Lyme Disease Prevention and Antibiotic Usage

Lyme Disease: Picture of a tick on a sign in the woods

(Adobe Stock 480211882 by 24K-Production)

Lyme disease is a bacterial infection caused by Borrelia burgdorferi and, less commonly, Borrelia mayonii.¹ 1It is transmitted to humans through the bite of infected black-legged ticks, predominantly in the Northeast, mid-Atlantic, and upper-Midwest regions of the US. Early symptoms typically include fever, headache, fatigue, and a distinctive skin rash called erythema migrans. If not treated promptly, the infection can spread to the joints, heart, and nervous system, leading to more severe health issues. Lyme disease is usually diagnosed based on symptoms and the likelihood of tick exposure, with laboratory tests providing additional confirmation. Most cases are effectively treated with antibiotics. To further explain, we answer Infection Control Today’s (ICT’s) questions.

ICT: What are the most effective strategies for preventing Lyme disease during the fall months, particularly in areas with high tick populations?

Anne Meneghetti, MD, and Walt Hadikin, MD: Lyme disease prevention strategies are important during summer and early fall months in areas in the US where the Ixodes tick is endemic, such as the Northeast, upper Midwest, and northern California.² The key to prevention is avoidance of tick bites and prolonged tick attachment. This includes avoidance of tick-infested areas (such as tall grass and wooded areas), wearing long sleeves and pants, tucking pants into socks, and opting for light-colored clothing to facilitate tick detection. Insect repellants such as DEET or picaridin are recommended for application to exposed skin areas, while permethrin may be used on clothing (but not skin).² After exposure to tick habitats, thorough skin checks are advised, focusing on the armpits, groin, scalp, neck, and head. Bathing within 2 hours and drying clothing on high heat for at least 1 hour can also help prevent disease. If a tick is found, it should be promptly removed with tweezers.²

ICT: Can you discuss the current recommendations for using antibiotics to treat Lyme disease and the potential risks of antimicrobial resistance associated with these treatments?

AM and WH: Lyme disease treatment varies by stage. Early localized Lyme, characterized by erythema migrans (EM) rash, typically requires 10 days of doxycycline or 14 days of amoxicillin or cefuroxime axetil. Early disseminated Lyme with multiple EM lesions and neurological or cardiac symptoms is treated with 14 to 21 days of doxycycline or intravenous ceftriaxone, cefotaxime, or penicillin G if doxycycline is contraindicated. Isolated facial nerve palsy may be treated with oral amoxicillin or cefuroxime axetil. Lyme carditis patients, if stable, receive 14 to 21 days of oral treatment; severe cases start with IV ceftriaxone, switching to oral therapy to complete 14 to 20 days. Lyme arthritis, a manifestation of late disseminated Lyme, is treated with a 28-day oral doxycycline course or amoxicillin or cefuroxime axetil. Lack of response may indicate the need for 2 to 4 weeks of IV ceftriaxone, with referral advised for no improvement post therapy.

Antibiotic resistance in Borrelia burgdorferi, Lyme’s causative agent, has not been seen, but broad-spectrum antibiotics could promote resistance in other bacteria.¹ Extended antibiotic courses beyond those that are recommended may promote such resistance. Adhering to guidelines for duration and choice of antibiotics is critical to avoid resistance risks.

For rapid access to guideline-recommended treatment options for the various stages and forms of Lyme disease, check out epocrates’ Lyme Disease Dx & Tx Guideline Synthesis, which is accessible on the mobile app and online.

ICT: What role do infection prevention and control professionals play in educating the public about Lyme disease prevention and the proper use of antibiotics?

AM and WH: Infection prevention and control specialists can be central to public health education about Lyme disease. This may involve educating the public by providing critical information on how to prevent Lyme disease, including avoiding tick-infested areas, using insect repellent, wearing protective clothing, and performing regular tick checks. They can also lead public awareness efforts about the early symptoms of Lyme disease and the importance of seeking timely medical intervention to facilitate early diagnosis and treatment. Infection control professionals can also work with frontline clinicians to promote the proper use of antibiotics when treating Lyme disease to mitigate risks of antimicrobial resistance.

They may also develop and distribute educational materials outlining practical tips for limiting tick exposure and educating the public about appropriate Lyme disease treatment, including information on posttreatment Lyme disease syndrome that affects a subset of patients (with estimates ranging between 5% and 30%) following Lyme disease treatment. This is especially important when vulnerable patients (and clinicians) are exposed to conflicting information from peers, friends, social media, and myriad other sources.

ICT: How can health care facilities better prepare for and manage increased Lyme disease cases during the fall, especially in preventing the spread of infection and minimizing antibiotic resistance?

AM and WH: As Lyme disease incidence continues its upward trend with no signs of slowing, health care organizations can take several proactive steps to prepare for Lyme disease cases this fall. Campaigns geared toward educating clinicians on the latest guidelines for prevention, diagnosis, and treatment will ensure that clinicians can spot the clinical manifestations of Lyme disease and institute early treatment. Public awareness campaigns will inform the community about preventive measures and the importance of seeking early intervention should signs or symptoms of Lyme disease appear.

Working with public health departments to monitor tick populations and infection rates can help predict possible outbreaks before they occur. Health care systems should encourage the use of preventive measures among the public, especially in high-tick population areas and during peak tick activity months. These actions, along with others such as the development of rapid response protocols, the use of telemedicine to promote early access to care, the maintenance of efficient reporting systems, and community engagement initiatives, will go a long way to addressing needs and gaps in Lyme disease care and control this fall.

ICT: Are there any recent advancements or research findings in preventing, diagnosing, or treating Lyme disease that infection prevention and control professionals should be aware of this fall?

AM and WH: The US has lacked an FDA-approved Lyme disease vaccine since LYMErix’s 2002 withdrawal. LYMErix, based on B burgdorferi’s outer surface protein A, was pulled due to low sales, safety concerns, and lawsuits. With rising Lyme cases and expanding tick habitats, vaccine development has been reinvigorated in recent years. Pfizer and Valneva’s VLA15 is in late trials, with FDA submission hoped for 2025. (same) Moderna has 2 mRNA vaccines in the pipeline, while University of Massachusetts researchers are exploring passive immunity with annual antibody administration.

CDC recommends 2-step serologic testing for Lyme, with an initial enzyme immunoassay [EIA] followed by a Western blot or another EIA. Early infection may yield false negatives, and persistent antibodies limit reinfection diagnosis. A new test developed at Tufts University detects autoantibodies against a host-derived substance B burgdorferi uses for growth, potentially improving diagnosis and treatment monitoring.

Hygromycin A, an antibiotic discovered in the 1950s that selectively inhibits
B burgdorferi is advancing to human trials this year. It’s a targeted Lyme treatment, unlike current broad-spectrum antibiotics, which risk resistance. Tulane University’s research on FGFR inhibitors offers a new approach to treating persistent neurological symptoms post-Lyme treatment.

Among the myths on The Global Lyme Alliance's list:

ICT: What are the common misconceptions about Lyme disease prevention, and how can infection prevention and control professionals effectively address these misconceptions?

AM and WH: The Global Lyme Alliance [GLA] released a list of common Lyme disease myths. Such misperceptions can impede effective prevention and treatment. Among the myths on GLA’s list: Lyme disease is always associated with erythema migrans rash. In fact, fewer than 50% of patients. See Figure.

Infection control professionals can help address these misconceptions about Lyme disease by educating the public using evidence-based materials, promoting tick-protective measures, including insect repellants and long-sleeved shirts, encouraging regular tick checks after outdoor exposure, and dispelling myths via community outreach initiatives and health education materials.

ICT: What measures can be taken to monitor and track Lyme disease cases during the fall to ensure timely intervention and minimize the impact on public health?

AM and WH: State and local health departments gather Lyme disease reports as part of their legal duties and surveillance efforts. To enhance these efforts and research, the CDC is developing improved platforms that utilize electronic health records from large health care systems in U.S. regions with a high incidence of Lyme disease, particularly the Northeast. The Surveillance-Based Lyme Disease Network collaborates with health care partners in Maine, Massachusetts, Pennsylvania, and Wisconsin. By integrating this data with conventional public health surveillance, the CDC seeks a more profound understanding of Lyme disease’s effects on the community.

References:

1. Lyme disease: About. CDC. Accessed October 14, 2024. https://www.cdc.gov/lyme/about/index.html
2. Lyme disease: Tick prevention. CDC. Accessed October 14, 2024. https://www.cdc.gov/ticks/prevention/index.html
3. Lyme disease vaccine approved by FDA. American Lyme Disease Foundation. Accessed October 14, 2024. https://aldf.com/vaccine/#:~:text=It%20might%20surprise%20you%20to,vaccine%20approved%20by%20the%20FDA
4. Clinical trials: mRNA-1975/1982-P101. Moderna. Accessed October 14, 2024. https://trials.modernatx.com/study/?id=mRNA-1975%2F1982-P101
5. Research points to potential new medical therapy for Lyme disease. University of Massachusetts Amherst. Accessed October 14, 2024. https://www.umass.edu/news/article/research-points-potential-new-medical-therapy-lyme-disease 
6. Lyme disease: Diagnosis and testing. CDC. Accessed October 14, 2024. https://www.cdc.gov/lyme/hcp/diagnosis-testing/index.html#:~:text=CDC%20recommends%20a%20two%2Dstep,and%20Drug%20Administration%20(FDA)
7. Potential new test for diagnosing Lyme disease. Tufts University. Accessed October 14, 2024. https://now.tufts.edu/2022/03/15/potential-new-test-diagnosing-lyme-disease
8. Targeted antibiotic for treating Lyme disease. National Institutes of Health. Accessed October 14, 2024. https://www.nih.gov/news-events/nih-research-matters/targeted-antibiotic-treating-lyme-disease
9. Lyme antibiotic treatment enters human trials. Northeastern University. Accessed October 14, 2024. https://news.northeastern.edu/2024/02/28/lyme-antibiotic-treatment-human-trials/
10. Crystal J. Top ten myths about Lyme disease. Global Lyme Alliance. April 6, 2020.