New Guidelines on Lyme Disease

Changes in Antibiotic Recommendations for Children

The public comment period on the 2019 Draft Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease has been extended until Sept. 9.

Although the guidelines are not final yet, they were developed after a great deal of discussion and literature review by experts from the Infectious Diseases Society of America, the American Academy of Neurology and the American College of Rheumatology, as well as people from other specialties, notably cardiology and pediatrics.

Dr. H. Cody Meissner, professor of pediatrics and director of pediatric infectious disease at Tufts, points particularly to a change in the antibiotics recommendations for children. He says the recommendation used to be that doctors should not prescribe doxycycline for children under 8 years old, because of concerns that this class of antibiotics might lead to tooth enamel damage and discoloration. While that can happen with tetracycline, a related antibiotic, the available evidence shows that doxycycline itself doesn’t do that.

One advantage of treating some cases of Lyme with doxycycline, rather than the amoxicillin that used to be the antibiotic recommended for young children, is that doxycycline is effective against ehrlichiosis, which can occur together with Lyme, and is transmitted by the same tick.

Doxycycline can also be used in children who seem to have neurological manifestations of Lyme, especially facial nerve palsy. “Most of those children don’t need to be admitted to the hospital for IV ceftriaxone,” Dr. Meissner says. “Oral doxycycline gives adequate levels.”

Many uncomplicated pediatric cases of Lyme will probably still be treated with amoxicillin.

Lyme remains challenging for many reasons, not least because the bacteria that cause the disease cannot be easily grown in the lab, like they can for e.g., strep. Without the ability to test directly for the organism, making that diagnosis early continues to depend on clinical assessment, not on the lab.

“About eighty percent of patients who have Lyme disease will have the rash of erythema migrans, and that’s a sufficient basis to start treatment,” Dr. Meissner said, referring to the signature rash, often resembling a target, which can appear (though it doesn’t always) soon after infection.

In these situations, “blood testing is not recommended because only about a third of people will have detectable antibodies when they present with erythema migrans,” he said. “If it’s the right season, if the rash has a quality that’s consistent with Lyme disease, and a person lives in an endemic area or visited an endemic area and particularly if there was a tick attachment, then it’s a clinical diagnosis,” he said.

The new recommendations also include post-exposure prophylaxis for children: a single dose of doxycycline to be given after an engorged tick has been removed, especially during the summer months, to reduce the risk of Lyme disease.

“In the vast majority of cases, Lyme disease can be readily diagnosed and readily treated,” Dr. Meissner said. “If a child or an adult gets treated with the appropriate antibiotics in the early stages of Lyme disease, it’s rare for that person to develop the neurologic or cardiologic symptoms that can come if not treated.”

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