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Recommendations for diagnosis and treatment of Lyme borreliosis: guidelines and consensus papers from specialist societies and expert groups in Europe and North America
Sue O'Connell, Health Protection Agency Lyme Borreliosis Unit, HPA Microbiology Laboratory,
Southampton University Hospitals NHS Trust, Southampton SO16 6YD
Introduction European and American Lyme Borreliosis Diagnostic / Treatment Guidelines First line treatment recommendations for non-pregnant, non-breastfeeding adults – See individual guidelines for further details
The European Union Concerted Action on Lyme Borreliosis (EUCALB) initiative,
Diagnostic / Treatment Guideline Diagnostic Erythema migrans Early disseminated Neuroborreliosis Lyme arthritis Refs Comment criteria cited(1) (non-nervous system) specified?
funded initially by the EU, continues to promote research and evidence-based
Czech Republic Vanousova D, Hercegova J. Lyme borreliosis
clinical practice through European multi-disciplinary collaboration and a highly-
treatment. Dermatol Ther 2008;21:101-9.
Doxycycline 100-200mg bd Doxycycline 100-200mg bd
regarded and frequently updated website. Its clinical case definitions for Lyme
borreliosis were published in 1997. An updated version has been published on-line
Dansk Selskab for Klinisk Mikrobiologi, Dansk
Doxycycline 200mg stat then Penicillin V 1.5MIU tid
Selskab for Infektions medicin og Dansk
Doxycycline 200mg bd on day 1, then 100mg bd
(Clin Microbiol Infect 2010 doi:10.1111/j.1469-0691.2010.03175.x). EUCALB’s
Dessau R, Bangsborg JM, Ejlertsen TP et al.
Ceftriaxone 2g daily or Cefotaxime 2g tid
work programme also includes a review of currently recommended treatments in
Ugeshr Laeger 2006:1682805-7 (summary)
(10 days)Agents given for 14 days for late NB
Europe and the evidence on which they are based. Oksi J, Seppala IJ, Hytonen J. Lymenborrelioosin diagnostiikka ja hoito. Duodecim
Since the publication of the Infectious Diseases Society of North America’s
updated guidelines for Lyme borreliosis in 2006 there has been considerable public
Societe de Pathologie Infectieuse de Langue
dispute in the USA and elsewhere regarding choice of antibiotic agents and
Francaise. Lyme borreliosis: diagnostic, therapeutic and preventive approaches. Med
Doxycycline 200mg daily (isolated facial palsy
duration of antibiotic treatment for Lyme borreliosis, particularly for patients who
[14-21days] or if other agents contraindicated
have persistent symptoms following standard treatment. Some patient support
Leitlinien der Deutschen Gesellschaft fur
Ceftriaxone 2g daily or Cefotaxime 2g tid or
groups and a minority of physicians have been very active in promoting prolonged
http://leitlinien.net/ AWMF Leitlinien-Register
(Acute neuroborreliosis: 14 days)
or multiple courses of antibiotics for patients with persistent symptoms in North
(Late NB: iv first line: 14-21 days)
America and in Europe. There has also been criticism about the use of the IDSA
Leitlinien der Deutschen DermatologischenGesellschaft 2009 http://leitlinien.net/ AWMF
guidelines for patients in Europe, prompting this evaluation of European guidelines
(14-21 days) or Azithromycin 250mg bd
and recommendations and a comparison with American recommendations. Netherlands CBO Richtlijn Lyme Borreliose 2004 ISBN:
(Acute neuroborreliosis: 14 days; late NB: 30
Speelman P, de Jongh BM, Wolfs TF, Wittenberg ; CBO. Ned Tijdschr Geneeskd
(Acute neuroborreliosis: 21 days; late NB: 30
Ljostad U, Mygland A.Lyme-borreliose hosvoksne. Tidsskr Nor Legeforen 2008; 128:
EUCALB participants collated diagnostic and treatment guidelines prepared
Norsk legemiddelhåndbok for helsepersonell
independently by specialist societies and expert groups in various European
countries and in North America. National and/or specialist society guidelines and
Flisiak R, Pancewicz S. Diagnosis and
Cefuroxime axetil 500mg bd Cefuroxime axetil 500mg bd Penicillin G 3-4 MIU four-hourly
recommendations of the Polish Society of
recommendations of experts from the Czech Republic, Denmark, Finland, France,
Epidemiology and Infectious Diseases. Przegl
Germany, the Netherlands, Norway, Poland, Slovenia, Sweden and Switzerland
Slovenia Strle F. Principles of the diagnosis and
Amoxicillin 500mg – 1g tid or Amoxicillin or
have been evaluated and compared with regard to clinical and laboratory
antibiotic treatment of Lyme borreliosis. Wien
diagnostic and treatment recommendations (including antibiotic agents, dosages
and durations) for erythema migrans, neuroborreliosis and Lyme arthritis. They
Doxycycline 100mg bd (10 Doxycycline 200mg daily (14 days) or
have also been compared to those of the IDSA and the American Academy of
Lakemedelsbehandling av borreliainfektion -ny recommendation. Information franSwitzerland
Ceftriaxone 2g daily or Penicillin G 3-4MIU x
The first-line treatment recommendations of the various European and North
Evison J, Aebi C, Francioli P et al. Borreliosede Lyme. Diagnostic et traitement de la
American guidelines are presented in tabular form to permit easy comparison. borreliose de Lyme chez l’adulte et l’enfant: recommandations de la Societe Suisse
Doxycycline 100mg bd or ceftriaxone 2 g daily
d’Infectiologie. Rev Med Suisse 2006; 2, 19-European Federation of Neurological Early NB without encephalitis, myelitis or Societies Mygland A, Ljostad U, Fingerle V et al.
Doxycycline 200mg daily or Ceftriaxone 2g daily
European Federation of Neurological Findings Societies guidelines on the diagnosis and neuroborreliosis Eur J Neurol 2010;17:8-16Late encephalomyelitis or vasculitis:Ceftriaxone 2g daily (21 days)ACA and peripheral neuropathy:
The majority of guidelines and reviews listed here give explicit details about quality
Doxycycline 200mg daily or Ceftriaxone 2g daily
of evidence and strength of recommendations. They list references of published
EUCALB website
Ceftriaxone 2g daily or Cefotaxime 2g tid or European Union Concerted Action on Lyme
randomised controlled treatment trials and numerous other peer-reviewed papers
http://meduni09.edis.at/eucalb/cms/index.php
Cefuroxime axetil 500mg bd Penicillin V 1g tid or
on diagnosis and management of Lyme borreliosis in the international literature.
All guidelines give recommendations for clinical diagnosis and for the application of
Wormser GP, Dattwyler DJ, Shapiro ED et al. The clinical assessment, treatment and
Cefuroxime axetil 500mg bd Penicillin G 3-4MIU x 6/day
laboratory tests. There is overall agreement regarding the clinical features of Lyme
prevention of Lyme disease, human
Cefuroxime axetil 500mg bd (14 days; range 14-21)
granulocytic anaplasmosis and babesiosis. Clinical Practice Guidelines by the Infectious
borreliosis and on the requirement for supporting laboratory evidence of a clinical
Diseases Society of America. Clin Infect Dis2006; 43, 1089-1134.
diagnosis of later-stage infection. Two-tier serological testing, with immunoblot as a
Halperin JJ, Shapiro ED, Logigian E et al.
second-stage test, is currently recommended in most guidelines and reviews. No
Practice Parameter: Treatment of nervous system Lyme disease (an evidence-based review) Report of the Quality Standards
guideline or review recommends serological testing in support of a diagnosis of
Subcommittee of the American Academy of Neurology. Neurology 2007;69:1-12.
1. Refs cited: Number of references cited in the guideline.
Overall there are great similarities of antibiotic choice between the various
2. NRVPMT = No recommendation for very prolonged or multiple courses of treatment
3. Netherlands references are for the treatment section only. (38)
4. Norwegian references are for the summary only. (50)
treatment guidelines and reviews, with some minor differences in dosing and
5. IDSA references are for the complete guideline, including diagnosis, treatment and prevention of Lyme borreliosis, anaplasmosis and babesiosis (405)
Comments The most commonly recommended first-line treatments for different stages of Lyme borreliosis in non-pregnant, non-breastfeeding adults in Europe are:
There are only minor differences in antibiotic treatment recommendations, with two
Scandinavian countries favouring the use of high dose penicillin V over amoxicillin as first-
Erythema migrans:
choice B-lactam agent for erythema migrans, and slightly shorter treatment courses.
Doxycycline 100mg bd (10-21days) or
Doxycycline is widely recommended for treatment of all stages of Lyme borreliosis other
Ceftriaxone is the antibiotic most widely recommended for parenteral use. Early neuroborreliosis:
The most recently prepared guidelines have stronger recommendations for the use of
doxycycline in neuroborreliosis without encephalitic or myelitic features, following
publication in 2008 of a Norwegian double-blind randomised controlled trial which showed
non-inferiority of oral doxycycline 200mg daily versus intravenous ceftriaxone 2g daily for
Late neuroborreliosis:
14 days. (Ljostad U et al. Lancet Neurology 2008;7:690-95)
No evidence-based European or North American guideline recommends prolonged or
multiple courses of antibiotics for persistent symptoms following previously treated Lyme
Lyme arthritis: Acknowledgements
I am most grateful to Drs Ram Dessau, Volker Fingerle, John Halperin, Joppe Hovius, Janusz Janiec, Benoit Jaulhac, Satu
These recommendations, independently developed by a wide range of European
Kurkela, Marjorie Monnickendam, Dag Nyman, Katharina Ornstein, Tone Skarpaas, Robert Smith, Gary Wormser, Mrs Anne
experts in infectious diseases and other specialities, are similar to those of the
Southwell, Miss Nicki Daughtrey and Mr Derek Nudd for their support in the development of this work. I thank Ms Loraine Chant,
Adriana Falcinelli and colleagues at SUHT Learning Media for skilled help and patience in poster preparation.
We should be most grateful for notification of other evidence-based European guidelines to EUCALB for collation.
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