over 10 minutes. This is also a pulse dose regimen . Ceftriaxone could be given daily instead as 2 gm IV 1 time a day.
- I have found various pulse dose regimens of tinidazole to work. These include 2 weeks on and 2 weeks off or in the regimen seen here.
Repellents To Prevent Tick Bites
For the prevention of tick bites, we recommend N,N-Diethyl-meta-toluamide , picaridin, ethyl-3- aminopropionate , oil of lemon eucalyptus , p-methane-3,8-diol , 2-undecanone, or permethrin .
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.
DEET, picaridin, IR3535, OLE, PMD, and 2-undecanone can be applied directly to skin and clothing. Different concentrations and preparations affect their efficacy and duration of activity. In general, products with higher concentrations provide greater and/or longer periods of efficacy compared with lower concentrations , although products containing > 50% DEET do not offer a meaningful increase in protection time over lower concentrations. Permethrin kills ticks on contact but must be applied to clothing. Field studies indicate that clothes sprayed with permethrin or made with pretreated, permethrin-impregnated material provide highly effective protection against tick bites and are more effective compared with clothes treated with DEET .
Rationale for Recommendation.
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History And Physical Examination
The clinical diagnosis of Lyme disease can be straightforward in patients with a history of tick exposure and the characteristic finding of an erythema migrans rash.12 The CDC has defined erythema migrans rash as an expanding red macule or papule that must reach at least 5 cm in size .11 According to the Infectious Diseases Society of America guidelines, erythema migrans rash is the only clinical manifestation sufficient to make the diagnosis of Lyme disease in the absence of laboratory confirmation.20 Although one study concluded that primary care physicians in a Lyme diseaseendemic area of France correctly identified erythema migrans in 72 percent of patients,22 the study was limited by lack of complete clinical information for the participants.
A number of conditions resemble erythema migrans however, the rapid and prolonged expansion of an erythematous lesion is unique to erythema migrans.11 Lesions most often occur at anatomic sites that are unusual for cellulitis and other conditions that mimic erythema migrans therefore, a complete skin examination should be performed before excluding erythema migrans.20
How Is It Treated
Facial palsy is treated with oral antibiotics and Lyme meningitis/radiculoneuritis can either be treated with oral or intravenous antibiotics, depending on severity . Most people with Lyme disease respond well to antibiotics and fully recover. Varying degrees of permanent nervous system damage may develop in people who do not receive treatment in the early stages of illness and who develop late-stage Lyme disease.
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Prevention Of Tick Bites
The best currently available method for preventing infection with B. burgdorferi and other Ixodes-transmitted infections is to avoid tick-infested areas . If exposure to I. scapularis or I. pacificus ticks is unavoidable, a number of measures may help to decrease the risk that ticks will attach and subsequently transmit infection. The use of protective clothing may interfere with attachment by ticks by increasing the time required for ticks to find exposed skin, thus facilitating their recognition and removal. By wearing light-colored clothing , persons in areas of endemicity may also be more likely to see ticks before they have attached.
Daily inspections of the entire body to locate ticks also provide an opportunity to prevent transmission of tick-borne infections . Attached ticks should be removed promptly with fine-toothed forceps, if possible . Tick and insect repellents applied to the skin and clothing provide additional protection .
Antibiotic Treatment Of Lyme Carditis
Table 1. Mild
|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||14-21||3|
Table 2. Severe *
|2 grams intravenously, once a day*||N/A|
|5075 mg/kg intravenously, once a day*||2 grams per day||1421||3 5 12|
*After resolution of symptoms and high-grade AV block, consider transitioning to oral antibiotics to complete treatment course .
Tissue sample from a patient who died of Lyme carditis. Image taken using Warthin-Starry stain at 158X.
The heart on the top shows how an electrical signal flows from the atrioventricular node to the chambers in the lower half of the heart, called the ventricles.
The heart on the bottom shows a case of third degree heart block. In this illustration, the electrical signal from the AV node to the ventricle is completely blocked. When this happens, the electrical signal of the atria does not transmit to the ventricles , which causes the ventricles to beat at their own, slower rate.
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What Is Lyme Carditis
Lyme carditis occurs when Lyme disease bacteria enter the tissues of the heart. This can interfere with the normal movement of electrical signals from the hearts upper to lower chambers, a process that coordinates the beating of the heart. The result is something physicians call heart block, which can vary in degree and change rapidly. Lyme carditis occurs in approximately one out of every hundred Lyme disease cases reported to CDC.
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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Azlocillin Comes Out On Top
The drug, which is not on the market, was tested in mouse models of Lyme disease at seven-day, 14-day and 21-day intervals and found to eliminate the infection. For the first time, azlocillin was also shown to be effective in killing drug-tolerant forms of B. burgdorferi in lab dishes, indicating that it may work as a therapy for lingering symptoms of Lyme disease.
Pothineni and Rajadas have patented the compound for the treatment of Lyme disease and are working with a company to develop an oral form of the drug. Researchers plan to conduct a clinical trial.
Rajadas is also a professor of bioengineering and therapeutic sciences at the University of California-San Francisco.
Other Stanford co-authors are Hari-Hara S. K. Potula, PhD, senior research scientist postdoctoral scholars Aditya Ambati, PhD, and Venkata Mallajosyula, PhD senior research scientist Mohammed Inayathullah, PhD and intern Mohamed Sohail Ahmed.
A researcher at Loyola College in India also contributed to the work.
The study was funded by the Bay Area Lyme Foundation and Laurel STEM Fund.
- Tracie White
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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Why Are Antibiotics The First Line Of Treatment For Lyme Disease
The use of antibiotics is critical for treating Lyme disease. Without antibiotic treatment, the Lyme disease causing bacteria can evade the host immune system, disseminate through the blood stream, and persist in the body. Antibiotics go into the bacteria preferentially and either stop the multiplication of the bacteria or disrupt the cell wall of the bacteria and kill the bacteria . By stopping the growth or killing the bacteria the human host immune response is given a leg up to eradicate the residual infection. Without antibiotics, the infection in Lyme disease can evade the host immune system and more readily persist.
What Are The Side Effects Of Lyme Disease Treatments
Antibiotics, like all medications, have the potential for side effects. Any antibiotic can cause skin rashes, and if an itchy red rash develops while on antibiotics, a patient should see their physician. Sometimes symptoms worsen for the first few days on an antibiotic. This is called a Herxheimer reaction and occurs when the antibiotics start to kill the bacteria. In the first 24 to 48 hours, dead bacterial products stimulate the immune system to release inflammatory cytokines and chemokines that can cause increased fever and achiness. This should be transient and last no more than a day or two after the initiation of antibiotics.
The most common side effect of the penicillin antibiotics is diarrhea, and occasionally even serious cases caused by the bacteria Clostridium difficile. This bacterial overgrowth condition occurs because antibiotics kill the good bacteria in our gut. It can be helpful to use probiotics to restore the good bacteria and microbiome balance.
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Antimicrobials That Kill Growing Phase Cysts
Intracellular and Extracellular
Note: I work with the following agents as anti-cyst agents based on the mechanism by which these antibiotics work and some scientific experiments. For the Rifamycins, there are no laboratory experiments showing these agents work against cysts. Clinically, I see great benefit in using the Rifamycins as my anti-cyst agents – so I list them here.
- Rifampin 300 mg 2 pills 1 time a day or 1 pill 2 times a day
- Rifabutin 150 mg 2 pills 1 time a day
- Tinidazole 500 mg 1 pill 2 or three times a day usually pulsed for four days on then three days off of each 7 days
- Metronidazole 500 mg 1 pill 2 or three times a day usually pulsed for four days on then three days off of each 7 days.
- Grapefruit seed extract 250 mg 1 pill 2 times a day. Note this is an herbal antibiotic that I find as effective as the prescription options in this list.
Lyme Disease: Clinical Diagnosis And Treatment
Hatchette TF1,2,3*, Davis I1,2, Johnston BL2
1 Department of Pathology and Laboratory Medicine, Capital District Health Authority , Halifax, Nova Scotia
2 Department of Medicine, CDHA and Dalhousie University, Halifax, Nova Scotia
3 Department of Pathology, Dalhousie University, Halifax, Nova Scotia
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Herbal And Prescription Antimicrobials By Function
Be aware the doses I provide below are for adults. These same prescriptions can be used with children but have lower doses. For pediatric dosing, talk with your family physician or pediatrician. Tetracyclines can be used in children under eight, but there is a risk of tooth staining. This staining seems not to be an issue if they are used for a month or less.
Rationale For The Recommendations
Serum antibody testing is the most sensitive diagnostic test in early Lyme neuroborreliosis, whereas culture or PCR tests performed on blood or CSF lack acceptable clinical sensitivity. An elevated CSF:serum antibody index can support the diagnosis of CNS Lyme neuroborreliosis and may rarely be elevated in early disease before peripheral blood serology is positive. A normal antibody index value, however, does not exclude the diagnosis. Measurement of CXCL13 has not been sufficiently studied or standardized to recommend at present.
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Clinical Judgment And Shared Decision
- 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.
Lyme Disease Surveillance In Canada
Lyme disease became a national notifiable disease in December 2009.
Canada continues to monitor the evolving geographic distribution and prevalence of infected ticks and cases of Lyme disease. Therefore, you must report clinically diagnosed or laboratory-confirmed cases to your provincial or territorial public health authorities.
Health professionals in Canada play a critical role in identifying and reporting cases of Lyme disease. See the surveillance section for more information on surveillance in Canada.
Consult the national case definition for additional information.
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Herbs For Lyme Disease Treatment
Herbs have been used as a medicinal treatment for thousands of years. Many people have turned to herbal remedies to help provide relief from Lyme disease when antibiotics didn’t completely help eliminate symptoms.
One research study found that a combination of doxycycline and baicalein provides additional healing benefits. According to a 2020 laboratory study, seven herbal medicines have been shown to kill B. burgdorferi in test tubes:
- Cryptolepis sanguinolenta
- Scutellaria baicalensis
Garlic has antibacterial effects and may help prevent tick bites. One study determined that people who took garlic supplements reported fewer tick bites than the placebo group. Garlic essential oil has been shown to eliminate the bacterium that causes Lyme disease.
Garlic can interact with certain medications, so speak with your healthcare provider before using it to prevent or treat Lyme disease.
Steviaa natural sweetener and sugar substitute derived from the leaves of the Stevia rebaudiana plantmay be effective in treating Lyme disease. A study published in the European Journal of Microbiology and Immunology discovered that stevia extracts are more effective in killing Lyme disease bacterium in the lab than the standard antibiotics.
Rationale For The Recommendation
In untreated patients with erythema migrans of short duration , none of the currently available serologic or direct detection tests for Lyme disease is sufficiently sensitive for accurate diagnostic use, necessitating clinical diagnosis. However, in patients with skin lesions that are atypical for erythema migrans, laboratory testing may aid in the diagnostic assessment . In such cases, if the patient will not be treated empirically with antimicrobial therapy, the most practical approach is to perform serologic testing on an acute-phase serum sample or on paired samples collected at least 23 weeks apart. An alternative to paired serologic testing is to attempt direct detection of B. burgdorferi in the skin lesion or blood. These methods offer the possibility of more timely diagnosis direct detection methods are generally more sensitive at the time of initial clinical presentation with erythema migrans, compared with acute-phase serologic testing. However, practical matters limit their use and availability recognition of these limitations has informed our testing recommendations.
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