Practice Parameter: Treatment of nervous system Lyme disease (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology [RETIRED]

Abstract

Objective: To provide evidence-based recommendations on the treatment of nervous system Lyme disease and post-Lyme syndrome. Three questions were addressed: 1) Which antimicrobial agents are effective? 2) Are different regimens preferred for different manifestations of nervous system Lyme disease? 3) What duration of therapy is needed? Methods: The authors analyzed published studies ) using a structured review process to classify the evidence related to the questions posed. Results: The panel reviewed 353 abstracts which yielded 112 potentially relevant articles that were reviewed, from which 37 articles were identified that were included in the analysis. Conclusions:There are sufficient data to conclude that, in both adults and children, this nervous system infection responds well to penicillin, ceftriaxone, cefotaxime, and doxycycline (Level B recommendation). Although most studies have used parenteral regimens for neuroborreliosis, several European studies support use of oral doxycycline in adults with meningitis, cranial neuritis, and radiculitis (Level B), reserving parenteral regimens for patients with parenchymal CNS involvement, other severe neurologic symptomatology, or failure to respond to oral regimens. The number of children (Ն8 years of age) enrolled in rigorous studies of oral vs parenteral regimens has been smaller, making conclusions less statistically compelling. However, all available data indicate results are comparable to those observed in adults. In contrast, there is no compelling evidence that prolonged treatment with antibiotics has any beneficial effect in post-Lyme syndrome (Level A). NEUROLOGY 2007;69:91-102

Diagnosis, treatment and prevention of Lyme borreliosis

“…13 Where there is encephalo myelitis there are insufficient data to indicate that oral therapy is not inferior and therefore an intravenous regimen is preferred (see Table 2). 14,15 The outcome following treatment is variable with age, duration of symptoms and severity of meningeal inflammation all influencing recovery. Follow-up of 102 appropriately treated patients in Norway found that 70 per cent had complete resolution of signs four months after treatment, with the remainder showing improvement.…”

The conflict on posttreatment Lyme disease syndrome: a clinical mini review

“…Additionally, all indicated known diagnostic workup regarding neuroborreliosis has to be negative. [1,2] A sufficient amount of data shows that patients with PTLDS have reduced life functioning than those without the syndrome, [3] or even when compared to patients with other chronic diseases. [4] Intuitively, the presence of PTLDS after recommended treatment is associated with significantly increased health care costs.…”

“…[1] Some already treated patients rarely develop a facial nerve palsy or meningitis. [1,2,6] Cranial neuritis, in most cases, appears to be benign, and it is attributed not to a persistent infection but to residual, irreversible neurologic damage. Conversely, if Lyme meningitis was developed shortly after the completion of a course of oral antimicrobial therapy, the patient undergoes another cycle of treatment with either ceftriaxone or with a similar parenteral antibiotic.…”

“…However, there is no scientific evidence that Borrelia burgdorferi persists in such patients. [1,2] Another study on patients with refractory late Lyme arthritis showed that these symptoms may persist for several years, but the incidence and severity of the symptoms do decrease over time, and the estimated number of individuals who continue to have recurrences is reduced by 10-20% each year. [7] The use of antibiotic regimen for a long time is not recommended, in fact, it does not improve patient outcome.…”

“…[8,9] Additionally, there is no clear evidence supporting the hypothesis that Lyme disease is a chronic, actively infectious disease requiring ongoing antibiotic therapy. [2,10,11] TO TREAT PTLDS In 2014, the International Lyme and Associated Diseases Society (ILADS) published its own treatment guidelines [12] for the management of Lyme disease patients, after adopting the GRADE scheme. [13] Among others, ILADS guidelines address the issue of antibiotic retreatment in patients with persistent symptoms.…”