AAN Releases Recommendations for Treating Lyme Disease Neuroborreliosis

Amber Randel

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Mar 1, 2008 Issue

Practice Guidelines

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).

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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

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.

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.

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Table 2

Antimicrobial Regimens for the Treatment of Lyme Disease Neuroborreliosis

Medication	Dosage
Medication	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.

Table 2

Antimicrobial Regimens for the Treatment of Lyme Disease Neuroborreliosis

Medication	Dosage
Medication	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.

AMBER HUNTZINGER

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