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No evidence to support prolonged antibiotic use for Lyme disease
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While there are numerous critical issues surrounding the topic of chronic Lyme disease, the duration of time required to treat the disease with antibiotics remains one of the most contentious. Despite several clinical trials indicating otherwise, many Lyme disease advocates insist that the disease requires a prolonged course of multiple antibiotics to completely eradicate it, and avoid the development of ‘chronic’ Lyme disease.
Infectious Diseases in Children asked Johan S. Bakken, MD, PhD, FACP, FIDSA, past president of IDSA and an infectious disease physician at St. Luke’s Health Care System in Duluth, Minnesota, about whether there is any new evidence to support the use – and associated risks — of prolonged antibiotics for Lyme disease.
As has been well outlined in the Lyme disease Diagnosis and Treatment guidelines published by IDSA in Clinical Infectious Diseases in November 2006, doxycycline or a beta-lactam antibiotic agent administered for up to 28 days is the recommended therapy for Lyme disease.
In collaboration with American College of Rheumatology and the American Academy of Neurology, a guidelines update is currently under preparation and is expected to be out in the first quarter 2018, but to my knowledge, no new evidence has been introduced that calls for a revision with regards to choice of primary therapeutic agents nor for the duration/length of therapy.
There is no credible scientific evidence to suggest clinical benefit from treatment with either heavy metals, ozone, or silver, nor is there reproducible published clinical information in support of extended therapy with any antibiotic agents — including doxycycline or a beta-lactam agent — for more than 28 days. Other antibiotic agents, popular in the LLMD (‘Lyme literate’ medical doctor) community, include metronidazole, trimethoprim-sulfa, and others; none of these agents have demonstrated antimicrobial activity against B. burgdorferi sensu lato. Macrolides are also popular; they do have some activity, but are considered secondary choices, as treatment failures have been well described.
There is furthermore no evidence to suggest that the infectious process remains active in patients with confirmed Lyme disease who have completed a treatment course with a recommended antibiotic (PO or IV) administered for the recommended length of time (not to exceed 28 days). In contrast, there is substantial evidence that injudicious antibiotic administration may be harmful and cause serious and sometimes fatal infections in individual patients, including central line-related sepsis and Clostridium difficile-associated diarrhea. Furthermore, overuse of antibiotic agents is the primary driver of the increasing rates of antibiotic resistance observed in local and global communities.
Given all the evidence that argues for good antibiotic stewardship, I do not believe that the cost for courses of antibiotics extending beyond 28 days, even with the drugs of choice — doxycycline or beta-lactams — should be covered by third party payors for the treatment of Lyme disease.
Disclosure: Bakken reported no relevant financial disclosures.