Red Book 28e
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Lyme Disease


Consensus practice guidelines for assessment, Treatment, and prevention of Lyme disease have been published by the Infectious Diseases Society of America. Care of children should follow recommendations in Table 3.33. Antimicrobial therapy for nonspecific symptoms or for asymptomatic seropositivity or by routes of administration or durations not specified in Table 3.33 is discouraged. Use of alternative diagnostic approaches or therapies recommended by other groups or people also is discouraged.

Table 3-33

Early Localized Disease

Doxycycline is the drug of choice for children 8 years of age and older and, unlike amoxicillin, also treats patients with anaplasmosis. For children younger than 8 years of age, amoxicillin is recommended. For patients who are allergic to penicillin, the alternative drug is cefuroxime. Erythromycin and azithromycin are less effective. Most experts treat people with early Lyme disease for 14 to 21 days.

Treatment of erythema migrans almost always prevents development of later stages of Lyme disease. Erythema migrans usually resolves within several days of initiating Treatment, but other signs and symptoms may persist for several weeks, even in successfully treated patients.

Early Disseminated and Late Disease

Orally administered antimicrobial agents are recommended for treating multiple erythema migrans and uncomplicated Lyme arthritis. Oral agents also are appropriate for Treatment of facial nerve palsy without Clinical Manifestations of meningitis; lumbar puncture is not indicated. If symptoms or signs of other central nervous system involvement, such as meningitis or raised intracranial pressure, are present, lumbar puncture is performed. If cerebrospinal fluid pleocytosis is found, parenterally administered antimicrobial therapy is indicated. Up to one third of patients with arthritis have persistence of synovitis and joint swelling at the conclusion of antimicrobial therapy, which almost always resolves without repeating the course of antimicrobial therapy. Some experts would treat a patient who has recurrent or persistent arthritis after Treatment with one course of oral antimicrobial therapy with another course of oral antimicrobial therapy. Central nervous system infection should be treated with parenterally administered antimicrobial therapy. The optimal duration of therapy for manifestations of early disseminated or late disease is not well established, but there is no evidence that children with any manifestation of Lyme disease benefit from prolonged courses of orally or parenterally administered antimicrobial agents. Accordingly, the maximum duration of a single course of therapy is 4 weeks (see Table 3.33).

The Jarisch-Herxheimer reaction (an acute febrile reaction accompanied by headache, myalgia, and an aggravated clinical picture lasting less than 24 hours) can occur when therapy is initiated. Nonsteroidal anti-inflammatory agents may be beneficial, and the antimicrobial agent should be continued.


Tetracyclines are contraindicated. Otherwise, therapy is the same as recommended for nonpregnant people.

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