Practice Guidelines



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Am Fam Physician. 2008 Mar 1;77(5):700-704.

AAN Releases Recommendations for Treating Lyme Disease Neuroborreliosis

Guideline source: American Academy of Neurology

Literature search described? Yes

Evidence rating system used? Yes

Published source: Neurology, July 3, 2007

Available at: http://www.neurology.org/cgi/content/full/69/1/91

Lyme disease is a multisystem, tick-borne infection that often affects the nervous system (neuroborreliosis). Although guidelines are available for the treatment of general Lyme disease, the best treatment option for neuroborreliosis is unclear. The Quality Standards Subcommittee of the American Academy of Neurology (AAN) convened an expert panel to review the literature and determine the following: (1) which antimicrobial agents are effective or ineffective, (2) whether different regimens are preferred for different manifestations, (3) what duration of therapy is needed, and (4) whether prolonged regimens are more beneficial.

The subcommittee concluded that parenteral penicillin, ceftriaxone (Rocephin), cefotaxime (Claforan), and oral doxycycline (Vibramycin) are probably safe and effective therapies for neuroborreliosis without parenchymal involvement. Oral amoxicillin and cefuroxime (Ceftin) are alternatives to doxycycline, although research on their use is lacking. Parenteral regimens are usually used to treat neuroborreliosis; however, doxycycline may be as effective in patients with some neuroborreliosis-related diseases (Table 1).

Table 1

Treatment Options for Manifestations of Lyme Disease Neuroborreliosis

Disease Treatment options

Meningitis

Parenteral antibiotics, particularly if severe, or oral doxycycline (Vibramycin)

Any neurologic disease with pleocytosis

Parenteral antibiotics, particularly if severe, or oral doxycycline

Peripheral nerve diseases (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy); normal cerebrospinal fluid

Oral doxycycline or parenteral antibiotics if severe or if doxycycline therapy fails

Encephalomyelitis

Parenteral antibiotics

Encephalopathy

Parenteral antibiotics

Posttreatment Lyme syndrome

Symptomatic management, antibiotics are not indicated


note: Doxycycline is usually contraindicated in children younger than eight years and in pregnant or lactating women; oral amoxicillin and cefuroxime (Ceftin) are alternatives to doxycycline.

Adapted with permission from Halperin JJ, Shapiro ED, Logigian E, et al. 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. 2007;69:99.

Table 1   Treatment Options for Manifestations of Lyme Disease Neuroborreliosis

View Table

Table 1

Treatment Options for Manifestations of Lyme Disease Neuroborreliosis

Disease Treatment options

Meningitis

Parenteral antibiotics, particularly if severe, or oral doxycycline (Vibramycin)

Any neurologic disease with pleocytosis

Parenteral antibiotics, particularly if severe, or oral doxycycline

Peripheral nerve diseases (radiculopathy, diffuse neuropathy, mononeuropathy multiplex, cranial neuropathy); normal cerebrospinal fluid

Oral doxycycline or parenteral antibiotics if severe or if doxycycline therapy fails

Encephalomyelitis

Parenteral antibiotics

Encephalopathy

Parenteral antibiotics

Posttreatment Lyme syndrome

Symptomatic management, antibiotics are not indicated


note: Doxycycline is usually contraindicated in children younger than eight years and in pregnant or lactating women; oral amoxicillin and cefuroxime (Ceftin) are alternatives to doxycycline.

Adapted with permission from Halperin JJ, Shapiro ED, Logigian E, et al. 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. 2007;69:99.

Prolonged courses of antibiotics do not improve outcomes in patients with neuroborreliosis and may be associated with adverse effects; therefore, prolonged courses are not recommended. Table 2 presents antimicrobial agents and dosages used to treat neuroborreliosis.

The subcommittee recommends future research to further clarify the best treatment regimens for neuroborreliosis.

Table 2

Antimicrobial Regimens for the Treatment of Lyme Disease Neuroborreliosis

Medication Dosage
Adults Children

Oral regimens

Doxycycline* (Vibramycin)

100 to 200 mg, twice per day

Children eight years or older: 4 to 8 mg per kg per day in two divided doses, maximum is 200 mg per dose

Amoxicillin†

500 mg, three times per day

50 mg per kg per day in three divided doses, maximum dose is 500 mg per dose

Cefuroxime† (Ceftin)

500 mg, twice per day

30 mg per kg per day in two divided doses, maximum is 500 mg per dose

Parenteral regimens

Ceftriaxone (Rocephin)

2 g IV, once per day

50 to 75 mg per kg IV per day in one dose, maximum is 2 g per dose

Cefotaxime (Claforan)

2 g IV, every eight hours

150 to 200 mg per kg IV per day in three or four divided doses, maximum is 6 g per day

Penicillin G‡

18 to 24 million U per day in divided doses given every four hours

200 to 400,000 U per kg per day in divided doses given every four hours; maximum is 18 to 24 million U per day


note: The recommended duration for all regimens is 14 days. IV = intravenously.

* —Preferred therapy; usually contraindicated in children younger than eight years and in pregnant or lactating women.

—When doxycycline is contraindicated.

—Reduce dosage in patients with impaired renal function.

Adapted with permission from Halperin JJ, Shapiro ED, Logigian E, et al. 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. 2007;69:98.

Table 2   Antimicrobial Regimens for the Treatment of Lyme Disease Neuroborreliosis

View Table

Table 2

Antimicrobial Regimens for the Treatment of Lyme Disease Neuroborreliosis

Medication Dosage
Adults Children

Oral regimens

Doxycycline* (Vibramycin)

100 to 200 mg, twice per day

Children eight years or older: 4 to 8 mg per kg per day in two divided doses, maximum is 200 mg per dose

Amoxicillin†

500 mg, three times per day

50 mg per kg per day in three divided doses, maximum dose is 500 mg per dose

Cefuroxime† (Ceftin)

500 mg, twice per day

30 mg per kg per day in two divided doses, maximum is 500 mg per dose

Parenteral regimens

Ceftriaxone (Rocephin)

2 g IV, once per day

50 to 75 mg per kg IV per day in one dose, maximum is 2 g per dose

Cefotaxime (Claforan)

2 g IV, every eight hours

150 to 200 mg per kg IV per day in three or four divided doses, maximum is 6 g per day

Penicillin G‡

18 to 24 million U per day in divided doses given every four hours

200 to 400,000 U per kg per day in divided doses given every four hours; maximum is 18 to 24 million U per day


note: The recommended duration for all regimens is 14 days. IV = intravenously.

* —Preferred therapy; usually contraindicated in children younger than eight years and in pregnant or lactating women.

—When doxycycline is contraindicated.

—Reduce dosage in patients with impaired renal function.

Adapted with permission from Halperin JJ, Shapiro ED, Logigian E, et al. 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. 2007;69:98.



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