Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

known high risk tick bite

1st line – single-dose antibiotic prophylaxis

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INITIAL
|
known high risk tick bite
1st line – 

single-dose antibiotic prophylaxis

Postexposure prophylaxis with a single dose of doxycycline may be used for a significant exposure meeting all of the following criteria:[25][22]​​[53]

1. High-risk tick bite: an Ixodes tick bite; at least an estimated 36 hours of attachment; and in an area highly endemic for Lyme disease.

2. Prophylaxis is started within 72 hours of tick removal.

3. Doxycycline is not contraindicated. Doxycycline is not recommended during pregnancy and lactation. In some countries outside of the US, doxycycline is not recommended in younger children; consult your local guidance.

An area with Borrelia burgdorferi prevalence of >20% in local ticks is considered a highly endemic area.[25]

Patients who cannot take doxycycline are started on treatment if early symptoms develop.

Primary options

doxycycline: children: 4.4 mg/kg/day orally as a single dose, maximum 200 mg/dose; adults: 200 mg orally as a single dose

ACUTE

erythema migrans

1st line – oral antibiotic therapy

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ACUTE
|
erythema migrans
|
classic presentation
1st line – 

oral antibiotic therapy

Oral antibiotics are recommended for patients with Lyme disease (local or disseminated) with erythema migrans, in the absence of cardiovascular or neurological manifestations: doxycycline for 10 days; or, amoxicillin or cefuroxime for 14 days.

Doxycycline, amoxicillin, or cefuroxime may be used in children.[25][47] In some countries outside of the US, doxycycline is not recommended in younger children; consult your local guidance

Doxycycline is not recommended during pregnancy and lactation. Amoxicillin is the preferred treatment.

Macrolides (e.g., azithromycin) are not recommended as first-line treatment. They should be reserved for patients with intolerance or allergy to first-line agents, with close monitoring for resolution of symptoms. In the US, macrolides are generally felt to be less effective than amoxicillin, based upon findings from a randomised trial, which demonstrated improved resolution of symptoms and reduced risk of relapse in patients treated with amoxicillin compared with those treated with azithromycin.[48]

Treatment course: 10 days (doxycycline); 14 days (amoxicillin, cefuroxime); 7-10 days (azithromycin). In the UK, longer courses are recommended: 21 days for doxycycline and amoxicillin, and 17 days for azithromycin.[33]

Primary options

doxycycline: children: 2.2 mg/kg orally twice daily, maximum 100 mg/dose; adults: 100 mg orally twice daily

OR

amoxicillin: children: 50 mg/kg/day orally given in 3 divided doses, maximum 500 mg/dose; adults: 500 mg orally three times daily

OR

cefuroxime: children: 30 mg/kg/day orally given in 2 divided doses, maximum 500 mg/dose; adults: 500 mg orally twice daily

Secondary options

azithromycin: children: 10 mg/kg/day orally once daily, maximum 500 mg/day; adults: 500 mg orally once daily

1st line – oral antibiotic therapy

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ACUTE
|
erythema migrans
|
indistinguishable from cellulitis
1st line – 

oral antibiotic therapy

When erythema migrans cannot be distinguished from cellulitis, cefuroxime or amoxicillin/clavulanate is recommended.

Various studies have used 10 to 21 days of treatment, but these have not been compared head to head. In most cases 14 days is adequate, but there is not complete consensus.

Primary options

cefuroxime: children: 30 mg/kg/day orally given in 2 divided doses, maximum 500 mg/dose; adults: 500 mg orally twice daily

OR

amoxicillin/clavulanate: adults: 500 mg orally three times daily

More

cardiac involvement

1st line – oral antibiotic therapy

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ACUTE
|
cardiac involvement
|
not at risk of severe cardiac complications
1st line – 

oral antibiotic therapy

Oral antibiotic therapy is recommended for patients who do not need to be hospitalised.[25]

Antibiotic therapy is recommended for 14-21 days.[25]

Doxycycline is not recommended during pregnancy and lactation. In some countries outside of the US, doxycycline is not recommended in younger children; consult your local guidance.

Primary options

doxycycline: children: 2.2 mg/kg orally twice daily, maximum 100 mg/dose; adults: 100 mg orally twice daily

OR

amoxicillin: children: 50 mg/kg/day orally given in 3 divided doses, maximum 500 mg/dose adults: 500 mg orally three times daily

OR

cefuroxime: children: 30 mg/kg/day orally given in 2 divided doses, maximum 500 mg/dose; adults: 500 mg orally twice daily

1st line – intravenous antibiotic therapy

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ACUTE
|
cardiac involvement
|
with or at risk of severe cardiac complications
1st line – 

intravenous antibiotic therapy

Intravenous antibiotics, hospitalisation, and continuous ECG monitoring are recommended for patients with or at risk for severe cardiac complications, including those with chest pain, syncope, dyspnoea, atrioventricular block, PR interval ≥300 milliseconds, other arrhythmias, or clinical manifestations of myopericarditis.[25]

Ceftriaxone is the drug of choice for both adults and children.

Alternative agents include cefotaxime or benzylpenicillin.

Doxycycline is an alternative agent for patients with cardiac complications who are intolerant of penicillins or cephalosporins, but it is not recommended during pregnancy and lactation. In some countries outside of the US, doxycycline is not recommended in younger children; consult your local guidance.

Patients may be switched to oral antibiotic therapy when there is evidence of clinical improvement.

Antibiotic therapy is recommended for 14-21 days.[25]

Primary options

ceftriaxone: children: 50-75 mg/kg/day intravenously once daily, maximum 2000 mg/dose; adults: 2 g intravenously once daily

Secondary options

benzylpenicillin sodium: children: 25-50 mg/kg intramuscularly/intravenously every 4-6 hours, maximum 2.4 g every 4 hours; adults: 2.4 g intramuscularly/intravenously every 4-6 hours

OR

cefotaxime: children: 150-200 mg/kg/day intravenously given in 3-4 divided doses, maximum 2000 mg/dose; adults: 2 g intravenously every 8 hours

Tertiary options

doxycycline: children: 2.2 mg/kg intravenously twice daily, maximum 100 mg/dose; adults: 100 mg intravenously twice daily

More

Consider – temporary pacemaker

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ACUTE
|
cardiac involvement
|
with or at risk of severe cardiac complications
Consider – 

temporary pacemaker

Additional treatment recommended for SOME patients in selected patient group

Temporary pacing is recommended for patients with symptomatic bradycardia who cannot be managed medically.[25]​​

neurological disease

1st line – oral or intravenous antibiotic therapy

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ACUTE
|
neurological disease
|
early symptoms with no parenchymal involvement
1st line – 

oral or intravenous antibiotic therapy

Patients with early neurological symptoms of Lyme disease confined to the meninges (including meningitis), cranial nerves, nerve roots, or peripheral nerves (Bannwarth syndrome) can be treated with a 2-week course of either an oral antibiotic (doxycycline) or an intravenous antibiotic (ceftriaxone, cefotaxime, or benzylpenicillin).[25][34]

Patients with Lyme disease-associated facial palsy should be treated with antibiotics; US guidelines recommend oral doxycycline.[25] Corticosteroids may have been started, as they are used for the treatment of idiopathic facial nerve palsy; however, they may be discontinued if the cause is identified as borreliosis.[25]

Doxycycline is not recommended during pregnancy and lactation. In some countries outside of the US, doxycycline is not recommended in younger children; consult your local guidance.

Treatment decisions for patients with both joint and neurological involvement are based on an individual patient's circumstances under specialist supervision.

Primary options

doxycycline: children: 2.2 mg/kg orally twice daily, maximum 100 mg/dose; adults: 100 mg orally twice daily

OR

ceftriaxone: children: 50-75 mg/kg/day intravenously once daily, maximum 2000 mg/dose; adults: 2 g intravenously once daily

OR

cefotaxime: children: 150-200 mg/kg/day intravenously given in 3-4 divided doses, maximum 2000 mg/dose; adults: 2 g intravenously every 8 hours

OR

benzylpenicillin sodium: children: 25-50 mg/kg intramuscularly/intravenously every 4-6 hours, maximum 2.4 g every 4 hours; adults: 2.4 g intramuscularly/intravenously every 4-6 hours

1st line – oral or intravenous antibiotic therapy

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ACUTE
|
neurological disease
|
late symptoms confined to peripheral nervous system
1st line – 

oral or intravenous antibiotic therapy

For late Lyme disease with peripheral neuropathy and acrodermatitis chronica atrophicans, treatment with either oral doxycycline or intravenous ceftriaxone for 3 weeks is recommended.[25][34]

Doxycycline is not recommended during pregnancy and lactation. In some countries outside of the US, doxycycline is not recommended in younger children; consult your local guidance.

Treatment decisions for patients with both joint and neurological involvement are based on an individual patient's circumstances under consultant supervision.

Primary options

doxycycline: children: 2.2 mg/kg orally twice daily, maximum 100 mg/dose; adults: 100 mg orally twice daily

OR

ceftriaxone: children: 50-75 mg/kg/day intravenously once daily, maximum 2000 mg/dose; adults: 2 g intravenously once daily

1st line – intravenous ceftriaxone

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ACUTE
|
neurological disease
|
central nervous system manifestations
1st line – 

intravenous ceftriaxone

Patients with manifestations such as myelitis, encephalitis, and vasculitis require intravenous ceftriaxone for 2 weeks (for early symptoms) or 3 weeks (for late symptoms).[34]

Patients with evidence of parenchymal Lyme disease on neurological exam or MRI findings should be treated with intravenous antibiotics for 2-4 weeks.[25][34]

Treatment decisions for patients with both joint and neurological involvement are based on an individual patient's circumstances under consultant supervision.

Primary options

ceftriaxone: children: 50-75 mg/kg/day intravenously once daily, maximum 2000 mg/dose; adults: 2 g intravenously once daily

arthritis

1st line – oral antibiotic therapy

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ACUTE
|
arthritis
1st line – 

oral antibiotic therapy

Lyme arthritis can be treated with the same preferred oral regimens as for uncomplicated Lyme disease, for an extended period of treatment (28 days total).[25][47]

Doxycycline is not recommended during pregnancy or lactation. In some countries outside of the US, doxycycline is not recommended in younger children; consult your local guidance.

Treatment decisions for patients with both joint and neurological involvement are based on an individual patient's circumstances under consultant supervision.

Primary options

doxycycline: children: 2.2 mg/kg orally twice daily, maximum 100 mg/dose; adults: 100 mg orally twice daily

OR

amoxicillin: children: 50 mg/kg/day orally given in 3 divided doses, maximum 500 mg/dose; adults: 500 mg orally three times daily

OR

cefuroxime: children: 30 mg/kg/day orally given in 2 divided doses, maximum 500 mg/dose; adults: 500 mg orally twice daily

Secondary options

azithromycin: children: 10 mg/kg/day orally once daily, maximum 500 mg/day; adults: 500 mg orally once daily

Consider – non-steroidal anti-inflammatory drugs

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ACUTE
|
arthritis
Consider – 

non-steroidal anti-inflammatory drugs

Additional treatment recommended for SOME patients in selected patient group

Non-steroidal anti-inflammatory drugs can be used for symptom relief for Lyme arthritis, along with antibiotic therapy.

Primary options

diclofenac potassium: adults: 50 mg orally (immediate-release) three times daily when required

OR

ibuprofen: children: 10 mg/kg/dose orally every 4-6 hours when required, maximum 40 mg/kg/day; adults: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

ONGOING

recurrent or persistent arthritis

1st line – intravenous antibiotic therapy

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ONGOING
|
recurrent or persistent arthritis
1st line – 

intravenous antibiotic therapy

Patients with persistence or recurrence of arthritis symptoms after an initial course of oral antibiotics should receive a 2- to 4-week course of intravenous ceftriaxone.[25][54][55]

Patients with arthritis who are non-responsive to antibiotic treatment should be referred to a rheumatologist for further work-up and appropriate treatment of other causes.

Primary options

ceftriaxone: children: 50-75 mg/kg/day intravenously once daily, maximum 2000 mg/dose; adults: 2 g intravenously once daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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