Treatment for Children with Borrelia burgdorferi (Lyme Disease)

First-line Treatment Options

The Infectious Diseases Society of America recommends amoxicillin as the preferred treatment for children under 8 years old with Lyme disease, with a dosage of 50 mg/kg per day in 3 divided doses for 14 days 1, 2
For children over 8 years old, the Infectious Diseases Society of America recommends doxycycline as a first-line treatment option, with a dosage of 4 mg/kg per day in 2 divided doses for 14 days 1, 2
Cefuroxime axetil is an alternative option for children under 8 years old, with a dosage of 30 mg/kg per day in 2 divided doses for 14 days 2, 3

Doxycycline has the advantage of being effective for treatment of human granulocytic anaplasmosis (HGA) which may occur simultaneously with early Lyme disease, and should be taken with 8 ounces of fluid to reduce esophageal irritation and with food to reduce gastrointestinal intolerance 1, 4, 5
Patients on doxycycline should avoid sun exposure due to risk of photosensitivity 4, 6

The standard duration for oral therapy in early Lyme disease is 14 days 1, 4
If doxycycline is used, 10 days of therapy is sufficient 4, 6
For β-lactam antibiotics (amoxicillin, cefuroxime axetil), a full 14-day course is recommended due to their shorter half-life 4, 6

If neurological involvement is present (meningitis, radiculopathy), parenteral therapy with ceftriaxone (50-75 mg/kg per day, maximum 2g) is recommended 1, 7
First-generation cephalosporins such as cephalexin are ineffective for Lyme disease and should not be used 3, 4
Macrolide antibiotics (azithromycin, clarithromycin, erythromycin) should only be used when patients cannot tolerate first-line agents, as they are less effective 2, 4

Most patients respond promptly and completely to appropriate antibiotic therapy, but less than 10% of individuals do not respond to antibiotic therapy as evidenced by persistent objective clinical manifestations 4, 6
Patients who are more systemically ill at diagnosis may take longer to have a complete response to therapy 4, 6
Patients treated with macrolides should be closely observed to ensure resolution of clinical manifestations 1, 8

Using first-generation cephalosporins like cephalexin, which are ineffective against B. burgdorferi 3, 4
Prescribing fluoroquinolones, carbapenems, or other antibiotics not recommended for Lyme disease 2, 8
Using long-term antibiotic therapy, which lacks supporting data and may cause harm 2, 8

The American Academy of Pediatrics and the Infectious Diseases Society of America recommend against using macrolide antibiotics, such as azithromycin, clarithromycin, and erythromycin, as first-line therapy for Lyme disease due to their lower efficacy compared to amoxicillin or doxycycline in patients with carditis and advanced heart block 9
The Infectious Diseases Society of America advises against using first-generation cephalosporins, such as cefalexin, and recommends against using macrolide antibiotics as first-line therapy for Lyme disease, as they are significantly less effective than amoxicillin or doxycycline in patients with neurological involvement, including meningitis, cranial nerve palsy, or radiculopathy 9

The Infectious Diseases Society of America recommends switching to intravenous ceftriaxone (50-75 mg/kg/day, maximum 2g daily) if the child develops carditis with advanced heart block 9