MANAGING LYME DISEASE, 15th edition, September, 2005

http://ilads.org/files/burrascano_0905.pdf

****ANTIBIOTIC CHOICES AND DOSES

ORAL THERAPY: Always check blood levels when using agents marked with an *, and adjust dose to

achieve a peak level above ten and a trough greater than three. Because of this, the doses listed below

may have to be raised. Consider Doxycycline first in early Lyme due to concern for Ehrlichia co-infections.

*Amoxicillin- Adults: 1g q8h plus probenecid 500mg q8h; doses up to 6 grams daily are

often needed

Pregnancy: 1g q6h and adjust.

Children: 50 mg/kg/day divided into q8h doses.

*Doxycycline- Adults: 200 mg bid with food; doses of up to 600 mg daily are often

needed, as doxycycline is only effective at high blood levels. Not for children or in

pregnancy.

If levels are too low at tolerated doses, give parenterally or change to another

drug.

*Cefuroxime axetil- Oral alternative that may be effective in amoxicillin and doxycycline

failures. Useful in EM rashes co-infected with common skin pathogens.

Adults and pregnancy: 1g q12h and adjust. Children: 125 to 500 mg q12h

based on weight.

Tetracycline- Adults only, and not in pregnancy. 500 mg tid to qid

Erythromycin- Poor response and not recommended.

Azithromycin- Adults: 500 to 1200 mg/d. Adolescents: 250 to 500 mg/d

Add hydroxychloroquine, 200-400 mg/d, or amantadine 100-200 mg/d

Cannot be used in pregnancy or in younger children.

Overall, poor results when administered orally

Clarithromycin- Adults: 250 to 500 mg q6h plus hydroxychloroquine, 200-400 mg/d,

or amantadine 100-200 mg/d. Cannot be used in pregnancy or in younger

children.

Clinically more effective than azithromycin

Telithromycin- Adolescents and adults: 800 mg once daily

Do not need to use amantadine or hydroxychloroquine

So far, the most effective drug of this class, and possibly the best oral agent

if tolerated. Expect strong and quite prolonged Herxheimer reactions.

Must watch for drug interactions (CYP3A-4 inhibitor), check the QTc interval, and

monitor liver enzymes.

Not to be used in pregnancy.

*Augmentin- Standard Augmentin cannot exceed three tablets daily due to the

clavulanate, thus is given with amoxicillin, so that the total dose of the amoxicillin

component is as listed above for amoxicillin. This combination can be effective when

Bb beta lactamase is felt to be significant.

*Augmentin XR 1000- This is a time-release formulation and thus is a better choice than

standard Augmentin.

Dose- 1000 mg q 8 h, to 2000 mg q 12 h based on blood levels.

Chloramphenicol- Not recommended as not proven and potentially toxic.

Metronidazole: 500 to 1500 mg daily in divided doses. Non-pregnant

adults only.

[cave note: Telithromycin (Ketek, since this Guideline was published, has proven to have some side effects that don't affect many---- but still needs to be monitored.]

*************************

His comments on the safety of abx follows:

*****SAFETY

Over two decades of experience in treating thousands of patients with Lyme has proven that therapy as

described above, although intense, is generally well tolerated. The most common adverse reaction seen is

allergy to probenecid. In addition, yeast superinfections are seen, but these are generally easily recognized

and managed.

The induction of Clostridium difficile toxin production is seen most commonly with ceftriaxone,

but can occur with any of the antibiotic regimens mentioned in this document. However, pulsed dose therapy and regular use of the lactobacillus preparations seems to be helpful in controlling yeast and antibiotic related colitis, as the number of cases of C. difficile in Lyme patients is low when these guidelines are followed.

Be sure to test stool for both toxin A and toxin B when evaluating for C. difficile colitis.******