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Extended use of antibiotics for Lyme disease increases
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Data collected from insurance claims suggested that the use of extended antibiotic regimens and multiple antibiotics for Lyme disease has increased in recent years.
However, there remains significant variability in the use of extended regimens and multiple drugs, the researchers wrote.
In the population-based retrospective cohort study, researchers evaluated insurance claims from a nationwide, employer-provided health insurance plan in the United States. Data from 2004 to 2006 and 2010 to 2012 was compiled and used for comparison. The study population comprised insurance plan enrollees from states with high rates of Lyme disease (LD), including Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia and Wisconsin.
Patients were originally included in the group of incident LD if they had at least one LD diagnostic code in the primary diagnosis field of a claim during either study interval. Cases were required to have documented blood test orders for Borrelia burgdorferi within 90 days before or after the two LD condition intervals. Treatment for LD was defined as a 2-week or longer course of one of the following antibiotics: amoxicillin, azithromycin, cefotaxime, ceftriaxone, cefuroxime axetil, clarithromycin, doxycycline, erythromycin or penicillin G within 30 days before or after the two LD condition intervals.
Compared with the mean annual rate of extended antibiotic therapy dispensed in 2004 to 2006 (9.94 per 100,000 person-years; n = 394), the prevalence of extended antibiotic regimens was greater in 2010 to 2012 (14.72 per 100,000 person-years; n = 684; P < .001). In the later interval, 48.8% of these patients were treated with more than two antibiotics as opposed to 29.9% during the earlier period (P < .001).
Patients were originally included in the group of incident LD if they had at least one LD diagnostic code in the primary diagnosis field of a claim during either study interval. Cases were required to have documented orders for serologic tests for Borrelia burgdorferi. Patients were treated with a 2-week or longer course of one of the following antibiotics, which were administered within 30 days before or after the two study intervals: amoxicillin, azithromycin, cefotaxime, ceftriaxone, cefuroxime axetil, clarithromycin, doxycycline, erythromycin or penicillin G. Cases were considered to have received extended treatment if antibiotic therapy persisted for more than 5 weeks.
According to the researchers, significant variation exists in the use of extended antibiotic regimens for LD, notwithstanding Infectious Diseases Society of America guidelines.
“Some of the variation in treatment patterns is likely generated by a belief that longer courses of treatment are better at preventing long-term consequences of LD, some of it may arise from belief that the persistence of LD symptoms requires more extended therapy, and a portion may be related to patient fear of the long-term consequences of LD from potential under-treatment,” the researchers wrote. – by Jen Byrne
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Eugene Shapiro, MD
This article documents what those who see patients concerned about Lyme disease already know: many patients who are diagnosed with Lyme disease (regardless of whether they actually have Lyme disease) are treated with unnecessarily long courses of antibiotics. B. burgdorferi, the bacterium that causes Lyme disease, is extremely susceptible to antibiotics. There has been no instance in which a strain of this bacterium has been found to be resistant to first-line antimicrobials, such as penicillin, amoxicillin or doxycycline. Moreover, there have been no studies that have indicated any benefit of treatment with extended courses of antibiotics, and there is good evidence that extended antimicrobial treatment is associated with substantial risks and adverse side effects.
The study by Tseng and colleagues shows that despite the scientific evidence, the proportion of patients diagnosed with Lyme disease who are receiving extended treatment (5 weeks or longer) with antimicrobials is increasing — up almost 50% from 2004-2006 to 2010-2012, nearly half of them received two or more different antibiotics. Also no surprise, a small group of doctors (3% to 4%) treated more than 20% of these patients. Why is this happening? We do not really know, though it would be easy to blame the misinformation and fearmongering that is rampant on the internet. No doubt, that contributes to the problem. And, no doubt, there are many patients with Lyme disease who are treated for an unnecessarily prolonged time. However, it is likely that many of these patients have persistent, nonspecific symptoms (sometimes known as “medically unexplained symptoms,” fibromyalgia or chronic fatigue syndrome) that are mislabeled or misdiagnosed as chronic Lyme disease. Sadly, there is a group of “Lyme-literate” doctors who cater to the subset of such patients who want to believe their persistent symptoms are due to Lyme disease and who promulgate the need for extended courses of antibiotic treatment. Unwittingly, the problem may be reinforced by doctors who know that these patients do not have Lyme disease, but who do not know how to help them. Doctors are good at treating diseases, but we are not so good at treating symptoms without a diagnosis. This is a complicated problem that will need our best efforts to solve.
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