Updated Lyme disease guide clarifies confusion

November 20, 2006

The Infectious Diseases Society of America (IDSA) recently updated its guidelines for the management of patients with Lyme disease, human granulocytic anaplasmosis (HGA, formerly known as human granulocytic ehrlichiosis), and babesiosis. Gary Wormser, M.D., lead author, said the guidelines were updated in response to mounting concern and confusion regarding Lyme disease. Wormser, who is also the chief of the division of infectious disease and vice-chairman of the department of medicine at the New York Medical College in Valhalla, went on to point out that the updated document differs from the previous guidelines, released in 2000, in several ways.

The guidelines, which are available on the IDSA Web site (http:// http://www.idsociety.org/), were published in the Nov. 1 issue of Clinical Infectious Diseases.

The new guidelines now include much more background information on Lyme disease and information regarding diagnosis, Wormser explained. He also said that borrelial lymphocytoma and acrodermatitis chronica atrophicans were cited as clinical manifestations of Lyme disease in the updated document.

Wormser continued by saying that the guidelines now recommend a single, 200-mg dose of doxycycline as chemoprophylaxis when the following conditions are met:

Wormser also said that the document now includes a very long, detailed discussion of post-Lyme syndromes.

According to the authors of the guidelines, early cutaneous infection with B. burgdorferi is called erythema migrans, which is the most common clinical manifestation of Lyme disease. They recommend doxycycline (100 mg taken twice per day) or cefuroxime axetil (500 mg twice per day) for approximately 14 days for the treatment of adults with early localized or early disseminated Lyme disease associated with erythema migrans, in the absence of specific neurologic complications (such as Lyme meningitis) or advanced atrioventricular heart block.

The authors stated that available data indicate that borrelial lymphocytoma may be treated with the same therapeutic regimens used to treat erythema migrans. Data also suggest that acrodermatitis chronica atrophicans may be treated with a 21-day regimen of the same antibiotics used to treat erythema migrans.

All symptomatic patients suspected of having HGA should be treated with antimicrobial therapy, because of the risk of complications, said the authors. They recommended doxycycline as the agent of choice, and said the appropriate dose for adults with symptomatic HGA is 100 mg taken twice daily for 10 days. Those with mild illness due to HGA, but for whom doxycycline therapy is not appropriate, may be treated with 300 mg of rifampin taken twice daily for seven to 10 days.

The authors cautioned that those with active babesiosis should also be treated with antimicrobials due to the risk of complications. For the treatment of this condition, they recommended a combination of either atovaquone and azithromycin or clindamycin and quinine for seven to 10 days.

The recommended dosage regimen for atovaquone plus azithromycin for adults is atovaquone, 750 mg administered orally every 12 hours, and azithromycin 500 mg to 1000 mg on day 1, and 250 mg taken once per day every day thereafter. The recommended dosage regimen for clindamycin and quinine for adults is clindamycin, 300 mg to 600 mg administered intravenously every six hours, or 600 mg administered orally every eight hours, and quinine 650 mg administered orally every six to eight hours.

Pharmacists should always consider the medication regimen in its entirety, including OTC and alternative therapies, advised Jim Hennig, R.Ph., the director of clinical services for Homecare Services in Metuchen, N.J. He added that pharmacists must be cognizant of alternative therapies such as hyperbaric oxygen and intravenous hydrogen peroxide, but that these therapies have always been very questionable.