Drug | Adult dose | Pediatric dose | Comment | |
Erythema migrans (early disease) | ||||
Doxycycline¶Δ◊ | 100 mg orally twice daily for 10 days | 4.4 mg/kg/day orally divided twice daily (maximum 100 mg per dose) for 10 days |
| |
or Amoxicillin | 500 mg orally 3 times daily for 14 days | 50 mg/kg/day orally divided 3 times daily (maximum 500 mg per dose) for 14 days | ||
or Cefuroxime axetil | 500 mg orally twice daily for 14 days | 30 mg/kg/day orally divided twice daily (maximum 500 mg per dose) for 14 days | ||
Neurologic disease§ | ||||
Acute neurologic disease, such as:
| Doxycycline¶Δ◊ | 100 mg orally twice daily for 14 to 21 days | 4.4 mg/kg/day orally divided twice daily (maximum 100 mg per dose) for 14 to 21 days |
|
Severe neurologic disease, including encephalitis | Ceftriaxone¥‡ | 2 g IV once daily for 14 to 28 days | 50 to 75 mg/kg IV once daily (maximum 2 g per dose) for 14 to 28 days | |
Carditis | ||||
Mild (eg, asymptomatic patients with first-degree atrioventricular block and PR interval <300 milliseconds) | Doxycycline¶Δ◊ | 100 mg orally twice daily for 14 to 21 days | 4.4 mg/kg/day orally divided twice daily (maximum 100 mg per dose) for 14 to 21 days | |
or Amoxicillin | 500 mg orally 3 times daily for 14 to 21 days | 50 mg/kg/day orally divided 3 times daily (maximum 500 mg per dose) for 14 to 21 days | ||
or Cefuroxime axetil | 500 mg orally twice daily for 14 to 21 days | 30 mg/kg/day orally divided twice daily (maximum 500 mg per dose) for 14 to 21 days | ||
More serious disease (eg, symptomatic, second- or third-degree atrioventricular block, first-degree atrioventricular block with PR interval ≥300 milliseconds) | Ceftriaxone¥‡ | 2 g IV once daily for 14 to 21 days | 50 to 75 mg/kg IV once daily (maximum 2 g per dose) for 14 to 21 days |
|
Arthritis | ||||
Initial treatment† | Doxycycline¶◊ | 100 mg orally twice daily for 28 days | ≥8 years: 4.4 mg/kg/day orally divided twice daily (maximum 100 mg per dose) for 28 days◊ |
|
or Amoxicillin | 500 mg orally 3 times daily for 28 days | 50 mg/kg/day orally divided 3 times daily (maximum 500 mg per dose) for 28 days | ||
Persistent arthritis with little or no response to oral antibiotics (despite adequate prior oral therapy) | Ceftriaxone¥ | 2 g IV once daily for 14 to 28 days | 50 to 75 mg/kg IV once daily (maximum 2 g per dose) for 14 to 28 days |
|
or Doxycycline¶◊ | 100 mg orally twice daily for 28 days | ≥8 years: 4.4 mg/kg/day orally divided twice daily (maximum 100 mg per dose) for 28 days◊ | ||
or Amoxicillin | 500 mg orally 3 times daily for 28 days | 50 mg/kg/day orally divided 3 times daily (maximum 500 mg per dose) for 28 days | ||
Acrodermatitis chronica atrophicans | ||||
Doxycycline¶◊ | 100 mg orally twice daily for 21 to 28 days | 4.4 mg/kg/day orally divided twice daily (maximum 100 mg per dose) for 21 to 28 days◊ | ||
or Amoxicillin | 500 mg orally 3 times daily for 21 to 28 days | 50 mg/kg/day orally divided 3 times daily (maximum 500 mg per dose) for 21 to 28 days | ||
or Cefuroxime | 500 mg orally twice daily for 21 to 28 days | 30 mg/kg/day orally divided twice daily (maximum 500 mg per dose) for 21 to 28 days |
IV: intravenous.
* A complete response to treatment may be delayed beyond the treatment duration, regardless of the clinical manifestation of Lyme disease. However, in most patients with persistent symptoms the duration of treatment should not be extended.
¶ For pregnant and lactating patients, tetracyclines are generally avoided in favor of a beta-lactam (eg, amoxicillin, cefuroxime). In the setting of neurologic disease or contraindication to a beta-lactam, the decision to use doxycycline must be decided on a case-by-case basis. Although most tetracyclines are contraindicated in pregnancy because of the risk of hepatotoxicity in the mother and potential adverse effects on fetal bone and teeth, limited data suggest these events are extremely rare with doxycycline when short courses are used.
Δ Doxycycline also has activity against coinfections such as Anaplasma phagocytophilum and Borrelia miyamotoi but not against Babesia microti.
◊ The American Academy of Pediatrics supports the use of doxycycline for children <8 years of age if it is administered for ≤21 days. However, the data on safety of doxycycline in this population are limited, and some providers still prefer a beta-lactam rather than doxycycline unless there is evidence of neurologic disease or infection with Anaplasma. Studies have not evaluated the safety of doxycycline in children <8 years of age when the duration of treatment is >21 days (eg, Lyme arthritis).
§ For patients with neurologic disease, there are no studies to help guide length of therapy within the range suggested by the guidelines, and there are no diagnostic tests to determine clearance of infection or predict the success of therapy.
¥ Alternative IV agents include cefotaxime 2 g IV every 8 hours for 14 to 28 days for adults and 150 to 200 mg/kg/day in 3 divided doses (maximum 6 g per day) for children, or penicillin G 18 to 24 million units per day divided into doses given every 4 hours in adults and 200,000 to 400,000 units/kg/day divided every 4 hours (maximum 18 to 24 million units per day) in children.
‡ Doxycycline can be used in patients intolerant of beta-lactam antibiotics.
† On rare occasion, patients may present with late-stage neurologic disease and arthritis. In this setting, IV therapy is usually preferred for initial treatment.Do you want to add Medilib to your home screen?