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What Is The Prophylactic Treatment For Lyme Disease

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Lyme Disease Antibiotic Treatment Research

Lyme Disease: The Latest Guidelines on Testing, Prophylaxis, and Treatment

For early Lyme disease, a short course of oral antibiotics, such as doxycycline or amoxicillin, cures the majority of cases. In more complicated cases, Lyme disease can usually be successfully treated with three to four weeks of antibiotic therapy.

After being treated for Lyme disease, a minority of patients may still report non-specific symptoms, including persistent pain, joint and muscle aches, fatigue, impaired cognitive function, or unexplained numbness. These patients often show no evidence of active infection and may be diagnosed with post-treatment Lyme disease syndrome .

Multiple clinical trials, funded by NIH and others, have shown no benefit to additional IV antibiotic treatment in patients with Lyme disease, although the interpretation of those results have been challenged by some.

Possible Complications To Watch For With Lyme Disease

Talk to your veterinarian if you have any questions or concerns about your dogs condition.

  • Some dogs who take antibiotics can develop loss of appetite, vomiting and diarrhea.
  • Once infected, a dog will always have the bacteria that cause Lyme disease in his or her body. Therefore, relapses are possible, and owners should be on the lookout for unexplained fever, swollen lymph nodes, and/or lameness.
  • A small percentage of dogs develop kidney failure as a result of Lyme disease. Clinical signs include vomiting, weight loss, poor appetite, lethargy, increased thirst and urination, and abnormal accumulations of fluid within the body.

What Are The Risk Factors For Post Treatment Lyme Disease

Risk factors for Post Treatment Lyme Disease include:

  • Delay in diagnosis
  • Increased severity of initial illness
  • Presence of neurologic symptoms

Increased severity of initial illness, the presence of neurologic symptoms, and initial misdiagnosis increase the risk of Post Treatment Lyme Disease. PTLD is especially common in people that have had neurologic involvement. The rates of Post Treatment Lyme Disease after neurologic involvement may be as high as 20% or even higher. Other risk factors being investigated are genetic predispositions and immunologic variables.

In addition to Borrelia burgdorferi, the bacteria that causes Lyme disease, there are several other tick-borne co-infections that may also contribute to more prolonged and complicated illness.

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What You Should Know About Blacklegged Tick Bites

When it comes to Lyme and other tick-borne illness, prevention is the best form of medicine. When spending time in areas where ticks may be present, wear long sleeves and pants, tuck your pants into your socks, and wear tick repellent containing DEET, picaridin, IR3535, or oil of lemon eucalyptus. Pretreat outdoor clothing and gear with permethrin, an insecticide that kills ticks on contact. Clothing can be treated at home with sprays or dips that are effective for 2-6 weeks . Always check yourself for ticks after each potential exposure check pets, even those treated with tick repellents, after every trip outside. For more on tick bite prevention, see our Lyme brochure.

If you are bitten by a tick, here is information you should have.

The information below is for educational purposes only. It is not intended to replace or supersede patient care by a healthcare provider. If you suspect the presence of a tick-borne illness, you should consult a healthcare provider who is familiar with the diagnosis and treatment of tick-borne diseases.

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Notes On Serological Tests

Vector

For patients with illness lasting over a month, only IgG testing should be performed . A positive IgM test alone is not sufficient to diagnose current disease in these patients.

Due to antibody persistence, a positive serological test cannot distinguish between active and past infection.

Serological tests:

  • should not be done as a test of cure
  • cannot be used to measure treatment response

The EIA test:

  • may yield false-positive results when used as a stand-alone test
  • may cross-react with antibodies to commensal or pathogenic spirochetes
  • there may be some viral infections for certain autoimmune diseases

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Lyme Disease Prophylaxis After Tick Bite

In areas that are highly endemic for Lyme disease, a single prophylactic dose of doxycycline may be used to reduce the risk of acquiring Lyme disease after a high-risk tick bite.

Benefits of prophylaxis may outweigh risks when all of the following circumstances are present:

  • Where the tick bite occurred, are ticks likely to be infected with Borrelia burgdorferi?
  • Was the tick removed within the last 72 hours?
  • Was the ticks body engorged with blood ?
  • Flat

  • Was the tick an Ixodes tick?
  • Nymph

    Adult

  • Is doxycycline safe for the patient? Considerations include allergy to doxycycline, pregnancy, and lactation.
  • Antibiotic treatment following a tick bite is not recommended as a means to prevent anaplasmosis, babesiosis, ehrlichiosis, Rocky Mountain spotted fever, or other rickettsial diseases. Instead, persons who experience a tick bite should be alert for symptoms suggestive of tickborne illness and consult a physician if fever, rash, or other symptoms of concern develop.

    What To Expect At Home

    Home care for dogs with Lyme disease is relatively straightforward. Doxycycline is usually given by mouth twice daily for at least 30 days. Improvement in the dogs symptoms should be noted within 24-48 hours. If the dogs condition fails to improve in 72 hours or worsens at any time, call your veterinarian.

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    What Are The Clinical Manifestations Of Ld

    Clinical manifestations are divided into early, localized disease, and later disease.

    Early, localized disease: Erythema migrans a rash at the site of a recent tick bite is the most common presentation in children and adults . EM typically develops seven to 14 days after a tick bite. EM is usually > 5 cm and mainly flat. There may be central clearing or some bluish discoloration but a classic bulls eye is uncommon. EM is usually asymptomatic but is not painful to the touch, like a cellulitis. EM can be confused with a localized hypersensitivity reaction from a tick or insect bite, which is usually swollen, smaller in size and pruritic). There can be either a single erythema migrans rash or multiple rashes without extracutaneous manifestations. However, fever, malaise, headache, mild neck stiffness, myalgia and arthralgia often accompany EM.

    Without treatment, EM resolves spontaneously over a four-week period, on average.

    Later disease: Approximately 20% of children with LD first present to a health care provider with extracutaneous signs or symptoms that are compatible with LD. These cases may also have a recent past history of EM lesions and non-specific low-grade fever, myalgia, and fatigue upon questioning further.

    Figure 4) Erythema migrans rash showing the classic bulls eye form. Reproduced from reference 1 © All rights reserved. With permission from the Minister of Health, 2014

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    How Prevalent Is Ld In Canada

    Lyme Disease Prophylaxis After Tick Bite

    Black-legged tick populations are well established in parts of British Columbia, Manitoba, Ontario, Quebec, New Brunswick and Nova Scotia, and may be expanding. Migratory birds can bring infected ticks into nonendemic areas, and people may also become infected while travelling to other endemic areas in North America and Europe. In 2009, LD became a nationally reportable disease. The number of reported cases has increased from 128 in 2009 to an estimated 500 in 2013.

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    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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    How Can Ld Be Prevented

    Physicians should be aware of the epidemiology of tick-borne LD in their area, and recommend some basic precautions for families living, hiking or camping in rural or wooded areas where they may be exposed to ticks.

    • Where play spaces adjoin wooded areas, landscaping can reduce contact with ticks. A pictogram from the Centers for Disease Control and Prevention is available at: www.cdc.gov/lyme/prev/in_the_yard.html
    • Apply 20% to 30% DEET or icaridin repellents. Repellents can be applied to clothing as well as to exposed skin. Always read and follow label directions.
    • Do a full body check every day for ticks. Promptly remove ticks found on yourself, children and pets. Shower or bathe within two hours of being outdoors to wash off unattached ticks.

    For more information on how to prevent tick bites, refer to a recent practice point from the Canadian Paediatric Society at: www.cps.ca/en/documents/position/preventing-mosquito-and-tick-bites.

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    Symptoms Of Post Treatment Lyme Disease

    • Include severe fatigue, musculoskeletal pain, & cognitive problems
    • Can significantly impact patients health and quality of life
    • Can be debilitating and prolonged

    Our research indicates the chronic symptom burden related to PTLD is significant. Although often invisible to others, the negative impact on quality of life and daily functioning is substantial for PTLD sufferers.

    The chronic symptom burden related to Lyme disease is considerable, as shown on the left side of the graph above, and statistically significantly greater than the aches and pains of daily living experienced by the control group, on the right.

    Borrelia Burgdorferi Infectious Cycle

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    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.

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    What Is The Treatment For Lyme Disease

    The first-line standard of care treatment for adults with Lyme disease is doxycycline, a tetracycline antibiotic. Other antibiotics that have activity against borrelia include the penicillin-like antibiotic, amoxicillin, and the second generation cephalosporin, Ceftin. The mainstay of treatment is with oral antibiotics, but intravenous antibiotics are sometimes indicated for more difficult to treat cases of neurologic-Lyme disease, such as meningitis, and cases of late Lyme arthritis.

    Should I Call My Doctor Right Away Or Wait To See If I Develop Symptoms

    ILADS recommends immediately contacting your health care provider. There are steps you can take to prevent a Lyme infection, as explained below. The onset of Lyme disease symptoms can be overlooked or mistaken for other illnesses. Once symptoms are more evident, the disease may have already entered the central nervous system, and could be hard to cure. Immediate care may prevent this from happening.

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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.

    Q3 Should Patients With Persistent Manifestations Of Lyme Disease Be Retreated With Antibiotics

    Preventative shot for Lyme disease in clinical trial

    Organizational values

    The panel placed a high value on reducing the morbidity associated with chronic Lyme disease and improving the patients QoL as well as on the need for individualized risk/benefit assessment and informed shared decision-making. The panel also placed a high value on the ability of the clinician to exercise clinical judgment. In the view of the panel, guidelines should not constrain the treating clinician from exercising clinical judgment in the absence of strong compelling evidence to the contrary.

    Recommendation 3a

    Clinicians should discuss antibiotic retreatment with all patients who have persistent manifestations of Lyme disease. These discussions should provide patient-specific riskbenefit assessments for each treatment option and include information regarding C. difficile infection and the preventative effect of probiotics . .

    Role of patient preferences

    Low: The benefits of educating patients about the potential benefits of retreatment and the risks associated with various treatment options, including not treating, clearly outweigh any attendant risks associated with education.

    Recommendation 3b

    Treatment options are extensive and choices must be individualized. Each of these options would benefit from further study followed by a GRADE assessment of the evidence and consideration of associated risks and benefits, but until this information is available, clinicians may act on the currently available evidence.

    Role of patient preferences

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    Questions To Ask Your Veterinarian

    If your dog has a positive Lyme test but no symptoms of the disease or protein in the urine, ask your veterinarian why he or she is recommending treatment. Experts currently recommend against antibiotic therapy under these circumstances because the dogs immune system is holding the bacteria in check and antibiotics are unable to eliminate the infection.

    Dogs who have contracted Lyme disease do not develop prolonged, protective immunity and can be reinfected at a later date. Talk to your veterinarian about how best to prevent future infections. Options include measures to prevent the ticks that carry Lyme disease from biting your dog and Lyme vaccination.

    Prevention Of Lyme Disease

    The key to preventing Lyme disease is to avoid tick bites and prolonged tick attachment. Basic protection measures include avoiding risky areas, wearing long sleeves and pants, tucking pants into socks, and using clothing treated with permethrin. Unlike permethrin, many effective repellants are safe to apply to skin including N,N-diethyl- m-toluamide , picaridin, ethyl-3- aminopropionate , oil of lemon eucalyptus, p-methane-3,8-diol , and 2-undecanone.

    Because spirochete transmission occurs after at least 36 hours of attachment, ticks should be removed promptly after discovery. After exposure to a tick habitat, thorough tick checks of exposed and intertriginous skin, bathing within two hours, and drying clothes for at least one hour on high heat can prevent disease. Ticks can be removed with tweezers and placed in a bag for later identification. To remove ticks, fine-tipped tweezers should be used to grasp the mouth parts as close to the skin as possible and steady traction applied directly away from the skin. Because B. burgdorferi in ticks does not predict infection in humans, testing ticks is not recommended.

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    If Bitten By A Tick Should I Consider Immediate Antibiotics To Prevent Lyme Disease

    ILADS recommends that prophylaxis be discussed with all who have had a blacklegged tick bite.An appropriate course of antibiotics has been shown to prevent the onset of infection.

    When the decision is made to use antibiotic prophylaxis, ILADS recommends 20 days of doxycycline . The decision to treat a blacklegged tick bite with antibiotics often depends on where in the country the bite occurred, whether there was evidence that the tick had begun feeding, and the age of the person who was bitten. Based on the available evidence, and provided that it is safe to do so, ILADS recommends a 20-day course of doxycycline.

    Patients should also know that although doxycycline can prevent cases of Lyme disease, ticks in some areas carry multiple pathogens, some of which, including Babesia, Powassan virus, and Bartonella, are not responsive to doxycycline. This means a person could contract a tick-borne illness despite receiving antibiotic prophylaxis for their known tick bite.

    ILADS recommends against single-dose doxycycline. Some doctors prescribe a single 200 mg dose of doxycycline for a known bite. However, as discussed in detail in the guidelines, this practice is based on a flawed study that has never been replicated. Read more in the ILADS treatment guidelines.

    The bottom line: If you have been bitten by a blacklegged tick, you should discuss immediate antibiotic treatment with your provider as a possible course of action.

    Data Sources And Study Selection

    Treatment of Lyme Disease

    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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