IDSA Recommendations for Management of Lyme Arthritis

Initial Antibiotic Therapy

The Infectious Diseases Society of America (IDSA) recommends oral doxycycline 100 mg twice daily for 28 days as first‑line treatment in adults without neurologic involvement. 1
A 28‑day course is considered essential; shorter regimens have not been adequately evaluated for arthritis outcomes. 1

Intra‑articular corticosteroid injections are not recommended during the initial treatment phase until bacterial eradication is confirmed, because steroids may impair the immune response needed to clear Borrelia burgdorferi. 1
No evidence supports any clinical benefit from concurrent corticosteroid use while the infection is active. 1

Corticosteroids become an option only after completion of both oral and intravenous antibiotic courses without resolution (antibiotic‑refractory disease). 1
After antibiotics, clinicians should wait several months to allow inflammation to resolve naturally before considering steroid therapy. 1
Prior to steroid use, a negative PCR test on synovial fluid (and tissue if available) must be confirmed to ensure the absence of B. burgdorferi. 1
When indicated, intra‑articular corticosteroid injections may be used for symptom control together with NSAIDs, disease‑modifying antirheumatic drugs (e.g., hydroxychloroquine), or arthroscopic synovectomy. 1

The IDSA advises careful screening for subtle neurologic symptoms (e.g., distal paresthesias, memory changes) before initiating oral antibiotics; patients with such findings may require upfront intravenous ceftriaxone. 1
In the pivotal trial, a small number of patients developed neuroborreliosis after oral treatment, all of whom had subtle baseline neurologic signs that were initially missed. 1

Non‑steroidal anti‑inflammatory drugs (NSAIDs) may be used for symptomatic relief while awaiting resolution of arthritis during the initial antibiotic phase. 1

The American College of Rheumatology recommends initiating oral antibiotic therapy for 28 days as first-line treatment for patients with Lyme arthritis, with doxycycline 100 mg twice daily or amoxicillin 500 mg three times daily as the preferred regimens 2, 3, 4
Doxycycline 100 mg twice daily is the preferred agent for adults and children ≥8 years old, while amoxicillin 500 mg three times daily is the alternative for children <8 years, pregnant women, or those intolerant to doxycycline 2, 5
Cefuroxime axetil 500 mg twice daily is another effective oral option for patients with Lyme arthritis 2, 5

For patients with mild residual swelling after completing the initial 28-day course, observation for several months before re-treatment may be considered, as inflammation resolves slowly even after successful bacterial eradication 2, 5
A second course of oral antibiotics for up to 28 days may be reasonable for patients with modest synovial proliferation who prefer avoiding IV therapy 2, 3
IV ceftriaxone 2 g once daily for 2-4 weeks is recommended for patients with no improvement or worsening after initial oral therapy, representing a weak recommendation with low-quality evidence 2, 3, 5

After completing both one course of oral antibiotics and one course of IV antibiotics without resolution, referral to a rheumatologist is recommended rather than continuing antibiotics 2, 3, 4
Treatment options at this stage include disease-modifying antirheumatic drugs (DMARDs) such as hydroxychloroquine, biologic agents, intra-articular corticosteroid injections, and arthroscopic synovectomy 2, 3, 5

Intra-articular corticosteroids should be avoided during the initial treatment phase before bacterial eradication is confirmed 5
First-generation cephalosporins, fluoroquinolones, carbapenems, vancomycin, metronidazole, and tinidazole are ineffective against B. burgdorferi and should not be used 6, 7
Macrolides (azithromycin, clarithromycin) are less effective than first-line agents and should only be used when patients cannot tolerate doxycycline, amoxicillin, or cefuroxime 6, 7

Patients with persistent nonspecific symptoms (fatigue, pain, cognitive impairment) without objective evidence of active disease should not be prescribed additional antibiotics 2, 3, 4
Subjective symptoms may persist in 35% at day 20, 24% at 3 months, and 17% at 12 months post-treatment without indicating treatment failure 6