Q2. Should the treatment of an EM rash be restricted to 20 or fewer days of oral azithromycin, cefuroxime, doxycycline and phenoxymethylpenicillin/amoxicillin?
Organizational values
The panel placed a high value on avoiding both the unnecessary progression from a potentially curable infection to one that is chronic and the morbidity and costs associated with chronic disease. The panel also placed a high value on the ability of the clinician to exercise clinical judgment. In the view of the panel, guidelines should not constrain the treating clinician from exercising clinical judgment in the absence of strong and compelling evidence to the contrary.
Recommendation 2a
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 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. (Recommendation, very low-quality evidence).
Role of patient preferences
Moderate: Although many patients will value avoiding the risk of treatment failure over a potentially modest increase in the risk of significant adverse events that may be associated with longer treatment durations, others may prefer to avoid the additional risks of longer treatment.
Clinicians should inform patients that: the combined failure rate for the individual agents investigated in the previously discussed EM trials were judged by this panel to be unacceptably high when antibiotic treatment was restricted to 20 or fewer days (provide the appropriate value for each); the evidence supporting the use of longer treatment durations is limited and of low quality [41–43] and increases in antibiotic duration may increase the risk of antibiotic-associated adverse events, although the risks associated with oral antibiotics are low and some of this risk can be mitigated by the concomitant use of probiotics [44,45].
Treatment risks, benefits and options should be discussed with the patient in the context of shared medical decision-making.
Recommendation 2b
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 (Recommendation, very low-quality evidence).
Role of patient preferences
Moderate: See recommendation 2a.
Recommendation 2c
Clinicians should provide ongoing assessments to detect evidence of disease persistence, progression or relapse or the presence of other tick-borne diseases. Lacking a test of cure, ongoing assessments are crucial for determining if treatment has been clinically effective.
The first assessment should immediately follow the completion of therapy and subsequent evaluations should occur on an as-needed basis (Recommendation, very low-quality evidence).
Role of patient preferences
Low: The benefits of monitoring the response to treatment clearly outweigh any attendant risks associated with monitoring.
Recommendation 2d
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.
Strong-to-moderate responses favor extending the duration of therapy of the initial agent; modest responses may prompt an increase in the dose of the original antibiotic or a switch to a different first-line agent or tetracycline. Minimal or absent responses suggest a need for a combination of first-line agents, which includes at least one that is able to effectively reach intracellular compartments; injectable penicillin G benzathine (Bicillin LA) or intravenous (iv.) ceftriaxone are other options.
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. Additionally, minimal or absent responses and disease progression require a re-evaluation of the original diagnosis (see remarks following Recommendation 2f). (Recommendation, very low-quality evidence).
Role of patient preferences
Moderate: While most patients will place a high value on the potential of regaining their pre-morbid health status and preventing chronic illness by continuing treatment, a substantial portion may also value avoiding unnecessary antibiotics. Hence, treatment risks, benefits and options should be discussed with the patient in the context of shared medical decision-making.
Recommendation 2e
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.
Prior to instituting additional antibiotic therapy, the original diagnosis should be reassessed and clinicians should evaluate patients for other potential causes that would result in the apparent relapse or progression of symptoms and/or findings (see remarks following Recommendation 2f). The presence of other tick-borne diseases, in particular, should be investigated if that had not already been done.
Following a long period of disease latency, minimal manifestations causing little deterioration in the patient’s QoL favor continued observation or repeating therapy with the initial agent; mild manifestations or QoL impairments may prompt a switch to a different first-line agent, tetracycline or the use of a combination of first-line agents.
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. Subsequent decisions regarding the modification or discontinuation of a patient’s treatment should be based on individual therapeutic response and preferences (Recommendation, very low-quality evidence).
Role of patient preferences
High: While most patients will place a high value on the potential of regaining their pre-morbid health status and improving their QoL and preventing chronic disease through continued antibiotic treatment, a substantial portion will also value avoiding potentially unnecessary antibiotics. Hence, treatment risks, benefits and options should be discussed with the patient in the context of shared medical decision-making.
Recommendation 2f
Clinicians should educate patients regarding the potential manifestations of Lyme disease, carefully explaining that disease latency can be prolonged. Education should also include information on preventing future bites, the manifestations of the other tick-borne diseases that they may have contracted as well as the symptoms and signs of a C. difficile infection and the preventative effect of probiotics.
Patients should be encouraged to immediately report the occurrence of any recurrent or newly developing manifestation of Lyme disease as well as those suggestive of other tick-borne diseases or a C. difficile infection. Clinicians should emphasize that the need to report manifestations of tick-borne diseases never expires (Recommendation, very low-quality evidence).
Role of patient preferences
Low: The benefits of educating patients about potential disease manifestations clearly outweigh any attendant risks associated with education.
Q3. Should patients with persistent manifestations of Lyme disease be retreated with antibiotics?
Organizational values
The panel placed a high value on reducing the morbidity associated with chronic Lyme disease and improving the patient’s QoL as well as on the need for individualized risk/benefit assessment and informed shared decision-making. The panel also placed a high value on the ability of the clinician to exercise clinical judgment. In the view of the panel, guidelines should not constrain the treating clinician from exercising clinical judgment in the absence of strong compelling evidence to the contrary.
Recommendation 3a
Clinicians should discuss antibiotic retreatment with all patients who have persistent manifestations of Lyme disease. These discussions should provide patient-specific risk–benefit assessments for each treatment option and include information regarding C. difficile infection and the preventative effect of probiotics (although none of the subjects in the retreatment trials developed C. difficile infection). (Strong recommendation, very low-quality evidence.
Note: In GRADE, a strong recommendation may be made in the face of very low-quality evidence when the risk–benefit analysis favors a particular intervention such that most patients would make the same choice).
Role of patient preferences
Low: The benefits of educating patients about the potential benefits of retreatment and the risks associated with various treatment options, including not treating, clearly outweigh any attendant risks associated with education.
Recommendation 3b
While continued observation alone is an option for patients with few manifestations, minimal QoL impairments and no evidence of disease progression, in the panel’s judgment, antibiotic retreatment will prove to be appropriate for the majority of patients who remain ill.
Prior to instituting antibiotic retreatment, the original Lyme disease diagnosis should be reassessed and clinicians should evaluate the patient for other potential causes of persistent disease manifestations. The presence of other tick-borne illnesses should be investigated if that had not already been done. Additionally, clinicians and their patients should jointly define what constitutes an adequate therapeutic trial for this particular set of circumstances.
When antibiotic retreatment is undertaken, clinicians should initiate treatment with 4–6 weeks of the selected antibiotic; this time span is well within the treatment duration parameters of the retreatment trials. Variations in patient-specific details and the limitations of the evidence imply that the proposed duration is a starting point and clinicians may, in a variety of circumstances, need to select therapeutic regimens of longer duration.
Treatment options are extensive and choices must be individualized. Each of these options would benefit from further study followed by a GRADE assessment of the evidence and consideration of associated risks and benefits, but until this information is available, clinicians may act on the currently available evidence.
In choosing between regimens, clinicians should consider the patient’s responsiveness to previous treatment for Lyme disease, whether the illness is progressing and the rate of this progression; whether untreated co-infections are present; whether the patient has impaired immune system functioning or has received immunosuppressant corticosteroids and whether other co-morbidities or conditions would impact antibiotic selection or efficacy.
Clinicians should also weigh the extent to which the illness interferes with the patient’s QoL, including their ability to fully participate in work, school, social and family-related activities and the strength of their initial response against the risks associated with the various therapeutic options. Antibiotic selection should also consider medication tolerability, cost, the need for lifestyle adjustments to accommodate the medication and patient preferences.
For patients with mild impairments who had a strong-to-moderate response to the initial antibiotic, repeat use of that agent is favored. Patients with moderate impairments or only a modest response to the initial antibiotic may benefit from switching to a different agent or combination of agents. For patients with significant impairments and/or a minimal or absent therapeutic response, a combination of oral antibiotics, injectable penicillin G benzathine or iv. ceftriaxone (with the latter two used alone or in combination with other agents) is preferred.
For patients who experienced disease progression despite earlier therapy, treatment with injectable penicillin G benzathine or iv. ceftriaxone, alone or in combination with other antibiotics, is advisable.
Additionally, minimal or absent responses and disease progression require a re-evaluation of the original diagnosis (Recommendation, very low-quality evidence).
Role of patient preferences
High: The heterogeneous nature of the patient population seen in clinical practice, particularly with regard to variations in disease severity, QoL impairments and aversion to treatment-related risk is likely to affect the risk–benefit assessment. Although many patients will value the opportunity to improve their individual QoL through antibiotic treatment over the risk of adverse events, others may prefer to avoid the risks associated with treatment. Hence, treatment options, including their associated risks and benefits, should be discussed with the patient in the context of shared medical decision-making.
Recommendation 3c
Clinicians should re-assess patients immediately following the completion of the initial course of retreatment to evaluate the effectiveness of retreatment and the need for therapeutic adjustments. Reassessment may need to be done much earlier and with greater scrutiny in patients with severe disease or when the therapeutic intervention carries substantial risk.
For patients who improve yet continue to have persistent manifestations and continuing QoL impairments following 4–6 weeks of antibiotic retreatment, decisions regarding the continuation, modification or discontinuation of treatment should be based on several factors.
In addition to those listed in Recommendation 3b, the decision to continue treatment may depend on the length of time between the initial and subsequent retreatment, the strength of the patient’s response to retreatment, the severity of the patient’s current impairments, whether diagnostic tests, symptoms or treatment response suggest ongoing infection and whether the patient relapses when treatment is withdrawn.
In cases where the patient does not improve after 4–6 weeks of antibiotic retreatment, clinicians should reassess the clinical diagnosis as well as the anticipated benefit. They should also confirm that other potential causes of persistent manifestations have been adequately investigated prior to continuing antibiotic retreatment. Decisions regarding the continuation, modification or discontinuation of treatment should consider the factors noted above as well as the definition of an adequate therapeutic trial.
Whenever retreatment is continued, the timing of subsequent follow-up visits should be based on the level of the therapeutic response, the severity of ongoing disease, the duration of current therapy and the need to monitor for adverse events. (Recommendation, very low-quality evidence).
Role of patient preferences
High: See Recommendation 3b.
Read More: http://informahealthcare.com/doi/full/10.1586/14787210.2014.940900