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Revision as of 13:24, 2 August 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The mainstay of therapy for Lyme disease is antimicrobial therapy. Antimicrobial therapy may include either doxycycline, amoxicillin, cephalosporins, or macrolides. Individuals who remove attached ticks should be monitored closely for signs and symptoms of tick-borne diseases for up to 30 days.

Medical Therapy

Lyme boreliosis (non-neuroborreliosis)

1. Early Lyme Disease^[1]

1.1 Erythema migrans

1.1.1 Adult

Preferred regimen (1): Doxycycline 100 mg PO bid for 10-21 days
Preferred regimen (2): Amoxicillin 500 mg PO tid for 14-21 days
Preferred regimen (3): Cefuroxime axetil 500 mg bid for 14-21 days
Alternative regimen (1): Azithromycin 500 mg PO qd for 7–10 days
Alternative regimen (2): Clarithromycin 500 mg PO bid for 14–21 days (if the patient is not pregnant)
Alternative regimen (3): Erythromycin 500 mg PO qid for 14–21 days

1.1.2 Pediatric

1.1.2.1 children < 8 years of age

Preferred regimen (1): Amoxicillin 50 mg/kg PO per day in 3 divided doses (maximum of 500 mg per dose)
Preferred regimen (2): Cefuroxime axetil 30 mg/kg PO per day in 2 divided doses（maximum, 500 mg per dose)

1.1.2.2 children ≥ 8 years of age

Preferred regimen (1): Doxycycline 4 mg/kg PO per day in 2 divided doses （maximum, 100 mg per dose）
Preferred regimen (2): Azithromycin 10 mg/kg PO qd (maximum, 500 mg qd)
Preferred regimen (3): Clarithromycin 7.5 mg/kg PO bid (maximum, 500 mg per dose)
Preferred regimen (4): Erythromycin 12.5 mg/kg PO qid (maximum, 500 mg per dose)

1.2 When erythema migrans cannot be reliably distinguished from community-acquired bacterial cellulitis

Preferred regimen: Amoxicillin-Clavulanate 500 mg PO tid
Pediatric regimen: Amoxicillin-Clavulanate 50 mg/kg per day in 3 divided doses (maximum, 500 mg per dose)

1.3. Lyme carditis, adult^[2]

Parenteral regimen

Preferred regimen: Ceftriaxone 2 g IV q24h for 14 (14–21) days
Alternative regimen: Cefotaxime 2 g IV q8h for 14 (14–21) days OR Penicillin G 18–24 million U/day IV q4h for 14 (14–21) days

Oral regimen

Preferred regimen: Amoxicillin 500 mg tid for 14 (14–21) days OR Doxycycline 100 mg bid for 14 (14–21) days OR Cefuroxime 500 mg bid for 14 (14–21) days
Alternative regimen: Azithromycin 500 mg PO qd for 7–10 days OR Clarithromycin 500 mg PO bid for 14–21 days (if the patient is not pregnant) OR Erythromycin 500 mg PO qid for 14–21 days

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.

Note (2): A temporary pacemaker may be required for patients with advanced heart block.

Note (3): Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifestations.

Lyme carditis, pediatric^[3]

Parenteral regimen

Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (maximum, 2 g) for 14 (14–21) days
Alternative regimen: Cefotaxime 150–200 mg/kg/day IV q6–8h (maximum, 6 g per day) for 14 (14–21) days OR Penicillin G 200,000–400,000 U/kg/day IV q4h (not to exceed 18–24 million U per day) for 14 (14–21) days

Oral regimen

Preferred regimen: Amoxicillin 50 mg/kg/day PO tid (maximum, 500 mg per dose) for 14 (14–21) days OR Doxycycline (for children aged ≥ 􏱢8 years) 4 mg/kg/day PO bid (maximum, 100 mg per dose) for 14 (14–21) days OR Cefuroxime 30 mg/kg/day PO bid (maximum, 500 mg per dose) for 14 (14–21) days
Alternative regimen: Azithromycin 10 mg/kg/day (maximum of 500 mg per day) for 7–10 days OR Clarithromycin 7.5 mg/kg PO bid (maximum of 500 mg per dose) for 14–21 days OR Erythromycin 12.5 mg/kg PO qid (maximum of 500 mg per dose) for 14–21 days

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

Note (2): A temporary pacemaker may be required for patients with advanced heart block

Note (3): Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifestations

1.4 Borrelial lymphocytoma

Preferred regimen: The same regimens used to treat patients with erythema migrans (see above)

2. Late Lyme Disease

2.1 Lyme arthritis

Preferred regimen (1): Doxycycline 100 mg PO bid
Preferred regimen (2): Amoxicillin 500 mg PO tid
Alternative regimen: Cefuroxime axetil 500 mg PO bid for 28 days
Pediatric regimen: Amoxicillin 50 mg/kg per day in 3 divided doses (maximum 500 mg per dose) OR Cefuroxime axetil 30 mg/kg per day in 2 divided doses (maximum,500 mg per dose); (≥8 years of age) Doxycycline 4 mg/ kg per day in 2 divided doses (maximum, 100 mg per dose)
Note: For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4 weeks course of Ceftriaxone IV

2.2 Patients with arthritis and objective evidence of neurologic disease

Preferred regimen: Ceftriaxone IV for 2–4 weeks
Alternative regimen (1): Cefotaxime IV
Alternative regimen (2): Penicillin G IV
Pediatric regime: Ceftriaxone OR Cefotaxime OR Penicillin G

2.3 Acrodermatitis chronica atrophicans

Preferred regimen (1): Doxycycline 100 mg PO bid for 21 days
Preferred regimen (2): Amoxicillin 500 mg PO tid for 21 days
Preferred regimen (3): Cefuroxime axetil 500 mg PO bid for 21 days

3. Post–Lyme Disease Syndromes

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)

Lyme neuroborreliosis

1. Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines^[4]

1.1 Early neurologic disease

1.1.1 Cranial nerve palsy (adult)

Preferred regimen (1): Amoxicillin 500 mg PO tid for 14 (14–21) days
Preferred regimen (2): Doxycycline 100 mg PO bid for 14 (14–21) days
Preferred regimen (3): Cefuroxime 500 mg PO bid for 14 (14–21) days
Alternative regimen (1): Azithromycin 500 mg PO qd for 7–10 days
Alternative regimen (2): Clarithromycin 500 mg PO bid for 14–21 days
Alternative regimen (3): Erythromycin 500 mg PO qid for 14–21 days
Note: Avoid clarithromycin among pregnant women

1.1.2 Cranial nerve palsy (pediatric)

Preferred regimen (1): Amoxicillin 50 mg/kg/day PO tid (maximum 500 mg/dose) for 14 (14–21) days
Preferred regimen (2): Doxycycline (for children aged ≥ 8 years) 4 mg/kg/day PO q12h (maximum 100 mg/dose) for 14 (14–21) days
Preferred regimen (3): Cefuroxime 30 mg/kg/day PO q12h (maximum 500 mg/dose) for 14 (14–21) days
Alternative regimen (1): Azithromycin 10 mg/kg/day PO (maxmium 500 mg/dose) for 7–10 days
Alternative regimen (2): Clarithromycin 7.5 mg/kg PO bid (maximum 500 mg/dose) for 14–21 days
Alternative regimen (3): Erythromycin 12.5 mg/kg PO bid (maximum 500 mg/dose) for 14–21 days

1.1.3 Meningitis or radiculopathy (adult)

Preferred regimen: Ceftriaxone 2 g IV q24h for 14 (10–28) days
Alternative regimen (1): Cefotaxime 2 g IV q8h for 14 (10–28) days
Alternative regimen (2): Penicillin G 18–24 MU/day IV q4h for 14 (10–28) days
Note: for non-pregnant adult patients intolerant of β-lactam agents, Doxycycline 200–400 mg/day PO/IV q12h may be considered.

1.1.4 Meningitis or radiculopathy (pediatric)

Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days
Alternative regimen (1): Cefotaxime 150–200 mg/kg/day IV q6-8h (maximum, 6 g/day) for 14 (10–28) days
Alternative regimen (2): Penicillin G 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days
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

1.2 Late neurologic disease

1.2.1 Central or peripheral nervous system disease (adult)

Preferred regimen: Ceftriaxone 2 g IV q24h for 14 (10–28) days
Alternative regimen (1): Cefotaxime 2 g IV q8h for 14 (10–28) days
Alternative regimen (2): Penicillin G 18–24 MU/day IV q4h for 14 (10–28) days

1.2.2 Central or peripheral nervous system disease (pediatric)

Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days.
Alternative regimen (1): Cefotaxime 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day) for 14 (10–28) days
Alternative regimen (2): Penicillin G 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days

2. American Academy of Neurology (AAN) Practice Parameter^[5]

2.1 Meningitis

Preferred regimen (1): Ceftriaxone 2 g IV q24h for 14 days
Preferred regimen (2):Cefotaxime 2 g IV q8h for 14 days
Preferred regimen (3):Penicillin G 18–24 MU/day q4h for 14 days
Alternative regimen: Doxycycline 100–200 mg BID for 14 days
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

2.2 Any neurologic syndrome with CSF pleocytosis

Preferred regimen (1): Ceftriaxone 2 g IV q24h for 14 days
Preferred regimen (2): Cefotaxime 2 g IV q8h for 14 days
Preferred regimen (3): Penicillin G 18–24 MU/day IV q4h for 14 days
Alternative regimen: Doxycycline 100–200 mg BID for 14 days
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

2.3 Peripheral nervous system disease (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy; normal CSF)

Preferred regimen: Doxycycline 100–200 mg BID for 14 days
Alternative regimen (1): Ceftriaxone 2 g IV q24h for 14 days
Alternative regimen (2): Cefotaxime 2 g IV q8h for 14 days
Alternative regimen (3): Penicillin G 18–24 MU/day IV q4h for 14 days
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

2.4 Encephalomyelitis

Preferred regimen (1): Ceftriaxone 2 g IV q24h for 14 days
Preferred regimen (2): Cefotaxime 2 g IV q8h for 14 days
Preferred regimen (3): Penicillin G 18–24 MU/day q4h for 14 days
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

2.5 Encephalopathy

Preferred regimen (1): Ceftriaxone 2 g IV q24h for 14 days
Preferred regimen (2): Cefotaxime 2 g IV q8h for 14 days
Preferred regimen (3): Penicillin G 18–24 MU/day q4h for 14 days
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

2.6 Post-treatment Lyme syndrome

Preferred regimen: symptomatic management
Note: Antibiotic therapy is not indicated

Follow-up

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.
The majority of patients with post-treatment Lyme disease syndrome gradually improve over months/years of the primary infection.

References

↑ 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 (2006). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clin. Infect. Dis. 43 (9): 1089–134. doi:10.1086/508667. PMID 17029130.
↑ Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.
↑ Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.
↑ Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.
↑ Halperin, J. J.; Shapiro, E. D.; Logigian, E.; Belman, A. L.; Dotevall, L.; Wormser, G. P.; Krupp, L.; Gronseth, G.; Bever, C. T.; Quality Standards Subcommittee of the American Academy of Neurology (2007-07-03). "Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 69 (1): 91–102. doi:10.1212/01.wnl.0000265517.66976.28. ISSN 1526-632X. PMID 17522387.

[1] 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 (2006). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clin. Infect. Dis. 43 (9): 1089–134. doi:10.1086/508667. PMID 17029130.

[2] Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.

[3] Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.

[4] Wormser, Gary P.; Dattwyler, Raymond J.; Shapiro, Eugene D.; Halperin, John J.; Steere, Allen C.; Klempner, Mark S.; Krause, Peter J.; Bakken, Johan S.; Strle, Franc; Stanek, Gerold; Bockenstedt, Linda; Fish, Durland; Dumler, J. Stephen; Nadelman, Robert B. (2006-11-01). "The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 43 (9): 1089–1134. doi:10.1086/508667. ISSN 1537-6591. PMID 17029130.

[5] Halperin, J. J.; Shapiro, E. D.; Logigian, E.; Belman, A. L.; Dotevall, L.; Wormser, G. P.; Krupp, L.; Gronseth, G.; Bever, C. T.; Quality Standards Subcommittee of the American Academy of Neurology (2007-07-03). "Practice parameter: treatment of nervous system Lyme disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 69 (1): 91–102. doi:10.1212/01.wnl.0000265517.66976.28. ISSN 1526-632X. PMID 17522387.

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@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Lyme disease}}
-{{CMG}};{{AE}} {{Anmol}},{{IMD}}
+{{CMG}}
 ==Overview==
-[[Laboratory]] [[blood tests]] are helpful if used correctly and performed with validated methods. Laboratory tests are not recommended for patients who do not have symptoms typical of [[Lyme disease]]. [[Centers for Disease Control]] recommends a two-tier testing protocol for [[Lyme disease]]. [[Polymerase chain reaction]] (PCR) tests for [[Lyme disease]] have also been developed to detect the [[genetic material]] ([[DNA]]) of the [[Lyme disease]] [[Spirochaete|spirochete]]. Currently, [[PCR]] is the only means to detect the presence of [[organism]]. Identification and testing of individual [[tick]] after removal is generally not useful.
+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.
-==Laboratory Findings==
+==Medical Therapy==
-* [[Lyme disease]] is diagnosed based on:
+===Lyme boreliosis (non-neuroborreliosis)===
-#Signs and symptoms
+* 1. '''Early Lyme Disease'''<ref>{{cite journal |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 |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=Clin. Infect. Dis. |volume=43 |issue=9 |pages=1089–134 |year=2006 |pmid=17029130 |doi=10.1086/508667 |url=}}</ref>
-#A history of possible exposure to [[infected]] [[Blacklegged tick|blacklegged ticks]]
+:* 1.1 '''Erythema migrans'''
-* [[Laboratory]] [[blood tests]] are helpful if used correctly and performed with validated methods.
+::* 1.1.1 '''Adult'''
-* Laboratory tests are not recommended for patients who do not have symptoms typical of [[Lyme disease]].
+:::* Preferred regimen (1): [[Doxycycline]] 100 mg PO bid for 10-21 days
-* Just as it is important to correctly diagnose [[Lyme disease]] when a patient has it, it is important to avoid misdiagnosis and treatment of [[Lyme disease]] when the true cause of the illness is something else.
+:::* Preferred regimen (2): [[Amoxicillin]] 500 mg PO tid for 14-21 days
+:::* Preferred regimen (3): [[Cefuroxime axetil]] 500 mg bid for 14-21 days
+:::* Alternative regimen (1): [[Azithromycin]] 500 mg PO qd for 7–10 days
+:::* Alternative regimen (2): [[Clarithromycin]] 500 mg PO bid for 14–21 days (if the patient is not pregnant)
+:::* Alternative regimen (3): [[Erythromycin]] 500 mg PO qid for 14–21 days
-===Serology===
+::* 1.1.2 '''Pediatric'''
-==== Two-step Laboratory Testing Process<ref name="urlTwo-step Laboratory Testing Process| Lyme Disease | CDC">{{cite web |url=https://www.cdc.gov/lyme/diagnosistesting/labtest/twostep/index.html |title=Two-step Laboratory Testing Process&#124; Lyme Disease &#124; CDC |format= |work= |accessdate=}}</ref> ====
+:::* 1.1.2.1 '''children < 8 years of age'''
-*The [[serology|serological]] laboratory tests most widely available and employed are the [[Western blot]] and [[ELISA test|ELISA]].
+::::* Preferred regimen (1): [[Amoxicillin]] 50 mg/kg PO per day in 3 divided doses (maximum of 500 mg per dose)
-*A two-tiered protocol is recommended by the [[Centers for Disease Control|Centers for Disease Control]]: the more sensitive [[Enzyme linked immunosorbent assay (ELISA)|ELISA]] is performed first, if it is positive or equivocal, the more [[Specificity (tests)|specific]] [[Western blot]] is run. The reliability of testing in diagnosis remains controversial, however studies show the [[Western blot]] [[IgM]] has a specificity of 94&ndash;96% for patients with clinical symptoms of early [[Lyme disease]].<ref name="Engstrom">{{cite journal | author=Engstrom SM, Shoop E, Johnson RC | title=Immunoblot interpretation criteria for serodiagnosis of early Lyme disease | journal=J Clin Microbiol | year=1995 | pages=419-27 | volume=33 | issue=2 | pmid = 7714202 | url=http://jcm.asm.org/cgi/reprint/33/2/419.pdf | format=PDF}}</ref><ref name="Sivak">{{cite journal | author=Sivak SL, Aguero-Rosenfeld ME, Nowakowski J, Nadelman RB, Wormser GP | title=Accuracy of IgM immunoblotting to confirm the clinical diagnosis of early Lyme disease | journal=Arch Intern Med | year=1996 | pages=2105-9 | volume=156 | issue=18 | pmid = 8862103}}</ref>
+::::* Preferred regimen (2): [[Cefuroxime axetil]] 30 mg/kg PO per day in 2 divided doses（maximum, 500 mg per dose)
-*The two steps of [[Lyme disease]] testing are designed to be done together. [[Centers for Disease Control and Prevention|CDC]] does not recommend skipping the first test and just doing the [[Western blot]]. Doing so will increase the frequency of [[false positive]] results and may lead to misdiagnosis and improper treatment.
+::*1.1.2.2 '''children ≥ 8 years of age'''
-* Erroneous test results have been widely reported in both early and late stages of the disease. These errors can be caused by several factors, including [[antibody]] cross-reactions from other [[Infection|infections]] including:
+::::* Preferred regimen (1): [[Doxycycline]] 4 mg/kg PO per day in 2 divided doses （maximum, 100 mg per dose）
-*[[Epstein-Barr virus]]<ref name="Gossens">{{cite journal | author=Goossens HA, Nohlmans MK, van den Bogaard AE | title=Epstein-Barr virus and cytomegalovirus infections cause false-positive results in IgM two-test protocol for early Lyme borreliosis | journal=Infection | year=1999 | pages=231 | volume=27 | issue=3 | pmid= 10378140}}</ref><ref name="pmid3049839">{{cite journal| author=Berardi VP, Weeks KE, Steere AC| title=Serodiagnosis of early Lyme disease: analysis of IgM and IgG antibody responses by using an antibody-capture enzyme immunoassay. | journal=J Infect Dis | year= 1988 | volume= 158 | issue= 4 | pages= 754-60 | pmid=3049839 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3049839  }} </ref>
+::::* Preferred regimen (2): [[Azithromycin]] 10 mg/kg PO qd (maximum, 500 mg qd)
-*[[Cytomegalovirus]]<ref name="Gossens">{{cite journal | author=Goossens HA, Nohlmans MK, van den Bogaard AE | title=Epstein-Barr virus and cytomegalovirus infections cause false-positive results in IgM two-test protocol for early Lyme borreliosis | journal=Infection | year=1999 | pages=231 | volume=27 | issue=3 | pmid= 10378140}}</ref>
+::::* Preferred regimen (3): [[Clarithromycin]] 7.5 mg/kg PO bid (maximum, 500 mg per dose)
-*[[Varicella zoster virus]]<ref name="pmid1961232">{{cite journal| author=Feder HM, Gerber MA, Luger SW, Ryan RW| title=False positive serologic tests for Lyme disease after varicella infection. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 26 | pages= 1886-7 | pmid=1961232 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1961232  }} </ref><ref name="pmid9835449">{{cite journal| author=Woelfle J, Wilske B, Haverkamp F, Bialek R| title=False-positive serological tests for Lyme disease in facial palsy and varicella zoster meningo-encephalitis. | journal=Eur J Pediatr | year= 1998 | volume= 157 | issue= 11 | pages= 953-4 | pmid=9835449 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9835449  }} </ref>
+::::* Preferred regimen (4): [[Erythromycin]] 12.5 mg/kg PO qid (maximum, 500 mg per dose)
-*[[Herpes simplex virus]] type 2<ref name="Strasfeld">{{cite journal | author=Strasfeld L, Romanzi L, Seder RH, Berardi VP | title=False-positive serological test results for Lyme disease in a patient with acute herpes simplex virus type 2 infection | journal=Clin Infect Dis | year=2005 | pages=1826-7 | volume=41 | issue=12 | pmid= 16288417}}</ref>
-*[[Rickettsial infections]]<ref name="pmid3049839">{{cite journal| author=Berardi VP, Weeks KE, Steere AC| title=Serodiagnosis of early Lyme disease: analysis of IgM and IgG antibody responses by using an antibody-capture enzyme immunoassay. | journal=J Infect Dis | year= 1988 | volume= 158 | issue= 4 | pages= 754-60 | pmid=3049839 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3049839  }} </ref>
-*[[Syphilis]]<ref name="pmid3049839">{{cite journal| author=Berardi VP, Weeks KE, Steere AC| title=Serodiagnosis of early Lyme disease: analysis of IgM and IgG antibody responses by using an antibody-capture enzyme immunoassay. | journal=J Infect Dis | year= 1988 | volume= 158 | issue= 4 | pages= 754-60 | pmid=3049839 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3049839  }} </ref>
-[[image:Two tiered testing for lyme disease 600px.jpg|center|600px|thumb|The Two-tier Testing Decision Tree describes the steps required to properly test for Lyme disease. The first required test is the Enzyme Immunoassay (EIA) or Immunofluorescence Assay (IFA). If this test yields negative results, the provider should consider an alternative diagnosis.  Or in cases where the patient has had symptoms for less than or equal to 30 days, the provider may treat the patient and follow up with a convalescent serum. If the first test yields positive or equivocal results, two options are available: 1) if the patient has had symptoms for less than or equal to 30 days, an IgM Western Blot is performed; 2) if the patient has had symptoms for more than 30 days, the IgG Western Blot is performed. The IgM should not be used if the patient has been ill for more than 30 days.]]
-====Polymerase chain reaction====
-* [[Polymerase chain reaction]] (PCR) tests for [[Lyme disease]] have also been developed to detect the [[genetic material]] ([[DNA]]) of the [[Lyme disease]] [[Spirochaete|spirochete]]. [[Polymerase chain reaction|PCR]] tests are rarely susceptible to [[Type I and type II errors|false-positive]] results but can often show [[Type I and type II errors|false-negative]] results, and the overall reliability of [[Polymerase chain reaction|PCR]] in this role remains unclear.
-* With the exception of [[Polymerase chain reaction|PCR]], there is no currently practical means for detection of the presence of the organism, as serologic studies only test for [[antibodies]] of ''[[Borrelia burgdorferi]]''.
-* [[Immunoglobulin G]] ([[IgG]]) or [[immunoglobulin M]] ([[Immunoglobulin M|IgM]]) [[antibodies]] to ''[[Borrelia]]'' [[Antigen|antigens]] high titres of either antibodies indicate disease, but lower titers can be deceiving.
-* The [[IgM]] [[antibodies]] may be present after the initial [[infection]] for a limited period but [[IgG]] [[antibodies]] may remain for years after the [[infection]].<ref>{{cite journal |author=Burdash N, Fernandes J |title=Lyme borreliosis: detecting the great imitator |journal=The Journal of the American Osteopathic Association |volume=91 |issue=6 |pages=573-4, 577-8 |year=1991 |pmid=1874654 |url=http://www.jaoa.org/cgi/content/abstract/91/6/573}}</ref>
-* [[Western blot]], [[ELISA]] and [[Polymerase chain reaction|PCR]] can be performed by either [[blood test]] via [[venipuncture]] or [[cerebral spinal fluid]] (CSF) via [[lumbar puncture]].
-* Though [[lumbar puncture]] is more definitive of diagnosis, [[antigen]] capture in the [[CSF]] is much more elusive, reportedly [[CSF]] yields positive results in only 10-30% of patients cultured.
-* The diagnosis of [[neurologic]] [[infection]] by [[Borrelia burgdorferi|''Borrelia'' ''burgdorferi'']] should not be excluded solely on the basis of normal routine [[CSF]] or negative [[CSF]] [[antibody]] analyses.<ref>{{cite journal |author=Coyle PK, Schutzer SE, Deng Z, ''et al'' |title=Detection of Borrelia burgdorferi-specific antigen in antibody-negative cerebrospinal fluid in neurologic Lyme disease |journal=Neurology |volume=45 |issue=11 |pages=2010-5 |year=1995 |pmid=7501150 }}</ref>
-* New techniques for clinical evaluation if ''[[Borrelia burgdorferi]]'' infection are under investigation, and includes:
-**[[Lymphocyte]] transformation tests <ref>{{cite journal |author=Valentine-Thon E, Ilsemann K, Sandkamp M |title=A novel lymphocyte transformation test (LTT-MELISA) for Lyme borreliosis |journal=Diagn. Microbiol. Infect. Dis. |volume=57 |issue=1 |pages=27-34 |year=2007 |pmid=16876371 |doi=10.1016/j.diagmicrobio.2006.06.008}}</ref>
-**Focus floating microscopy<ref>{{cite journal |author=Eisendle K, Grabner T, Zelger B |title=Focus floating microscopy: "gold standard" for cutaneous borreliosis? |journal=Am. J. Clin. Pathol. |volume=127 |issue=2 |pages=213-22 |year=2007 |pmid=17210530 |doi=10.1309/3369XXFPEQUNEP5C}}</ref>
-* New research indicates [[chemokine]] [[CXCL13]] may also be a possible marker for neuroborreliosis.<ref>{{cite journal |author=Cadavid D |title=The mammalian host response to borrelia infection |journal=Wien. Klin. Wochenschr. |volume=118 |issue=21-22 |pages=653-8 |year=2006 |pmid=17160603 |doi=10.1007/s00508-006-0692-0}}</ref>
-===Other Types of Laboratory Testing===
+:* 1.2 '''When erythema migrans cannot be reliably distinguished from community-acquired bacterial cellulitis'''
-* Some laboratories offer [[Lyme disease]] testing using assays whose accuracy and clinical usefulness have not been adequately established. These tests include:<ref name="urlLaboratory tests that are not recommended| Lyme Disease | CDC">{{cite web |url=https://www.cdc.gov/lyme/diagnosistesting/labtest/otherlab/index.html |title=Laboratory tests that are not recommended&#124; Lyme Disease &#124; CDC |format= |work= |accessdate=}}</ref>
+::* Preferred regimen: [[Amoxicillin-Clavulanate]] 500 mg PO tid
-**Capture [[Assay|assays]] for [[Antigen|antigens]] in [[urine]]
+::* Pediatric regimen: [[Amoxicillin-Clavulanate]] 50 mg/kg per day in 3 divided doses (maximum, 500 mg per dose)
-**Culture, [[immunofluorescence]] staining, or cell sorting of cell wall-deficient or cystic forms of [[B. burgdorferi]]
-**[[Lymphocyte]] transformation tests
-**Quantitative [[CD57]] [[lymphocyte]] [[Assay|assays]]
-**Reverse Western blots
-**In-house criteria for interpretation of immunoblots
-**Measurements of [[antibodies]] in [[joint]] [[fluid]] ([[synovial fluid]])
-**[[Immunoglobulin M|IgM]] or [[IgG]] tests without a previous [[Enzyme linked immunosorbent assay (ELISA)|ELISA]]/EIA/IFA
-*In general, [[Centers for Disease Control and Prevention|CDC]] does not recommend these tests.
-*Patients are encouraged to ask their [[Physician|physicians]] whether their testing for [[Lyme disease]] was performed using validated methods and whether results were interpreted using appropriate guidelines.
-===Testing Ticks===
+:* 1.3.  '''Lyme carditis, adult'''<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>
-* Patients who have removed a [[tick]] often wonder if they should have it tested.
+::* Parenteral regimen
-* In general, the identification and testing of individual [[Tick|ticks]] is not useful for deciding if a person should get [[Antibiotic|antibiotics]] following a [[tick]] bite because:<ref name="urlTick removal and testing | Lyme Disease | CDC">{{cite web |url=https://www.cdc.gov/lyme/removal/index.html |title=Tick removal and testing &#124; Lyme Disease &#124; CDC |format= |work= |accessdate=}}</ref>
+:::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 14 (14–21) days
-**If the test shows that the [[tick]] contained disease-causing organisms, that does not necessarily mean that the patient have been [[Infection (disambiguation)|infected]].
+:::* Alternative regimen: [[Cefotaxime]] 2 g IV q8h for 14 (14–21) days {{or}} [[Penicillin G]] 18–24 million U/day IV q4h for 14 (14–21) days
-**If the patient have been [[Infection (disambiguation)|infected]], symptoms will develop probably before results of the [[tick]] test are available. So, appropriate treatment should not be withhold for availability [[tick]] testing results.
+::* Oral regimen
-**Negative results can lead to false assurance. For example, the patient may have been unknowingly bitten by a different tick that was [[Infection (disambiguation)|infected]].
+:::* Preferred regimen: [[Amoxicillin]] 500 mg tid for 14 (14–21) days {{or}} [[Doxycycline]] 100 mg bid for 14 (14–21) days {{or}} [[Cefuroxime]] 500 mg bid for 14 (14–21) days
+:::* Alternative regimen: [[Azithromycin]] 500 mg PO qd for 7–10 days {{or}} [[Clarithromycin]] 500 mg PO bid for 14–21 days (if the patient is not pregnant) {{or}} [[Erythromycin]] 500 mg PO qid for 14–21 days
+:::: 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.
+:::: Note (2): A temporary pacemaker may be required for patients with advanced heart block.
+:::: Note (3): Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifestations.
+:* '''Lyme carditis, 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>
+::* Parenteral regimen
+:::* Preferred regimen: [[Ceftriaxone]] 50–75 mg/kg IV q24h (maximum, 2 g) for 14 (14–21) days
+:::* Alternative regimen: [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g per day) for 14 (14–21) days {{or}} [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (not to exceed 18–24 million U per day) for 14 (14–21) days
+::* Oral regimen
+:::* Preferred regimen: [[Amoxicillin]] 50 mg/kg/day PO tid (maximum, 500 mg per dose) for 14 (14–21) days {{or}} [[Doxycycline]] (for children aged ≥ 􏱢8 years) 4 mg/kg/day PO bid (maximum, 100 mg per dose) for 14 (14–21) days {{or}} [[Cefuroxime]] 30 mg/kg/day PO bid (maximum, 500 mg per dose) for 14 (14–21) days
+:::* Alternative regimen: [[Azithromycin]] 10 mg/kg/day (maximum of 500 mg per day) for 7–10 days {{or}} [[Clarithromycin]] 7.5 mg/kg PO bid (maximum of 500 mg per dose) for 14–21 days {{or}} [[Erythromycin]] 12.5 mg/kg PO qid (maximum of 500 mg per dose) for 14–21 days
+:::: 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
+:::: Note (2): A temporary pacemaker may be required for patients with advanced heart block
+:::: Note (3): Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifestations
+:* 1.4 '''Borrelial lymphocytoma'''
+::* Preferred regimen: The same regimens used to treat patients with erythema migrans (see above)
+* 2. '''Late Lyme Disease'''
+:* 2.1 '''Lyme arthritis'''
+::* Preferred regimen (1): [[Doxycycline]] 100 mg PO bid
+::* Preferred regimen (2): [[Amoxicillin]] 500 mg PO tid
+::* Alternative regimen: [[Cefuroxime axetil]] 500 mg PO bid for 28 days
+::* Pediatric regimen: [[Amoxicillin]] 50 mg/kg per day in 3 divided doses (maximum 500 mg per dose) {{or}} [[Cefuroxime axetil]] 30 mg/kg per day in 2 divided doses (maximum,500 mg per dose); (≥8 years of age) [[Doxycycline]] 4 mg/ kg per day in 2 divided doses (maximum, 100 mg per dose)
+::* Note: For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4 weeks course of [[Ceftriaxone]] IV
+:* 2.2 '''Patients with arthritis and objective evidence of neurologic disease'''
+::* Preferred regimen: [[Ceftriaxone]] IV for 2–4 weeks
+::* Alternative regimen (1): [[Cefotaxime]] IV
+::* Alternative regimen (2): [[Penicillin G]] IV
+::* Pediatric regime: [[Ceftriaxone]] {{or}} [[Cefotaxime]] {{or}} [[Penicillin G]]
+:* 2.3 '''Acrodermatitis chronica atrophicans'''
+::* Preferred regimen (1): [[Doxycycline]] 100 mg PO bid for 21 days
+::* Preferred regimen (2): [[Amoxicillin]] 500 mg PO tid for 21 days
+::* Preferred regimen (3): [[Cefuroxime axetil]] 500 mg PO bid for 21 days
+* 3. '''Post–Lyme Disease Syndromes'''
+::* 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)
+===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>
+:* 1.1 '''Early neurologic disease'''
+::* 1.1.1 '''Cranial nerve palsy (adult)'''
+:::* Preferred regimen (1): [[Amoxicillin]] 500 mg PO tid for 14 (14–21) days
+:::* Preferred regimen (2): [[Doxycycline]] 100 mg PO bid for 14 (14–21) days
+:::* Preferred regimen (3): [[Cefuroxime]] 500 mg PO bid for 14 (14–21) days
+:::* Alternative regimen (1): [[Azithromycin]] 500 mg PO qd for 7–10 days
+:::* Alternative regimen (2): [[Clarithromycin]] 500 mg PO bid for 14–21 days
+:::* Alternative regimen (3): [[Erythromycin]] 500 mg PO qid for 14–21 days
+:::*Note: Avoid clarithromycin among pregnant women
+::* 1.1.2 '''Cranial nerve palsy (pediatric)'''
+:::* Preferred regimen (1): [[Amoxicillin]] 50 mg/kg/day PO tid (maximum 500 mg/dose) for 14 (14–21) days
+:::* Preferred regimen (2): [[Doxycycline]] (for children aged ≥ 8 years) 4 mg/kg/day PO q12h (maximum 100 mg/dose) for 14 (14–21) days
+:::* Preferred regimen (3): [[Cefuroxime]] 30 mg/kg/day PO q12h (maximum 500 mg/dose) for 14 (14–21) days
+:::* Alternative regimen (1): [[Azithromycin]] 10 mg/kg/day PO (maxmium 500 mg/dose) for 7–10 days
+:::* Alternative regimen (2): [[Clarithromycin]] 7.5 mg/kg PO bid (maximum 500 mg/dose) for 14–21 days
+:::* Alternative regimen (3): [[Erythromycin]] 12.5 mg/kg PO bid (maximum 500 mg/dose) for 14–21 days
+::* 1.1.3 '''Meningitis or radiculopathy (adult)'''
+:::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 14 (10–28) days
+:::* Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 14 (10–28) days
+:::* Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 14 (10–28) days
+:::* Note: for non-pregnant adult patients intolerant of β-lactam agents, [[Doxycycline]] 200–400 mg/day PO/IV q12h may be considered.
+::* 1.1.4 '''Meningitis or radiculopathy (pediatric)'''
+:::* Preferred regimen: [[Ceftriaxone]] 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days
+:::* Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6-8h (maximum, 6 g/day) for 14 (10–28) days
+:::* Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days
+:::* 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
+:* 1.2 '''Late neurologic disease'''
+::* 1.2.1 '''Central or peripheral nervous system disease (adult)'''
+:::* Preferred regimen: [[Ceftriaxone]] 2 g IV q24h for 14 (10–28) days
+:::* Alternative regimen (1): [[Cefotaxime]] 2 g IV q8h for 14 (10–28) days
+:::* Alternative regimen (2): [[Penicillin G]] 18–24 MU/day IV q4h for 14 (10–28) days
+::* 1.2.2 '''Central or peripheral nervous system disease (pediatric)'''
+:::* Preferred regimen: [[Ceftriaxone]] 50–75 mg/kg IV q24h (maximum, 2 g/day) for 14 (10–28) days.
+:::* Alternative regimen (1): [[Cefotaxime]] 150–200 mg/kg/day IV q6–8h (maximum, 6 g/day) for 14 (10–28) days
+:::* Alternative regimen (2): [[Penicillin G]] 200,000–400,000 U/kg/day IV q4h (maximum, 18–24 MU/day) for 14 (10–28) days
+* 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>
+:* 2.1 '''Meningitis'''
+::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
+::* Preferred regimen (2):[[Cefotaxime]] 2 g IV q8h for 14 days
+::* Preferred regimen (3):[[Penicillin G]] 18–24 MU/day q4h for 14 days
+::* Alternative regimen: [[Doxycycline]] 100–200 mg BID for 14 days
+::* 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
+:* 2.2 '''Any neurologic syndrome with CSF pleocytosis'''
+::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
+::* Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
+::* Preferred regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days
+::* Alternative regimen: [[Doxycycline]] 100–200 mg BID for 14 days
+::* 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
+:* 2.3 '''Peripheral nervous system disease (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy; normal CSF)'''
+::* Preferred regimen: [[Doxycycline]] 100–200 mg BID for 14 days
+::* Alternative regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
+::* Alternative regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
+::* Alternative regimen (3): [[Penicillin G]] 18–24 MU/day IV q4h for 14 days
+::* 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
+:* 2.4 '''Encephalomyelitis'''
+::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
+::* Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
+::* Preferred regimen (3): [[Penicillin G]] 18–24 MU/day q4h for 14 days
+::* 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
+:* 2.5 '''Encephalopathy'''
+::* Preferred regimen (1): [[Ceftriaxone]] 2 g IV q24h for 14 days
+::* Preferred regimen (2): [[Cefotaxime]] 2 g IV q8h for 14 days
+::* Preferred regimen (3): [[Penicillin G]] 18–24 MU/day q4h for 14 days
+::* 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
+:* 2.6 '''Post-treatment Lyme syndrome'''
+::* Preferred regimen: symptomatic management
+::* Note: Antibiotic therapy is not indicated
+===Follow-up===
+*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.
+*The majority of patients with post-treatment Lyme disease syndrome gradually improve over months/years of the primary infection.
 ==References==
 {{reflist|2}}
+[[Category:Infectious Disease Project]]
 [[Category:Needs overview]]
 [[Category:Bacterial diseases]]
@@ Line 73: / Line 163: @@
 [[Category:Emergency medicine]]
 [[Category:Intensive care medicine]]
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