Lyme disease

The information below is based on NICE NG95 Lyme disease (April 2018).

The bacteria that cause Lyme disease are transmitted by the bite of an infected tick, but most tick bites do not transmit Lyme disease. The prompt, correct removal of the tick reduces the risk of contamination (Public Health England information on removing ticks).

Do not diagnose Lyme disease in people without symptoms, even if they have had a tick bite.

If a person presents with symptoms that suggest the possibility of Lyme disease, explore how long the person has had symptoms and their history of possible tick exposure.

Treat Lyme disease in people with erythema migrans, a red rash that; increase in size and may sometimes have a central clearing, is not usually itchy, hot, or painful, usually becomes visible from one to four weeks (but can appear from three days to three months) after a tick bite and lasts for several weeks, is usually at the site of a tick bite.

Serology is not required if erythema migrans is present, in all other cases, serological testing is required (see below).

For additional guidance on the diagnosis of Lyme disease, refer to NICE NG95.

Serology

Serology should ideally be taken more than 4-6 weeks after the potential exposure. Early serology should be considered if patients present with symptoms suggestive of Lyme disease.

Early serology can lead to false negative results, discuss with microbiology if Lyme is strongly suspected but serology is negative.

If an exposure event is known the details should be included. In general treatment should only follow confirmed diagnosis.

For Exeter Clinical Laboratory Serology FAQs, see here

Specialist advice

Discuss the diagnosis and management of Lyme disease in children and young people under 18 years with a specialist, unless they have a single erythema migrans lesion and no other symptoms, then treat as Lyme disease. Children under 9 years of age should be referred to a specialist.

If an adult diagnosed with Lyme disease has focal symptoms, consider a discussion with or referral to a specialist, without delaying treatment.

Jarisch-Herxheimer reaction

Some patients who are starting antibiotics of Lyme disease may have a Jarisch-Herxheimer reaction to treatment. Explain that:

  • this causes a worsening of symptoms early in treatment
  • it can happen when large numbers of bacteria in the body are killed
  • it does not happen to everyone treated for Lyme disease
  • they should contact their doctor and keep taking their antibiotics if their symptoms worsen.

​Adults and young people aged 12 years and over

Discuss the diagnosis and management of Lyme disease in children and young people under 18 years with a specialist, unless they have a single erythema migrans lesion and no other symptoms, then treat as Lyme disease.

If an adult with Lyme disease has focal symptoms, consider a discussion with or referral to a specialist, without delaying treatment.

Lyme disease without focal symptoms

Erythema migrans and/or non-focal symptoms
Doxycycline
  • 100mg twice daily, or
  • 200mg daily for 21 days
  • Be aware of the risk of photosensitivity, patients should avoid exposure to direct sunlight
Amoxicillin
  • 1g three times a day for 21 days
Azithromycin (unlicensed indication)
  • 500mg daily for 17 days
  • Do not use azithromycin to treat people with cardiac abnormalities associated with Lyme disease because of its effect on QT interval.

See section: 5.1.1 Penicillins, 5.1.3 Tetracyclines, 5.1.5 Macrolides

Lyme disease with focal symptoms

Affecting cranial nerves or peripheral nervous system
Doxycycline
  • 100mg twice daily, or
  • 200mg daily for 21 days
  • Be aware of the risk of photosensitivity, patients should avoid exposure to direct sunlight
Amoxicillin
  • 1g three times a day for 21 days
Affecting the central nervous system

Admit to secondary care for consideration of intravenous ceftriaxone (2g twice daily, or 4g daily), via outpatient or home parenteral antibiotic therapy service where available. When patients are stabilised, a switch to oral doxycycline (200mg twice daily, or 400mg once daily) may be considered. Total antibiotic course length 21 days.

Lyme arthritis or acrodermatitis chronica atrophicans
Doxycycline
  • 100mg twice daily, or
  • 200mg daily for 28 days
  • Be aware of the risk of photosensitivity, patients should avoid exposure to direct sunlight
Amoxicillin
  • 1g three times a day for 28 days

If doxycycline or amoxicillin are not suitable, admit to secondary care for consideration of intravenous ceftriaxone 2g daily for 28 days, via outpatient or home parenteral antibiotic therapy service where available.

Lyme carditis

Haemodynamically stable:

Doxycycline
  • 100mg twice daily, or
  • 200mg daily for 21 days
  • Be aware of the risk of photosensitivity, patients should avoid exposure to direct sunlight

If doxycycline is not suitable, admit to secondary care for consideration of intravenous ceftriaxone 2g daily for 21 days, via outpatient or home parenteral antibiotic therapy service where available.

Haemodynamically unstable:

Admit patients who are haemodynamically unstable to secondary care for consideration of intravenous ceftriaxone 2g daily, via outpatient or home parenteral antibiotic therapy service where available. When patients are stabilised, a switch to oral doxycycline (100mg twice daily, or 200mg once daily) may be considered. Total antibiotic course length 21 days.

See section: 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.3 Tetracyclines

​Children aged under 12 years

Discuss the diagnosis and management of Lyme disease in children and young people under 12 years with a specialist, unless aged 9 to 12 years with a single erythema migrans lesion and no other symptoms, then treat as Lyme disease.

Aged under 9 years

Refer to a specialist.

Aged 9 to 12 years with single erythema migrans lesion

Doxycycline
  • Body weight 45kg and under: 5mg/kg in two divided doses on day 1 followed by 2.5mg/kg daily in one or two divided doses for a total of 21 days
  • For severe infections, up to 5mg/kg daily for 21 days
  • Be aware of the risk of photosensitivity, patients should avoid exposure to direct sunlight
Amoxicillin
  • Body weight 33kg and under: 30mg/kg three times daily for 21 days
Azithromycin (unlicensed indication)
  • Body weight 50kg and under: 10mg/kg daily for 17 days
  • Do not use azithromycin to treat people with cardiac abnormalities associated with Lyme disease because of its effect on QT interval.

Children weighing more than the amounts specified should be treated as per doses in adults and young people aged 12 years and over (see above).

See section: 5.1.1 Penicillins, 5.1.3 Tetracyclines, 5.1.5 Macrolides

Aged 9 to 12 years with multiple erythema migrans lesions, and/or any other focal or non-focal symptoms

Children presenting with multiple lesions, and/or focal or non-focal symptoms should be referred to a specialist.

​Lyme disease and pregnancy

Discuss the diagnosis and management of Lyme disease in patients who are pregnant with a specialist without delaying treatment

Assess and diagnose Lyme disease during pregnancy in the same way as for people who are not pregnant. Refer also to NICE guidance on management for women with Lyme disease during pregnancy and their babies. The UK teratology information service website Best Use of Medicines in Pregnancy (BUMPS) is also useful.

If an adult with Lyme disease has focal symptoms, consider a discussion with or referral to a specialist, without delaying treatment.

For penicillin allergy, seek specialist advice.

Lyme disease without focal symptoms

Erythema migrans and/or non-focal symptoms
Amoxicillin
  • 1g three times a day for 21 days

See section: 5.1.1 Penicillins

Lyme disease with focal symptoms

Affecting cranial nerves or peripheral nervous system
Amoxicillin
  • 1g three times a day for 21 days
Affecting the central nervous system

Admit to secondary care for consideration of intravenous ceftriaxone (2g twice daily, or 4g once daily) for 21 days, via outpatient or home parenteral antibiotic therapy service where available.

Lyme arthritis or acrodermatitis chronica atrophicans
Amoxicillin
  • 1g three times a day for 28 days

If amoxicillin is not suitable, admit to secondary care for consideration of intravenous ceftriaxone 2g daily for 28 days, via outpatient or home parenteral antibiotic therapy service where available.

Lyme carditis

Admit to secondary care for consideration of intravenous ceftriaxone 2g twice daily for 21 days, via outpatient or home parenteral antibiotic therapy service where available.

See section: 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams

 

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