Tick and Vector Borne Diseases
STARI Master's Disease Exposure to Lyme and other tick borne diseases can be a minor inconvenience or a life time struggle. Treating aggressively and quickly can make the difference in the final outcome.
The old "wait and see approach" is not advised. The "one-dose of doxycycline cures all" theory, administered shortly after a tick bite is also not advised and has been disproven in a follow up study. If you suspect you've been exposed to ticks, please contact your health care professional and insist on being properly treated.
For treatment recommendations for a tick bite, please go to www.TreatTheBite.com There you will find a one page handout with treatment recommendations that can be printed and taken with you to your doctor's office.
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ADVANCED TREATMENT PROTOCOLS
The excerpts below are from Dr. Joseph Burrascao's Advanced Topic's in Lyme Disease. To date it is the most widely used diagnostic and treatment protocol for people with chronic Lyme and tick borne diseases and those hoping to avoid progressing to later stages of the diseases. The entire document can be located at the following site.
ADVANCED TOPICS IN LYME DISEASE DIAGNOSTIC HINTS AND TREATMENT GUIDELINES FOR LYME AND OTHER TICK BORNE ILLNESSES
JOSEPH J. BURRASCANO JR., M.D.
Sixteenth Edition Copyright October, 2008 
MANAGING LYME DISEASE, 16h edition, October, 2008 Page 19 of 37
TREATMENT CATEGORIES
TICK BITES - Embedded Deer Tick With No Signs or Symptoms of Lyme (see appendix): Decide to treat based on the type of tick, whether it came from an endemic area, how it was removed, and length of attachment (anecdotally, 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 - Single erythema migrans 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.
DISSEMINATED DISEASE - Multiple lesions, constitutional symptoms, lymphadenopathy, or any other manifestations of dissemination.
EARLY DISSEMINATED: Milder symptoms present for less than one year and not complicated by immune deficiency or prior steroid treatment: 1) Adults: oral therapy until no active disease for 4 to 8 weeks (4-6 months typical) 2) Pregnancy: As in localized disease, but treat throughout pregnancy. 3) Children: Oral therapy with duration based upon clinical response.
PARENTERAL ALTERNATIVES for more ill patients and those unresponsive to or intolerant of oral medications: 1) Adults and children: I.V. therapy until clearly improved, with a 6 week minimum. Follow with oral therapy or IM benzathine penicillin until no active disease for 6-8 weeks. I.V. may have to be resumed if oral or IM therapy fails. 2) Pregnancy: IV then oral therapy as above.
LATE DISSEMINATED: present greater than one year, more severely ill patients, and those with prior significant steroid therapy or any other cause of impaired immunity: 1) Adults and pregnancy: extended I.V. therapy (14 or more weeks), then oral or IM, if effective, to same endpoint. Combination therapy with at least two dissimilar antibiotics almost always needed. 2) Children: IV therapy for 6 or more weeks, then oral or IM follow up as above. Combination therapy usually needed.
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.
PARENTERAL THERAPY
Ceftriaxone- Risk of biliary sludging (therefore often Actigall is co-administered- one to three tablets daily). Adults and pregnancy: 2g q12 h, 4 days in a row each week Children: 75 mg/kg/day up to 2g/day
Cefotaxime- Comparable efficacy to ceftriaxone; no biliary complications. Adults and pregnancy: 6g to 12g daily. Can be given q 8 h as divided doses, but a continuous infusion may be more efficacious. When exceeding 6 g daily, use pulsed- dose schedule Children: 90 to 180 mg/kg/day dosed q6h (preferred) or q8h, not to exceed 12 g daily.
*Doxycycline- Requires central line as is caustic. Surprisingly effective, probably because blood levels are higher when given parenterally and single large daily doses optimize kinetics of killing with this drug. Always measure blood levels. Adults: Start at 400 mg q24h and adjust based on levels. Cannot be used in pregnancy or in younger children.
Azithromycin- Requires central line as is caustic. Dose: 500 to 1000 mg daily in adolescents and adults.
Penicillin G- IV penicillin G is minimally effective and not recommended.
Benzathine penicillin- Surprisingly effective IM alternative to oral therapy. May need to begin at lower doses as strong, prolonged (6 or more week) Herxheimer-like reactions have been observed. Adults: 1.2 million U- three to four doses weekly. Adolescents: 1.2 to 3.6 million U weekly. May be used in pregnancy.
Vancomycin- observed to be one of the best drugs in treating Lyme, but potential toxicity limits its use. It is a perfect candidate for pulse therapy to minimize these concerns. Use standard doses and confirm levels.
Primaxin and Unisyn- similar in efficacy to cefotaxime, but often work when cephalosporins have failed. Must be given q6 to q8 hours.
Cefuroxime- useful but not demonstrably better than ceftriaxone or cefotaxime.
*Ampicillin IV- more effective than penicillin G. Must be given q6 hours.
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Tick Borne Diseases
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