The Infectious Diseases Society of America, American Academy of Neurology, and American College of Rheumatology collaborated to provide new clinical practice guidelines for the prevention, diagnosis, and treatment of Lyme disease, published in Neurology.
The 2020 recommendations for the management of Lyme disease are based on the available evidence; the panel followed a systematic process using a standardized methodology to rate the certainty of the evidence and strength of recommendations. They did so by utilizing the Grading of Recommendations Assessment, Development, and Evaluation approach.
For prevention of tick bites and tick-borne infections, the panel recommends implementing personal protective measures, using repellents, and the immediate removal of attached ticks using a clean, fine-tipped tweezer. Burning an attached tick or using noxious chemicals or petroleum products is discouraged.
Following a tick bite, submitting the removed tick for species identification is recommended, but testing a removed Ixodes tick for Borrelia burgdorferi is not. Prophylactic oral doxycycline therapy is only recommended for adults and children within 72 hours of removal of an identified high-risk tick bite, defined as a tick bite from an identified Ixodes spp. vector species, one that occurred in a highly endemic area, and from a tick that was attached for at least 36 hours. Antibiotic therapy is not recommended in cases of equivocal or low risk. The panel recommends a wait-and-watch approach when the tick bite cannot be classified with a high level of certainty.
The diagnosis of erythema migrans should be based on clinical findings in patients with skin lesions typical of it, while antibody testing should be used in the presence of atypical skin lesions. The recommended antibiotic therapies for erythema migrans include oral doxycycline for 10 days, or 14 day course of amoxicillin or cefuroxime axetil.
For the diagnosis of Lyme neuroborreliosis, the panel recommends serum antibody testing instead of polymerase chain reaction (PCR) or culture of cerebrospinal fluid or serum. Testing for Lyme disease should be considered in patients presenting with various neurologic symptoms, but the panel recommends against routine testing in patients with psychiatric illness.
Intravenous ceftriaxone, cefotaxime, penicillin G, or oral doxycycline are the recommended antibiotic regimens for the treatment of acute neurologic manifestations of Lyme disease without parenchymal involvement of the brain or spinal cord.
Hospital admission with continuous ECG monitoring is recommended for patients with or at risk for severe cardiac complications of Lyme disease. The panel also recommends temporary pacing modalities for symptomatic bradycardia due to Lyme carditis that cannot be managed medically. Additionally, oral antibiotic therapy is recommended for outpatients with Lyme carditis, while intravenous ceftriaxone is recommended initially for hospitalized patients until clinical improvement. After clinical improvement, they can be switched to oral antibiotics.
Serum antibody testing is the recommended diagnostic testing for Lyme arthritis, while PCR may be used when further information is required to guide treatment decisions. 28 days of oral antibiotic should be used for Lyme arthritis. However, in patients with no or minimal response to this initial course of oral antibiotics, the panel suggests a 2 to 4 week course of intravenous ceftriaxone.
The panel recommends against additional antibiotic therapy for persistent or recurrent non-specific symptoms following treatment for Lyme disease in the absence of objective evidence for re-infection or treatment failure.
These guidelines are aimed to provide recommendations for the management of Lyme disease and address clinical questions related to its prevention, diagnosis, and treatment, as well as complications from its neurologic, cardiac, and rheumatic symptoms.
Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical practice guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the prevention, diagnosis and treatment of Lyme disease. Neurology. Published online November 30, 2020. doi:10.1212/WNL.0000000000011151