Guideline sources The following summarized guidelines for the evaluation and management of lyme disease are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/ACR/AAN 2021), the Wilderness Medical Society (WMS 2021), and the American Heart Association (AHA/HRS/ACC 2019). 1 2 3 Calculator Rule of 7's for Lyme meningitis Guidelines 1. Screening and diagnosis Screening for Lyme disease in neurological manifestations: Test for Lyme disease in patients with epidemiologically plausible exposure to ticks infected with Borrelia burgdorferi and presenting https://web.pathway.md/diseases/recvbF90rcBoCQuFM 1/6 6/29/23, 6:02 AM Lyme disease Pathway with one or more of the following: acute meningitis painful radiculoneuritis mononeuropathy multiplex including confluent mononeuropathy multiplex acute cranial neuropathies (particularly VII, VIII, less commonly III, V, VI, and others) evidence of spinal cord (or rarely brain) inflammation, particularly in association with painful radiculitis involving related spinal cord segments. B Show 3 more Screening for Lyme disease in psychiatric, developmental and behavioral disorders: Do not routinely test for Lyme disease in patients with psychiatric illness. D Do not routinely test for Lyme disease in pediatric patients presenting with developmental, behavioral, or psychiatric disorders. D Screening for Lyme disease in heart diseases of unknown cause: Test for Lyme disease in patients with acute myocarditis/pericarditis of unknown cause in an appropriate epidemiologic setting. B Do not routinely test for Lyme disease in patients with chronic cardiomyopathy of unknown cause. D 2. Diagnostic investigations Tick testing: Send the removed tick for species identification. B Do not test the removed Ixodes tick for Borrelia burgdorferi. D Testing of asymptomatic patients: do not test asymptomatic patients for exposure to Borrelia burgdorferi following an Ixodes species tick bite. D Testing for erythema migrans: Make a clinical diagnosis rather than obtain laboratory testing in patients with potential tick exposure in a Lyme disease endemic area who have one or more skin lesions compatible with erythema migrans. B Consider antibody testing rather than currently available direct detection methods (such as PCR or culture performed on blood or skin samples) in patients with one or more skin lesions suggestive of, but atypical for erythema migrans, performed on an acute-phase serum sample (followed by a convalescent-phase serum sample if the initial result is negative). C Testing for Lyme neuroborreliosis: obtain serum antibody testing rather than PCR or culture of either CSF or serum when assessing patients for possible Lyme neuroborreliosis involving either the PNS or CNS. B Show 2 more Testing for Lyme carditis: As per IDSA 2021 guidelines: https://web.pathway.md/diseases/recvbF90rcBoCQuFM 2/6 6/29/23, 6:02 AM Lyme disease Pathway Consider obtaining electrocardiography only in patients with signs or symptoms consistent with Lyme carditis. C Hospitalize and perform continuous electrocardiography monitoring in patients with or at risk for severe cardiac complications of Lyme disease including those with significant PR prolongation (PR > 300 milliseconds), other arrhythmias, or clinical manifestations of myopericarditis. B As per WMS 2021 guidelines, obtain a screening ECG as soon as possible in patients developing symptoms suggestive of Lyme carditis, such as dyspnea, dizziness, or syncope, and consider obtaining a thorough cardiovascular evaluation in an appropriate clinical setting. B Testing for Lyme arthritis: Obtain serum antibody testing rather than PCR or culture of blood or synovial fluid/tissue when assessing patients with possible Lyme arthritis. B Obtain PCR applied to synovial fluid or tissue rather than Borrelia culture of those samples in seropositive patients for whom the diagnosis of Lyme arthritis is being considered but treatment decisions require more definitive information. B Evaluation for coinfection: assess for possible coinfection with Anaplasma phagocytophilum and/or Borrelia microti infection in patients with Lyme disease who have a high-grade fever or characteristic laboratory abnormalities in geographic regions where these infections are endemic. B 3. Medical management Antibiotics for erythema migrans: As per IDSA 2021 guidelines: Offer oral antibiotic therapy with doxycycline, amoxicillin, or cefuroxime axetil to patients with erythema migrans. B Offer either a 10-day course of doxycycline or a 14-day course of amoxicillin or cefuroxime axetil rather than longer treatment courses to patients with erythema migrans. B As per WMS 2021 guidelines, initiate doxycycline if the patient develops a fever, erythema migrans, or arthralgias within 30 days of the presumed tick bite. B Antibiotics for southern tick-associated rash illness: insufficient evidence to recommend for or against the use of antibiotics in patients who develop an erythema migrans-like skin lesion following the bite of the lone star tick (Amblyomma americanum), an illness referred to as southern tick-associated rash illness. I Antibiotics for neurological manifestations of Lyme disease: Offer IV ceftriaxone, cefotaxime, penicillin G, or oral doxycycline rather than other antimicrobials to patients with Lyme disease-associated meningitis, cranial neuropathy, radiculoneuropathy, or with other PNS manifestations. B Offer IV rather than oral antibiotics to patients with Lyme disease-associated parenchymal involvement of the brain or spinal cord. B https://web.pathway.md/diseases/recvbF90rcBoCQuFM 3/6 6/29/23, 6:02 AM Lyme disease Pathway Antibiotics for Lyme carditis: consider oral antibiotics rather than IV antibiotics in outpatients with Lyme carditis. C Show 2 more Antibiotics for Lyme arthritis: offer oral antibiotic therapy for 28 days to patients with Lyme arthritis. B Show 2 more Antibiotics for borrelial lymphocytoma: consider oral antibiotic therapy for 14 days in patients with borrelial lymphocytoma. C Antibiotics for acrodermatitis chronica atrophicans: consider oral antibiotic therapy for 21-28 days rather than shorter durations in patients with acrodermatitis chronica atrophicans. C Corticosteroids for neurological manifestations of Lyme disease: insufficient evidence to recommend on the use of corticosteroids in addition to antibiotics in patients with Lyme disease- associated facial nerve palsy. I 4. Therapeutic procedures Temporary cardiac pacing for Lyme carditis: perform temporary rather than permanent pacing in patients with symptomatic bradycardia due to Lyme carditis not being manageable medically. B Permanent cardiac pacing for Lyme carditis: attempt medical therapy and supportive care, including temporary transvenous pacing if necessary, before determination of need for permanent pacing in patients with transient or reversible causes of AV block, such as Lyme carditis. B 5. Preventative measures Immunization: Recognize that there are no vaccines for tick-borne encephalitis currently available in the United States, even though vaccines such as Encepur appear effective for inducing seroconversion against tick-borne encephalitis. B Recognize that Lyme vaccination is effective at reducing the risk of infection, although not currently available in the United States. B Personal protective measures: As per IDSA 2021 guidelines, implement personal protective measures among individuals at risk of exposure to reduce the risk of tick exposure and infection with tick-borne pathogens. B As per WMS 2021 guidelines, advise wearing long-sleeved clothing when traveling in tick habitat. E Show 2 more Tick repellents: https://web.pathway.md/diseases/recvbF90rcBoCQuFM 4/6 6/29/23, 6:02 AM Lyme disease Pathway As per IDSA 2021 guidelines, use DEET, picaridin, ethyl 3-(N-n butyl N- acetyl) aminopropionate (IR3535), oil of lemon eucalyptus, p methane 3, 8-diol, 2 undecanone, or permethrin for the prevention of tick bites. B As per WMS 2021 guidelines, advise applying DEET or picaridin as effective tick repellents, and reapplied based on the concentration of formulation. Recognize that DEET can be used in children aged > 2 months. B Recognize that picaridin may have a superior safety profile when compared to DEET. B Show 2 more Showering and cloth washing: Advise taking shower or bathe within 2 hours of returning from tick habitat. Consider advising tick checks combined with bathing within 2 hours of being outdoors to help prevent tick-borne illnesses. B Advise washing clothes at temperatures over 54 C (130 F) and drying clothes in high heat for 10 minutes to kill ticks and help reduce the risk of tick-borne illnesses. B Removal of attached ticks: As per IDSA 2021 guidelines: Promptly remove attached ticks by mechanical means using a clean fine-tipped tweezer (or a comparable device) inserted between the tick body and the skin. B Do not burn an attached tick (with a match or other heat device) or apply noxious chemicals or petroleum products to coax its detachment. D As per WMS 2021 guidelines, remove ticks as soon as possible once discovered. Remove ticks within 36 hours of attachment in order to significantly reduce the risk of Lyme disease. B Show 4 more Antibiotic prophylaxis: As per IDSA 2021 guidelines: Offer prophylactic antibiotic therapy to adult and pediatric patients only within 72 hours of removal of an identified high-risk tick bite, but not for bites that are equivocal risk or low risk. A Administer a single dose of oral doxycycline within 72 hours of tick removal rather than offering observation to patients with high-risk Ixodes species bites in all age groups. B As per WMS 2021 guidelines: Administer a single dose of 200 mg doxycycline PO within 72 hours after a high-risk tick bite to reduce the risk of Lyme disease. B Offer a period of watchful waiting rather than administering prophylaxis if the tick cannot be identified or if the time of attachment is unknown. B 6. Follow-up and surveillance Referral for Lyme arthritis: consider referring patients who have failed one course of oral antibiotics and one course of IV antibiotics to a rheumatologist or other trained specialist for https://web.pathway.md/diseases/recvbF90rcBoCQuFM 5/6 6/29/23, 6:02 AM Lyme disease Pathway consideration of the use of DMARDs, biologic agents, intraarticular steroids, or arthroscopic synovectomy. C Antibiotics for persistent or recurring symptoms: do not offer additional antibiotic therapy to patients who have persistent or recurring nonspecific symptoms such as fatigue, pain, or cognitive impairment following recommended treatment for Lyme disease, but who lack objective evidence of reinfection or treatment failure. D 7. Quality improvement Educational programs: implement and encourage educational programs to change behavior and lower rates of tick-borne illnesses. B References 1. Paul M Lantos, Jeffrey Rumbaugh, Linda K Bockenstedt et al. Clinical Practice Guidelines by the Infectious Diseases Society of America IDSA , American Academy of Neurology AAN , and American College of Rheumatology ACR 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Arthritis Care Res Hoboken). 2021 Jan;73 1 1 9. Open 2. Benjamin M Ho, Hillary E Davis, Joseph D Forrester et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Management of Tick-Borne Illness in the United States. Wilderness Environ Med. 2021 Dec;32 4 474 494. Open 3. Fred M Kusumoto, Mark H Schoenfeld, Coletta Barrett et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2019 Aug 20;140 8):e382-e482. Open 4. Robert L Bratton, John W Whiteside, Michael J Hovan et al. Diagnosis and treatment of Lyme disease. Am Fam Physician. 2012 Jun 1;85 11 1086 1093. Open 5. Georgia Besant, Douglas Wan, Cynthia Yeung et al. Suspicious index in Lyme carditis: Systematic review and proposed new risk score. Clin Cardiol. 2018 Dec;41 12 1611 1616. Open https://web.pathway.md/diseases/recvbF90rcBoCQuFM 6/6