Treat The Bite!

Treatment Recommendations

 
TICK BITES
Embedded Deer Tick With 
No Signs or Symptoms of Lyme 




As little as four hours of attachment can transmit pathogens.  The risk of transmission is greater if the tick is engorged, or of it was removed improperly allowing the tick's contents to spill into the bite wound.  High-risk bites are treated as follows (remember the possibility of co-infection!): 

 

1) Adults:  Oral therapy for 28 days.

 

2) Pregnancy:  Amoxicillin 1000 mg q6h for 6 weeks.  Test for Babesia, Bartonella and Ehrlichia.  
  
Alternative: Cefuroxime axetil 1000 mg q12h for 6 weeks.

 

3) Young Children:  Oral therapy for 28 days. 

 





EARLY LOCALIZED TREATMENT
(WHEN YOU HAVE A RASH)




Single erythema migrans [Lyme rash] with no constitutional symptoms: 

1) Adults:  oral therapy- must continue until symptom and sign free for at least one month, with a 6 week minimum.

 

2) Pregnancy:  1st and 2nd trimesters:  I.V.  X 30 days then oral X 6 weeks 3rd trimester:  Oral therapy X 6+ weeks as above. Any trimester- test for Babesia and Ehrlichia. 

3) Children:  oral therapy for 6+ weeks.


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. 



*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.

SOURCE:  ADVANCED TOPICS IN LYME DISEASEDIAGNOSTIC HINTS AND TREATMENT GUIDELINES FOR LYME AND OTHER TICK BORNE ILLNESSES  Sixteenth Edition.  Copyright October, 2008.  JOSEPH J. BURRASCANO JR., M.D.  Board Member, International Lyme and Associated Diseases Society [MANAGING LYME DISEASE, 16h  edition, October, 2008  Page 18 of 37]   


About the Author-  Dr. Joseph Burrascano lives and worked in one of the most Lyme endemic areas of the country.  He has treated over 11,000 people for Lyme and tick borne diseases.  He has over 25 years experience in the therapeutic areas of Internal Medicine and Infectious Diseases.  Dr. Burrascano also has a wide range of experience with clinical trials and has been a contributing author to numerous scientific articles for both the lay and peer-reviewed press.


Treating A Tick Bite




One Page Printable Document 
To Take To Your Local Doctor





Full Treatment Guidelines 

DIAGNOSTIC HINTS AND TREATMENT 

GUIDELINES FOR LYME AND OTHER 

TICK BORNE ILLNESSES 

Sixteenth Edition 
JOSEPH J. BURRASCANO JR., M.D.
Lyme & Tick Borne Diseases


~ ~ ~


UPDATE- March 2017- Two Points To Make

1. CDC basically states AGAIN in their 2016 guidelines to throw the rules out the window if a health care professional suspects spotted fever (Rickettsia) or Anaplasmosis and treat immediately, even without a known tick bite.

2. CDC also states the number of different Rickettsia organisms being discovered is growing quickly (in 2016 they mention 3 new ones since 2004). However, SEVEN additional Rickettsia organisms have been reported just in the past month from various countries.

Something to Consider- If you are treating tick bite patients and/or Lyme patients and have ANY concerns about anaplasmosis or a spotted fever possibly being involved- TREAT IMMEDIATELY if there is, and even if there isn’t, a reported tick bite and document your suspicions in the patient's charts.

With the 2017 “tick season” approaching, perhaps you should also print out the CDC official report now and the list of newly described and multiple Rickettsia organisms, both linked below, and put them in with your patient charts/documentation for additional justification for treating outside the 2006 IDSA Lyme disease guidelines (currently recognized “standard of care”).

The CDC report below states…

"This report updates the 2006 CDC recommendations on the diagnosis and management of tickborne rickettsial diseases in the United States and includes information on the practical aspects of epidemiology, clinical assessment, treatment, laboratory diagnosis, and prevention of tickborne rickettsial diseases.” << Those guidelines are located here.


QUOTES

CDC STATES- "Although the recognition of a tick bite is helpful, unrecognized tick bites are common in patients who are later confirmed to have a tickborne rickettsial disease.

A history of a tick bite within 14 days of illness onset is reported in only 55%–60% of RMSF cases (9,12,25) and 68% of ehrlichiosis cases (10). Therefore, absence of a recognized tick bite should never dissuade health care providers from considering tickborne rickettsial disease in the appropriate clinical context. In fact, the absence of classic features, such as a reported tick bite, has been associated with delays in RMSF diagnosis and increased risk for death (9,18,74,75).” AND...

"Delay in diagnosis and treatment is the most important factor associated with increased likelihood of death, and early empiric therapy is the best way to prevent RMSF progression. Without treatment, RMSF progresses rapidly. Patients treated after the fifth day of illness are more likely to die than those treated earlier in the course of illness (9,18,74,75).” AND...

"Long-term neurologic sequelae of RMSF include cognitive impairment; paraparesis; hearing loss; blindness; peripheral neuropathy; bowel and bladder incontinence; cerebellar, vestibular, and motor dysfunction; and speech disorders (7,110,121–124).” AND...

"Doxycycline is the drug of choice for treatment of all tickborne rickettsial diseases in patients of all ages, including children aged <8 years, and should be initiated immediately in persons with signs and symptoms suggestive of rickettsial disease (8,178–180) (Box 7).

Diagnostic tests for rickettsial diseases, particularly for RMSF, are usually not helpful in making a timely diagnosis during the initial stages of illness. Treatment decisions for rickettsial pathogens should never be delayed while awaiting laboratory confirmation. Delay in treatment can lead to severe disease and long-term sequelae or death (74,116,181).” AND….

"Previously undescribed tickborne rickettsial diseases continue to be recognized, and since 2004, three additional agents have been described as causes of human disease in the United States: Rickettsia parkeri, Ehrlichia muris-like agent, and Rickettsia species 364D."

Link to above quotes
https://www.cdc.gov/mmwr/volumes/65/rr/rr6502a1.htm

In the past month alone (Feb-March 2017), SEVEN Rickettsia organisms have been reported in various areas around the globe. See list below.


Lyme Disease Treatment Guidelines- 2014

Very Limited Excerpts Only

A Basic Overview 

Introduction- The IDSA Lyme disease treatment guidelines have not been updated since they were written in 2005. There have been many scientific publications, clinical trials and another decade of observing and data collecting that is available now to potentially improve the outcome of those contracting Lyme disease. Some of the conclusions, based on the most recent science and clinical observations, are:

“Clinicians should not use a single 200 mg dose of doxycycline for Lyme disease prophylaxis. Clinicians should promptly offer antibiotic prophylaxis for known Ixodes tick bites in which there is evidence of tick feeding, regardless of the degree of tick engorgement or the infection rate in the local tick population.

The preferred regimen is 100–200 mg of doxycycline, twice daily for 20 days. Other treatment options may be appropriate on an individualized basis. Most patients will place a high value on preventing chronic illness.

Treatment regimens of 20 or fewer days of phenoxymethyl-penicillin, amoxicillin, cefuroxime or doxycycline and 10 or fewer days of azithromycin are not recommended for patients with EM [Lyme] rashes because failure rates in the clinical trials were unacceptably high. Failure to fully eradicate the infection may result in the development of a chronic form of Lyme disease, exposing patients to its attendant morbidity and costs, which can be quite significant.

Clinicians should prescribe amoxicillin, cefuroxime or doxycycline as first-line agents for the treatment of EM. Azithromycin is also an acceptable agent, particularly in Europe, where trials demonstrated it either outperformed or was as effective as the other first-line agents [46–49].

Initial antibiotic therapy should employ 4–6 weeks of amoxicillin 1500–2000 mg daily in divided doses, cefuroxime 500 mg twice daily or doxycycline 100 mg twice daily or a minimum of 21 days of azithromycin 250–500 mg daily.

Pediatric dosing for the individual agents is as follows: amoxicillin 50 mg/kg/day in three divided doses, with a maximal daily dose of 1500 mg; cefuroxime 20–30 mg/kg/day in two divided doses, with a maximal daily dose of 1000 mg and azithromycin 10 mg/kg on day 1 then 5–10 mg/kg daily, with a maximal daily dose of 500 mg.

For children 8 years and older, doxycycline is an additional option. Doxycycline is dosed at 4 mg/kg/day in two divided doses, with a maximal daily dose of 200 mg. Higher daily doses of the individual agents may be appropriate in adolescents.

Selection of the antibiotic agent and dose for an individual patient should take several factors into account. In the absence of contraindications, doxycycline is preferred when concomitant Anaplasma or Ehrlichia infections are possibilities.

Other considerations include the duration [27,32,50] and severity [50–53] of symptoms, medication tolerability, patient age, pregnancy status, co-morbidities, recent or current corticosteroid use [54,55] cost, the need for lifestyle adjustments to accommodate certain antibiotics and patient preferences.

Variations in patient-specific details and the limitations of the evidence imply that clinicians may, in a variety of circumstances, need to select therapeutic regimens utilizing higher doses, longer durations or combinations of first-line agents.

Clinicians should continue antibiotic therapy for patients who have not fully recovered by the completion of active therapy. Ongoing symptoms at the completion of active therapy were associated with an increased risk of long-term failure in some trials and therefore clinicians should not assume that time alone will resolve symptoms. There is a wide range of options and choices must be individualized, based on the strength of the patient’s initial response.

Disease progression or recurrence suggests that the iv. antibiotics or injectable penicillin G benzathine, as discussed previously, may be required. For patients requiring antibiotic therapy beyond the initial treatment period, subsequent decisions regarding the modification or discontinuation of treatment should be based on the therapeutic response and treatment goals.

Clinicians should retreat patients who were successfully treated initially but subsequently relapse or have evidence of disease progression. Therapeutic options include repeating the initial agent, changing to another oral agent or instituting injectable penicillin G benzathine or iv. ceftriaxone therapy. Choices must be individualized and based on several factors, including: the initial response to treatment; the time to relapse or progression; the current disease severity and the level of QoL impairments.

Disease relapse or progression with mild manifestations or QoL impairments occurring within a few months of treatment suggests a need for longer regimens using either tetracycline, a combination of oral first-line agents, injectable penicillin G benzathine or iv. ceftriaxone.

Regardless of the duration of disease latency, when disease manifestations or QoL impairments are significant or rapidly progressive, injectable penicillin G benzathine or iv. ceftriaxone may be required.”

Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. September 2014, Vol. 12, No. 9 , Pages 1103-1135 (doi:10.1586/ 14787210.2014.940900) Daniel J Cameron, Lorraine B Johnson, and Elizabeth L Maloney PDF (633 KB) PDF Plus (639 KB) 1 International Lyme and Associated Diseases Society, PO Box 341461, Bethesda MD, 20827-1461, USA 2 LymeDisease.org, PO Box 1352, Chico, CA 95927, USA 3 Partnership for Healing and Health Ltd, PO Box 84, Wyoming, MN 55092, USA *Author for correspondence: +1 914 666 4665 contact@danielcameronmd.com

PLEASE READ THE FULL SET OF TREATMENT GUIDELINES AT THE FOLLOWING LINK...

http://informahealthcare.com/doi/full/10.1586/14787210.2014.940900



A printable version of 

Dr. Burrascano's Treatment Guidelines 

(Treating Tick Bites & Rashes) 

Can also be found below.


NEW Lyme Disease Treatment Guidelines- Print & Distribute.docx


Treating Tick Bites & Rashes- June 2014.pdf


ADVANCED TOPICS IN LYME DISEASE


PLEASE NOTE- Information and links to various Treatment Protocols are listed for your convenience only. This listing is not an endorsement of the protocol or the individual(s) promoting them. Please check with your own doctor concerning the diagnosis and treatment of Lyme and tick borne diseases. Thank you!






Last Updated
June 2017
Lucy Barnes