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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
Erythema migrans
Early disseminated
Lyme arthritis
Refs Comment
(non-nervous system)
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. Lymen borrelioosin 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 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 Dermatologischen Gesellschaft 2009 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.
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 hos voksne. 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 fran Switzerland
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. Borreliose de 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;17:8-16 Late 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 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 Dis 2006; 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:
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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