What Is The Best Antibiotic For Lyme Disease?
Lyme disease causing organism – Borrelia burgdorferi is sensitive to many antibiotics (penicillins, cephalosporins, tetracyclines, macrolides, etc.) and it has not been described secondary resistances or during treatment. Depending on the stage of the disease and the clinical manifestations, one pattern or another is used. In principle, whenever possible, the treatment of choice in the adult is doxycycline orally.
The management of adult patients with early localized or early disseminated Lyme disease, in the presence of migratory erythema and absence of neurological manifestations and/or complete atrioventricular (AV) block, can be performed with 10-21 days of oral doxycycline 100 mg twice a day, 14-21 days of oral amoxicillin 500 mg three times a day or 14-21 days of oral cefuroxime 500 mg twice a day. In case of allergy, intolerance or presence of other contraindications for the use of doxycycline, oral azithromycin 500 mg daily for 7-10 days, oral clarithromycin 500 mg twice daily for 14-21 days, or oral erythromycin 500 mg four times a day for 14-21 days is recommended.
Although antibiotic treatment for early Lyme disease is considered effective, there are a significant proportion of patients who continue to have clinical manifestations despite treatment.
However, to date, there is no evidence to suggest acquired resistance of Borrelia to the antibiotics commonly used in the treatment of Lyme disease. Circumstantial evidence of resistance development, mainly to erythromycin, has been reported in strains of B. burgdorferi isolated from patients with previous exposure to erythromycin. For children under eight years of age in which the use of tetracyclines is contraindicated, the recommended treatment in localized or disseminated early Lyme disease is oral amoxicillin at a dose of 50 mg/kg/day, divided into three doses per day, or oral cefuroxime 30 mg/kg/day in two doses a day. Patients who have an affectation of the Central nervous system require treatment with intravenous ceftriaxone for a maximum of 28 days to ensure adequate penetration of the drug through the blood-brain barrier. The patients who develop cardiac manifestations as atrioventricular blockage or myopericarditis can be treated with parenteral antibiotics or orally for a period of 14 days.
The intra-hospital treatment should be performed with intravenous ceftriaxone 2 g daily and then continue with oral doxycycline as maintenance.
Patients with Lyme arthritis can be treated with oral or intravenous antibiotics; most of them show improvement during the first month of treatment. Oral doxycycline 100 mg twice daily, oral amoxicillin 500 mg three times a day or oral cefuroxime 500 mg twice daily is recommended for 28 days in adult patients in the absence of neurological manifestations.
For patients who persist with rheumatologic manifestations after the first month of treatment, a second four-week schedule with oral doxycycline, or a 2-4 week course of intravenous (IV) ceftriaxone. The application of intraarticular steroids and disease-modifying drugs are reserved for those patients who do not the present resolution of the symptoms despite the administration of intravenous antibiotics and with results of PCR negative for B. burgdorferi in synovial fluid samples. Approximately one 15% of patients experience a “Jarisch-Herxheimer-type reaction” within 24 hours of starting treatment. This reaction is characterized by an exacerbation of systemic symptoms and an increase in the size and number of existing skin lesions. It is important to remind patients that they can remain symptomatic once the treatment is completed and that, in most cases, they will continue to show improvement over time. The treatment of the post-Lyme syndrome is controversial since its pathophysiology is not yet completely known. The post-Lyme syndrome occurs in those patients who have already been treated adequately for Lyme disease, but who continue with residual symptoms, mainly arthralgias, fatigue, and cognitive difficulties.
There is controversy about whether the post-Lyme syndrome represents a chronic infection or only a non-infectious state of chronic fatigue. This has led to the generation of opposite opinions regarding treatment: some advocate prolonged management with antibiotics, while others are opposed to it.