New Lyme Disease Guidelines Save

2020 evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was cooperatively developed the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The guideline was developed for primary care physicians and specialists caring for this condition (infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists) in North America.

Tthis guideline is focused on:

• the prevention of Lyme disease
• the diagnosis and treatment of Lyme disease and its complications

The guideline group included a total of 36 panelists representing all 3 societies and patients  Below are selected questions and guidelines from this effort.

II. WHICH DIAGNOSTIC TESTS SHOULD BE USED FOLLOWING A TICK BITE?

• We recommend submitting the removed tick for species identification (good practice statement). We recommend against testing a removed Ixodes tick for B. burgdorferi (strong recommendation, moderate-quality evidence).  Comment: The presence or absence of B. burgdorferi in an Ixodes tick removed from a person does not reliably predict the likelihood of clinical infection.(B)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 (strong recommendation, moderate-quality evidence).

III. WHO SHOULD RECEIVE ANTIBIOTIC PROPHYLAXIS TO PREVENT LYME DISEASE FOLLOWING PRESENTATION WITH A TICK BITE?

• We recommend that prophylactic antibiotic therapy be given only to adults and children within 72 hours of removal of an identified high-risk tick bite, but not for bites that are equivocal risk or low risk (strong recommendation, high-quality evidence).  Comment: If a tick bite cannot be classified with a high level of certainty as a high-risk bite, a wait-and-watch approach is recommended. A tick bite is considered to be high-risk only if it meets the following three criteria: the tick bite was from (a) an identified Ixodes spp. vector species, (b) it occurred in a highly endemic area, and (c) the tick was attached for ≥36 hours.

IV. WHAT IS THE PREFERRED ANTIBIOTIC REGIMEN FOR THE CHEMOPROPHYLAXIS OF LYME DISEASE FOLLOWING A HIGH-RISK TICK BITE?

• For high-risk Ixodes spp. bites in all age groups, we recommend the administration of a single dose of oral doxycycline within 72 hours of tick removal over observation (strong recommendation, moderate-quality evidence).  Comment: Doxycycline is given as a single oral dose, 200 mg for adults and 4.4 mg/kg (up to a maximum dose of 200 mg) for children.

XXI. WHAT IS THE PREFERRED DIAGNOSTIC TESTING STRATEGY FOR LYME ARTHRITIS?

• When assessing possible Lyme arthritis, we recommend serum antibody testing over PCR or culture of blood or synovial fluid/tissue (strong recommendation, moderate quality of evidence).
• In seropositive patients for whom the diagnosis of Lyme arthritis is being considered but treatment decisions require more definitive information, we recommend PCR applied to synovial fluid or tissue rather than Borrelia culture of those samples (strong recommendation, moderate quality of evidence).

XXII. WHAT ARE THE PREFERRED ANTIBIOTIC REGIMENS FOR THE INITIAL TREATMENT OF LYME ARTHRITIS?

• For patients with Lyme arthritis, we recommend using oral antibiotic therapy for 28 days (strong recommendation, moderate-quality evidence).

XXIII. WHAT ARE THE APPROACHES TO PATIENTS IN WHOM LYME ARTHRITIS HAS NOT COMPLETELY RESOLVED?

• In patients with Lyme arthritis with partial response (mild residual joint swelling) after a first course of oral antibiotic, we make no recommendation for a second course of antibiotic versus observation (no recommendation, knowledge gap).  Comment: Consideration should be given to exclusion of other causes of joint swelling than Lyme arthritis, medication adherence, duration of arthritis prior to initial treatment, degree of synovial proliferation versus joint swelling, patient preferences, and cost. A second course of oral antibiotics for up to 1 month may be a reasonable alternative for patients in whom synovial proliferation is modest compared to joint swelling and for those who prefer repeating a course of oral antibiotics before considering IV therapy.
• In patients with Lyme arthritis with no or minimal response (moderate to severe joint swelling with minimal reduction of the joint effusion) to an initial course of oral antibiotic, we suggest a 2- to 4-week course of IV ceftriaxone over a second course of oral antibiotics (weak recommendation, low-quality evidence).

XXIV. HOW SHOULD POST-ANTIBIOTIC (PREVIOUSLY TERMED ANTIBIOTIC-REFRACTORY) LYME ARTHRITIS BE TREATED?

• In patients who have failed one course of oral antibiotics and one course of IV antibiotics, we suggest a referral to a rheumatologist or other trained specialist for consideration of the use of disease modifying anti-rheumatic drugs (DMARDs), biologic agents, intraarticular steroids, or arthroscopic synovectomy (weak recommendation, very low-quality evidence).  Comment: Antibiotic therapy for longer than 8 weeks is not expected to provide additional benefit to patients with persistent arthritis if that treatment has included 1 course of IV therapy.

XXV. SHOULD PATIENTS WITH PERSISTENT SYMPTOMS FOLLOWING STANDARD TREATMENT OF LYME DISEASE RECEIVE ADDITIONAL ANTIBIOTICS?

• For patients who have persistent or recurring nonspecific symptoms such as fatigue, pain, or cognitive impairment following recommended treatment for Lyme disease, but who lack objective evidence of reinfection or treatment failure, we recommend against additional antibiotic therapy (strong recommendation, moderate-quality evidence).  Comment: Evidence of persistent infection or treatment failure would include objective signs of disease activity, such as arthritis, meningitis, or neuropathy.