Methodological Quality Assessment with the AGREE II Scale and a Comparison of European and American Guidelines for the Treatment of Lyme Borreliosis: A Systematic Review

Abstract

Background: Most European and American countries recently updated their guidelines on Lyme borreliosis (LB). The aim of this study was to provide a comparative overview of existing guidelines on the treatment of LB in Europe and America and to assess the methodological quality of their elaboration. Methods: A systematic search was carried out in MEDLINE, Google Scholar, and the national databases of scientific societies from 2014 to 2020. Quality was assessed by two independent reviewers using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Results: Twelve guidelines were included. The scores for the AGREE II domains (median ± IQR) were: overall assessment 100 ± 22, scope and purpose 85 ± 46, stakeholder involvement 88 ± 48, rigour of development 67 ± 35, clarity of presentation 81 ± 36, applicability 73 ± 52 and editorial independence 79% ± 54%. Cohen’s weighted kappa showed a high agreement (K = 0.90, 95%CI 0.84–0.96). Guidelines were quite homogeneous regarding the recommended molecules (mostly doxycycline in the first intention and ceftriaxone in the second intention), their duration (10 to 28 days), and their dosage. The differences were due to the lack of well-conducted comparative trials. The International Lyme and Associated Diseases Society (ILADS) guidelines were the only ones to suggest longer antibiotics based on an expert consensus. Conclusion: European and American guidelines for the treatment of LB were quite homogeneous but based on moderate- to low-evidence studies. Well-conducted comparative trials are needed to assess the best molecules, the optimal duration and the most effective doses.

Multidisciplinary Management of Suspected Lyme Borreliosis: Clinical Features of 569 Patients, and Factors Associated with Recovery at 3 and 12 Months, a Prospective Cohort Study

“…Treatment of LB relies on antibiotic therapy for 10–28 days according to its stage and its clinical manifestation [ 15 , 17 ]. No studies have yet proven to be of benefit for longer treatment [ 18 , 19 , 20 , 21 , 22 ].…”

Unusual Presentation of Acrodermatitis Chronica Atrophicans Resulting in Delay of Diagnosis and Inappropriate Treatment in Three Cases

“…In the case of ACA, acrocyanosis, acute arthritis, cellulitis, livedo reticularis, complex regional pain syndrome, hypodermitis in chronic venous insufficiency, eosinophilic fasciitis, and erythromelalgia may be considered differential diagnoses [24]. In accordance with a recent review on international guidelines for LD treatment, recommendations for antibiotic choice are relatively homogeneous across the countries [25]. Doxycycline (200 mg/d) is recommended to treat ACA in all guidelines and ceftriaxone (2 g/d) in almost all guidelines, particularly if associated with neuroborreliosis.…”

“…However, there is no explicit recommendation for ACA in this setting. In pregnancy, amoxicillin is the first-line agent in all published guidelines, whereas azithromycin is the second-line agent according to French guidelines and penicillin G or ceftriaxone is the second-line therapy according to German guidelines [25].…”

Acceptance of diagnosis and management satisfaction of patients with “suspected Lyme borreliosis” after 12 months in a multidisciplinary reference center: a prospective cohort study

“…European guidelines recommend a mono-antibiotic therapy for LB treatment. The therapy should be given for 14 to 28 days according to the infection’s stage and its clinical manifestation [ 6 , 7 ]. No studies have yet proven the clinical benefit of a longer antibiotic treatment [ 8 – 12 ].…”