Lyme Disease Treatment Guidelines

Adult Dosing

The American College of Physicians and the Infectious Diseases Society of America recommend doxycycline 100 mg orally twice daily for 10-14 days for early Lyme disease in adults 1, 2
Doxycycline has the added advantage of treating co-infection with Human Granulocytic Anaplasmosis (HGA), which may occur simultaneously 1, 2
For neurologic manifestations, doxycycline 200-400 mg per day orally in 2 divided doses for 10-28 days is an acceptable alternative to intravenous therapy 3

For children ≥8 years of age, doxycycline 4 mg/kg per day in 2 divided doses (maximum 100 mg per dose) is recommended for early Lyme disease 1
For neurologic manifestations in children ≥8 years of age, doxycycline 4-8 mg/kg per day in 2 divided doses (maximum 100-200 mg per dose) for 10-28 days is recommended 3
For children ≥8 years of age, a single dose of doxycycline 4 mg/kg (maximum 200 mg) is recommended for prophylaxis when the tick is identified as Ixodes scapularis, attached ≥36 hours, prophylaxis can start within 72 hours of removal, and local infection rate is ≥20% 4

Doxycycline should be administered with 8 ounces of fluid to reduce esophageal irritation 2, 4
Doxycycline can be taken with food to reduce gastrointestinal intolerance 2, 4
Patients should be advised to avoid sun exposure due to photosensitivity risk 2, 4

Doxycycline is contraindicated in pregnancy and lactation (relative contraindication) 1, 2
Doxycycline is relatively contraindicated in children <8 years of age (though evolving) 1, 2

First-generation cephalosporins (e.g., cephalexin) are completely ineffective against B. burgdorferi and should never be used 2, 4, 5
Macrolide antibiotics (azithromycin, clarithromycin, erythromycin) are less effective than doxycycline and should only be reserved for patients intolerant of first-line agents 1, 2, 5

When doxycycline is contraindicated or not tolerated, amoxicillin 500 mg orally 3 times daily for 14 days (adults) is an alternative first-line agent 1, 2, 5
When doxycycline is contraindicated or not tolerated, cefuroxime axetil 500 mg orally twice daily for 14 days (adults) is an alternative first-line agent 1, 2, 5

The Centers for Disease Control and Prevention recommends that treatment should not be delayed while awaiting laboratory confirmation in suspected cases, as supported by the MMWR Recommendations and Reports 6
If concurrent anaplasmosis is suspected, extend doxycycline treatment to 10 days minimum, according to the MMWR Recommendations and Reports 6
In endemic areas where co-infection rates are higher, it is particularly important to consider anaplasmosis co-infection and extend doxycycline treatment accordingly, as stated in the MMWR Recommendations and Reports 6

Never delay treatment while awaiting laboratory confirmation in suspected cases, and do not extend treatment beyond 21 days for early Lyme disease, as this is not supported by evidence and does not improve outcomes, as recommended by the MMWR Recommendations and Reports 6