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| __NOTOC__ | | __NOTOC__ |
| {{Lyme disease}}
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| {{CMG}}
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| ==Overview==
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| The mainstay of therapy for Lyme disease is antimicrobial therapy. Antimicrobial therapy may include either [[doxycycline]], [[amoxicillin]], [[cephalosporin]]s, or [[macrolide]]s. Individuals who remove attached ticks should be monitored closely for signs and symptoms of tick-borne diseases for up to 30 days.
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| ==Medical Therapy==
| | {{CMG}}; {{AE}} {{Anmol}} |
| ===Lyme boreliosis (non-neuroborreliosis)===
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| '''Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for treatment of Lyme disease<ref>{{cite journal|year=2006|title=The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America|url=|journal=Clin. Infect. Dis.|volume=43|issue=9|pages=1089–134|doi=10.1086/508667|pmid=17029130|vauthors=Wormser GP, Dattwyler RJ, Shapiro ED, Halperin JJ, Steere AC, Klempner MS, Krause PJ, Bakken JS, Strle F, Stanek G, Bockenstedt L, Fish D, Dumler JS, Nadelman RB}}</ref>'''
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| * '''1 Early localized Lyme disease'''
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| :* 1.1 '''Erythema migrans'''
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| ::* 1.1.1 '''Adult'''
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| :::* Preferred regimen (1): [[Doxycycline]] 100 mg PO bid for 10-21 days '''(avoid in pregnancy)'''
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| :::* Preferred regimen (2): [[Amoxicillin]] 500 mg PO tid for 14-21 days
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| :::* Preferred regimen (3): [[Cefuroxime axetil]] 500 mg bid for 14-21 days
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| :::* Alternative regimen (1): [[Azithromycin]] 500 mg PO qd for 7–10 days
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| :::* Alternative regimen (2): [[Clarithromycin]] 500 mg PO bid for 14–21 days '''(avoid in pregnancy)'''
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| :::* Alternative regimen (3): [[Erythromycin]] 500 mg PO qid for 14–21 days
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| ::* 1.1.2 '''Pediatric'''
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| :::* 1.1.2.1 '''children < 8 years of age'''
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| ::::* Preferred regimen (1): [[Amoxicillin]] 50 mg/kg PO per day in 3 divided doses (maximum, 500 mg per dose)
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| ::::* Preferred regimen (2): [[Cefuroxime axetil]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
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| ::::* Alternative regimen (1): [[Azithromycin]] 10 mg/kg PO qid (maximum, 500 mg per day)
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| ::::* Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO bid (maximum, 500 mg per dose)
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| ::::* Alternative regimen (3): [[Erythromycin]] 12.5 mg/kg PO qid (maximum, 500 mg per dose)
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| ::*1.1.2.2 '''children ≥ 8 years of age'''
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| ::::* Preferred regimen (1): [[Doxycycline]] 4 mg/kg PO per day in 2 divided doses （maximum, 100 mg per dose）
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| ::::* Alternative regimen (1): [[Azithromycin]] 10 mg/kg PO qid (maximum, 500 mg per day)
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| ::::* Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO bid (maximum, 500 mg per dose)
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| ::::* Alternative regimen (3): [[Erythromycin]] 12.5 mg/kg PO qid (maximum, 500 mg per dose)
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| :* 2. '''When erythema migrans cannot be reliably distinguished from community-acquired bacterial cellulitis'''
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| ::* 2.1.1 '''Adult'''
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| ::** Preferred regimen (1): [[Amoxicillin-Clavulanate]] 500 mg PO tid
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| ::* 2.1.2 '''Pediatric'''
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| ::** Preferred regimen (1): [[Amoxicillin-Clavulanate]] 50 mg/kg per day in 3 divided doses (maximum, 500 mg per dose)
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| * 2 '''Early disseminated Lyme disease'''
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| ** 2.1 '''Lyme carditis<ref>{{Cite journal|doi=10.1086/508667|issn=1537-6591|volume=43|issue=9|pages=1089–1134|last1=Wormser|first1=Gary P.|last2=Dattwyler|first2=Raymond J.|last3=Shapiro|first3=Eugene D.|last4=Halperin|first4=John J.|last5=Steere|first5=Allen C.|last6=Klempner|first6=Mark S.|last7=Krause|first7=Peter J.|last8=Bakken|first8=Johan S.|last9=Strle|first9=Franc|last10=Stanek|first10=Gerold|last11=Bockenstedt|first11=Linda|last12=Fish|first12=Durland|last13=Dumler|first13=J. Stephen|last14=Nadelman|first14=Robert B.|title=The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America|journal=Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America|date=2006-11-01|pmid=17029130}}</ref>'''
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| **: '''Note (1):''' Parenteral regimen is recommended at the start of therapy for patients who have been hospitalized for cardiac monitoring; oral regimen may be substituted to complete a course of therapy or to treat ambulatory patients.
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| **: '''Note (2)''': A temporary pacemaker may be required for patients with advanced heart block.
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| **: '''Note (3):''' Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifest
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| *** 2.1.1 '''Adult'''
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| **** Parenteral regimen
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| ***** Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 (14–21) days
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| ***** Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 14 (14–21) days
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| ***** Alternative regimen (2): [[Penicillin G]] 18–24 million U/day IV q4h for 14 (14–21) days
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| **** Oral regimen
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| ***** Preferred regimen (1): [[Amoxicillin]] 500 mg tid for 14 (14–21) days
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| ***** Preferred regimen (2): [[Doxycycline]] 100 mg bid for 14 (14–21) days
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| ***** Preferred regimen (3): [[Cefuroxime]] 500 mg bid for 14 (14–21) days
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| ***** Alternative regimen (1): [[Azithromycin]] 500 mg PO qid for 7–10 days
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| ***** Alternative regimen (2): [[Clarithromycin]] 500 mg PO bid for 14–21 days (avoid in pregnancy)
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| ***** Alternative regimen (3): [[Erythromycin]] 500 mg PO qid for 14–21 days
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| *** 2.1.2 '''Pediatric'''<ref>{{Cite journal| doi = 10.1086/508667| issn = 1537-6591| volume = 43| issue = 9| pages = 1089–1134| last1 = Wormser| first1 = Gary P.| last2 = Dattwyler| first2 = Raymond J.| last3 = Shapiro| first3 = Eugene D.| last4 = Halperin| first4 = John J.| last5 = Steere| first5 = Allen C.| last6 = Klempner| first6 = Mark S.| last7 = Krause| first7 = Peter J.| last8 = Bakken| first8 = Johan S.| last9 = Strle| first9 = Franc| last10 = Stanek| first10 = Gerold| last11 = Bockenstedt| first11 = Linda| last12 = Fish| first12 = Durland| last13 = Dumler| first13 = J. Stephen| last14 = Nadelman| first14 = Robert B.| title = The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2006-11-01| pmid = 17029130}}</ref>
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| **** Parenteral regimen
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| ***** Preferred regimen (1): [[Ceftriaxone]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
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| ***** Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
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| ***** Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
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| **** Oral regimen
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| ***** Preferred regimen (1): [[Amoxicillin]] 50 mg/kg/day PO tid for 14 (14–21) days (maximum, 500 mg per dose)
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| ***** Preferred regimen (2): [[Doxycycline]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO bid for 14 (14–21) days (maximum, 100 mg per dose)
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| ***** Preferred regimen (3): [[Cefuroxime]] 30 mg/kg/day PO bid for 14 (14–21) days (maximum, 500 mg per dose)
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| ***** Alternative regimen (1): [[Azithromycin]] 10 mg/kg/day for 7–10 days (maximum, 500 mg per day)
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| ***** Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO bid for 14–21 days (maximum, 500 mg per dose)
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| ***** Alternative regimen (3): [[Erythromycin]] 12.5 mg/kg PO qid for 14–21 days (maximum,500 mg per dose)
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| ** 2.2 '''Borrelial lymphocytoma'''
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| *** The same regimens used to treat patients with erythema migrans (see above)
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| * 3. '''Late disseminated Lyme Disease'''
| | ==Tables== |
| ** 3.1 '''Lyme arthritis'''
| | {| class="wikitable" |
| *** 3.1.1 '''Adult'''
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| **** Preferred regimen (1): [[Doxycycline]] 100 mg PO bid for 28 days '''(avoid in pregnancy)'''
| | !Diagnosis |
| **** Preferred regimen (2): [[Amoxicillin]] 500 mg PO tid for 28 days
| | !Lab findings |
| **** Preferred regimen (3): [[Cefuroxime axetil]] 500 mg PO bid for 28 days
| | ! |
| *** 3.1.2 '''Pediatric'''
| | ! |
| **** Preferred regimen (1): [[Amoxicillin]] 50 mg/kg/day PO tid for 28 days (maximum, 500 mg per dose)
| | |- |
| **** Preferred regimen (1): [[Cefuroxime axetil]] 30 mg/kg/day PO bid for 28 days (maximum, 500 mg per dose)
| | ! |
| **** Preferred regimen (1): [[Doxycycline]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO bid for 28 days (maximum, 100 mg per dose) '''Note:''' Patient with persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy are suggested re-treatment with another 4-week course of oral antibiotics or with a 2–4 weeks course of [[Ceftriaxone]] (2 g IV q24h).
| | ! |
| | | ! |
| ** 3.2 '''Patients with arthritis and objective evidence of neurologic disease'''
| | ! |
| *** 3.2.1 '''Adult'''
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| **** Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 2–4 weeks
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| **** Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 2–4 weeks
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| **** Alternative regimen (2): [[Penicillin G]] 18–24 million U/day IV q4h for 2-4 weeks
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| *** 3.2.2 '''Pediatric'''
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| **** Preferred regimen (1): [[Ceftriaxone]] 50–75 mg/kg IV q24h for 2–4 weeks (maximum, 2 g)
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| **** Preferred regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h for 2–4 weeks (maximum, 6 g per day)
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| **** Alternative regimen (1): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h for 14 for 2–4 weeks (maximum, 18–24 million U per day)
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| ** 3.3 '''Acrodermatitis chronica atrophicans'''
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| *** Preferred regimen (1): [[Doxycycline]] 100 mg PO bid for 21 days '''(avoid in pregnancy)'''
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| *** Preferred regimen (2): [[Amoxicillin]] 500 mg PO tid for 21 days
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| *** Preferred regimen (3): [[Cefuroxime axetil]] 500 mg PO bid for 21 days
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| * 4. '''Post–Lyme Disease Syndromes'''
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| ** Preferred regimen: Further antibiotic therapy for Lyme disease should not be given unless there are objective findings of active disease (including physical findings, abnormalities on cerebrospinal or synovial fluid analysis, or changes on formal neuropsychologic testing)
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| ===Lyme neuroborreliosis=== | | |} |
| * 1. '''Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines'''<ref>{{Cite journal| doi = 10.1086/508667| issn = 1537-6591| volume = 43| issue = 9| pages = 1089–1134| last1 = Wormser| first1 = Gary P.| last2 = Dattwyler| first2 = Raymond J.| last3 = Shapiro| first3 = Eugene D.| last4 = Halperin| first4 = John J.| last5 = Steere| first5 = Allen C.| last6 = Klempner| first6 = Mark S.| last7 = Krause| first7 = Peter J.| last8 = Bakken| first8 = Johan S.| last9 = Strle| first9 = Franc| last10 = Stanek| first10 = Gerold| last11 = Bockenstedt| first11 = Linda| last12 = Fish| first12 = Durland| last13 = Dumler| first13 = J. Stephen| last14 = Nadelman| first14 = Robert B.| title = The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2006-11-01| pmid = 17029130}}</ref>
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| :* 1.1 '''Early neurologic disease (Stage 1 - early disseminated Lyme disease)'''
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| ::* 1.1.1 '''Cranial nerve palsy'''
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| ::** 1.1.1.1 '''Adult'''
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| ::*** Preferred regimen (1): [[Amoxicillin]] 500 mg PO tid for 14 (14–21) days
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| ::*** Preferred regimen (2): [[Doxycycline]] 100 mg PO bid for 14 (14–21) days '''(avoid in pregnancy)'''
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| ::*** Preferred regimen (3): [[Cefuroxime]] 500 mg PO bid for 14 (14–21) days
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| ::*** Alternative regimen (1): [[Azithromycin]] 500 mg PO qid for 7–10 days
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| ::*** Alternative regimen (2): [[Clarithromycin]] 500 mg PO bid for 14–21 days
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| ::*** Alternative regimen (3): [[Erythromycin]] 500 mg PO qid for 14–21 days
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| ::** 1.1.1.2. '''Pediatric'''
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| ::*** Preferred regimen (1): [[Amoxicillin]] 50 mg/kg/day PO tid for 14 (14–21) days (maximum, 500 mg/dose)
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| ::*** Preferred regimen (2): [[Doxycycline]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg/dose)
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| ::*** Preferred regimen (3): [[Cefuroxime]] 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg/dose)
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| ::*** Alternative regimen (1): [[Azithromycin]] 10 mg/kg/day PO for 7–10 days (maximum, 500 mg/day)
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| ::*** Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO bid for 14–21 days (maximum, 500 mg/dose)
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| ::*** Alternative regimen (3): [[Erythromycin]] 12.5 mg/kg PO bid for 14–21 days (maximum, 500 mg/dose)
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| ::* 1.1.3 '''Meningitis or radiculopathy (adult)'''
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| :::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 14 (10–28) days
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| :::* Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 14 (10–28) days
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| :::* Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 14 (10–28) days
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| :::* Note: for non-pregnant adult patients intolerant of β-lactam agents, [[Doxycycline]] 200–400 mg/day PO/IV q12h may be considered.
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| ::* 1.1.4 '''Meningitis or radiculopathy (pediatric)'''
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| :::* Preferred regimen: [[Ceftriaxone]] 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days
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| :::* Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6-8h (maximum, 6 g/day) for 14 (10–28) days
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| :::* Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days
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| :::* Note: for children ≥ 8 years of age intolerant of β-lactam agents, [[Doxycycline]] 4–8 mg/kg/day PO/IV q12h, maximum 200–400 mg/day may be considered
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| :* 1.2 '''Late neurologic disease'''
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| ::* 1.2.1 '''Central or peripheral nervous system disease (adult)'''
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| :::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 14 (10–28) days
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| :::* Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 14 (10–28) days
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| :::* Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 14 (10–28) days
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| ::* 1.2.2 '''Central or peripheral nervous system disease (pediatric)'''
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| :::* Preferred regimen: [[Ceftriaxone]] 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days.
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| :::* Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day) for 14 (10–28) days
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| :::* Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days
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| * 2. '''American Academy of Neurology (AAN) Practice Parameter'''<ref>{{Cite journal| doi = 10.1212/01.wnl.0000265517.66976.28| issn = 1526-632X| volume = 69| issue = 1| pages = 91–102| last1 = Halperin| first1 = J. J.| last2 = Shapiro| first2 = E. D.| last3 = Logigian| first3 = E.| last4 = Belman| first4 = A. L.| last5 = Dotevall| first5 = L.| last6 = Wormser| first6 = G. P.| last7 = Krupp| first7 = L.| last8 = Gronseth| first8 = G.| last9 = Bever| first9 = C. T.| last10 = Quality Standards Subcommittee of the American Academy of Neurology| title = Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology| journal = Neurology| date = 2007-07-03| pmid = 17522387}}</ref>
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| :* 2.1 '''Meningitis'''
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| ::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
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| ::* Preferred regimen (2):[[Cefotaxime]] 2 g IV q8h for 14 days
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| ::* Preferred regimen (3):[[Penicillin G]] 18–24 MU/day q4h for 14 days
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| ::* Alternative regimen: [[Doxycycline]] 100–200 mg BID for 14 days
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| ::* Pediatric regimen: [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g/day {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day {{or}} [[Doxycycline]] (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day
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| :* 2.2 '''Any neurologic syndrome with CSF pleocytosis'''
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| ::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
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| ::* Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
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| ::* Preferred regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days
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| ::* Alternative regimen: [[Doxycycline]] 100–200 mg BID for 14 days
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| ::* Pediatric regimen: [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day q4h, max 18–24 MU/day {{or}} [[Doxycycline]] (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day
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| :* 2.3 '''Peripheral nervous system disease (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy; normal CSF)'''
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| ::* Preferred regimen: [[Doxycycline]] 100–200 mg BID for 14 days
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| ::* Alternative regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
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| ::* Alternative regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
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| ::* Alternative regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days
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| ::* Pediatric regimen: [[Doxycycline]] (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day {{or}} [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g/day {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day; [[Doxycycline]] (≥ 8 y/o) 4–8 mg/kg/day q12h, max 200 mg/day
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| :* 2.4 '''Encephalomyelitis'''
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| ::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
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| ::* Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
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| ::* Preferred regimen (3): [[Penicillin G]] 18–24 MU/day q4h for 14 days
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| ::* Pediatric regimen: [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g/day {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day
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| :* 2.5 '''Encephalopathy'''
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| ::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
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| ::* Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
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| ::* Preferred regimen (3): [[Penicillin G]] 18–24 MU/day q4h for 14 days
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| ::* Pediatric regimen: [[Ceftriaxone]] 50–75 mg/kg/day IV q24h, max 2 g/day {{or}} [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h, max 6 g/day {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h, max 18–24 MU/day
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| :* 2.6 '''Post-treatment Lyme syndrome'''
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| ::* Preferred regimen: symptomatic management
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| ::* Note: Antibiotic therapy is not indicated
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| ===Follow-up===
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| *Approximately 10 to 20% of patients treated for Lyme disease with a recommended 2-4 week course of antibiotics will develop post-treatment Lyme disease syndrome (PTLDS). Patients report lingering symptoms of fatigue, pain, or joint and muscle aches. In some cases, these can last for more than 6 months.
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| *The majority of patients with post-treatment Lyme disease syndrome gradually improve over months/years of the primary infection.
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| ==References== | | ==References== |
| {{reflist|2}} | | {{reflist|2}} |
|
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| [[Category:Infectious Disease Project]]
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| [[Category:Needs overview]]
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| [[Category:Bacterial diseases]]
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| [[Category:Insect-borne diseases]]
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| [[Category:Lyme disease]]
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| [[Category:Zoonoses]]
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| [[Category:Spirochaetes]]
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| [[Category:Disease]]
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| [[Category:Infectious disease]]
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| [[Category:Dermatology]]
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| [[Category:Emergency medicine]]
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| [[Category:Intensive care medicine]]
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