Treatment of Lyme Disease

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Table of Recommended Antibiotics and Dosages for Treatment of Lyme Disease¹

Symptom	Drug (oral/intravenous)	Adult Dosage	Pediatric Dosage2	Side Effects
Tick Bite	Doxycycline3,4 or observation only	200 mg PO single dose	Age < 8 y: not recommended; Age ≥ 8 y: 4 mg/kg (max. 200 mg/dose)	See below.
ERYTHEMA MIGRANS & OTHER SYMPTOMS OF EARLY DISSEMINATION Alternative:	Doxycycline3,5,6,7 OR	100 mg PO b.i.d.	Age < 8 y: not recommended; Age ≥ 8 y: 4 mg/kg div. b.i.d. (max. 100 mg/dose)	Photosensitivity reactions from sun exposure, pseudomembranous colitis.
	Amoxicillin6,8	500 mg PO t.i.d.	50 mg/kg/day div. t.i.d. (max. 500 mg/dose)	Rash, diarrhea, pseudomembranous colitis.
	Cefuroxime axetil6,8	500 mg PO b.i.d.	30 mg/kg/day div. b.i.d. (max. 500 mg/dose)	Rash, diarrhea, pseudomembranous colitis.
NEUROLOGIC DISEASE Facial nerve palsy More serious CNS disease9	Doxycycline3,5 OR	100 mg PO b.i.d.	Age < 8 y: not recommended; Age ≥ 8 y: 4 mg/kg div. b.i.d. (max. 100 mg/dose)	See above.
	Amoxicillin8	500 mg PO t.i.d.	50 mg/kg/day div. t.i.d. (max. 500 mg/dose)	See above.
	Ceftriaxone OR	2 g/day IV	50-75 mg/kg/day IV (max. 2 g/dose)	Rash, diarrhea, pseudomembranous colitis, biliary lithiasis, risk of sepsis through intravenous catheter.
	Cefotaxime OR	2 g IV given q8h	150-200 mg/kg/day IV div. t.i.d. or div. q.i.d. (max. 6 g/day; max. 2 g/dose)	Rash, diarrhea, pseudomembranous colitis, risk of sepsis through intravenous catheter.
	Penicillin G10	18-24 million units/day IV div. doses given q4h	200,000 – 400,000 units/kg/day IV div. doses given q4h (max. 18-24 million units/day)	Upset stomach, diarrhea, risk of sepsis through intravenous catheter.
CARDIAC DISEASE Mild More serious9,11	Doxycycline3,5 OR	100 mg PO b.i.d.	Age < 8 y: not recommended; Age ≥ 8 y: 4 mg/kg b.i.d. (max. 100 mg/dose)	See above.
	Amoxicillin8	500 mg PO t.i.d.	50 mg/kg/day div. t.i.d. (max. 500 mg/dose)	See above.
	Ceftriaxone OR	2 g/day IV	50-75 mg/kg/day IV (max. 2 g/dose)	See above.
	Cefotaxime OR	2 g IV given q8h	150-200 mg/kg/day IV div. t.i.d. or div. q.i.d. (max. 6 g/day; max. 2 g/dose)	Rash, diarrhea, pseudomembranous colitis, risk of sepsis through intravenous catheter.
	Penicillin G10	18-24 million units/day IV div. doses given q4h	200,000 – 400,000 units/kg/day IV div. doses given q4h (max. 18-24 million units/day)	See above.
ARTHRITIS Mild More serious9	Doxycycline3,5 OR	100 mg PO b.i.d.	Age < 8 y: not recommended; Age ≥ 8 y: 4 mg/kg b.i.d. (max. 100 mg/dose)	See above.
	Amoxicillin8	500 mg PO t.i.d.	50 mg/kg/day div. t.i.d. (max. 500 mg/dose)	See above.
	Ceftriaxone OR	2 g/day IV	50-75 mg/kg/day IV (max. 2 g/dose)	See above.
	Penicillin G10	18-24 million units/day IV div. doses given q4h	200,000 – 400,000 units/kg/day IV div. doses given q4h (max. 18-24 million units/day)	See above.
NOTES: 1 Clinicians generally recommend 14-21 days for oral drugs and 14-28 days for intravenous treatment. Table adapted from Clinical Infectious Diseases 2000; 31(Suppl 1):S1-14. and from Wormser, GP. N Engl J Med 2006; 354:2794-801. 2 Should not exceed adult dosage. 3 Or use tetracycline HCI (acromycin, and others), 250-500 mg q.i.d.;  Doxycycline (and any other tetracyclines) are relatively contraindicated for pregnant and lactating women. 4 A single preventative dose of doxycycline can be used within 72 hours after tick removal for patients age ≥ 8 if the attached tick is identified as an adult or nymphal Ixodes scapularis tick estimated to have been attached for at least 36 hours (on the basis of degree of engorgement with blood or certainty about the time of exposure) and if the local rate of Borrelia burgdorferi infection among ticks is at least 20 percent. If any one of these criteria is not met, then observation is recommended instead. The efficacy of this single preventative dose of doxycycline is unknown for human granulocytic anaplasmosis (HGA) and babesiosis. 5 Doses should be taken with 8 oz. of fluid and with food to reduce risk of esophageal irritation and gastrointestinal intolerance. Effective for HGA. 6 Adult patients who cannot tolerate doxycycline, amoxicillin, or cefuroxime axetil may use the following alternatives (however, these treatments are less effective): azithromycin (500 mg PO daily for 7 to 10 days), clarithromycin (500 mg PO twice daily for 14 to 21 days if patient is not pregnant), or erythromycin (500 mg orally four times per day for 14 to 21 days). Children should use the following recommended dosages: azithromycin, 10 mg / kg daily (max. 500 mg / day); clarithromycin, 7.5 mg / kg twice daily (max. 500 mg per dose); and erythromycin, 12.5 mg / kg four times daily (max. 500 mg / dose). Patients treated with macrolides should be followed closely to ensure resolution of clinical symptoms. 7 Duration of doxycycline treatment for patients presenting erythema migrans (in absence of cardiac or neurological symptoms) is 14 (range: 10-21) days. 8 Not effective for HGA. 9 In late disease, the response to treatment may be delayed for several weeks or months. 10 Patients with impaired renal function should receive a reduced penicillin dosage. 11 A temporary pacemaker may be necessary.

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