Latest NICE Guidelines on Lyme Disease

Written by Dr. Kamal Kant Kohli Kohli Published On 2018-04-28T19:02:54+05:30 | Updated On 28 April 2018 7:02 PM IST

Lyme disease spreads to humans through an infected tick bite. Ticks are mainly found in grassy and wooded areas, including gardens and parks, but only a small number carry the bacteria that causes Lyme disease. Typical symptoms can include combinations of a headache, fever, joint pain or fatigue as well as others that are more specific such as problems with nerves or joints.

NICE has released its new Lyme disease guidelines that will help in early diagnosis & treatment of the disease according to Saul Faust, Professor of paediatric immunology and chair of the NICE guideline committee.

Major Recommendations:

1.Awareness of Lyme disease

Be aware that the bacteria that cause Lyme disease are transmitted by the bite of an infected tick.Most tick bites do not transmit Lyme disease and that prompt, correct removal of the tick reduces the risk of transmission.

2.Diagnosis

A.Clinical assessment

Diagnose Lyme disease in people with erythema migrans, a red rash that:increases in size and may sometimes have a central clearing,is not usually itchy, hot or painful,usually becomes visible from 1 to 4 weeks (but can appear from 3 days to 3 months) after a tick bite and lasts for several weeks and is usually at the site of a tick bite.

Consider the possibility of Lyme disease in people presenting with -fever and sweats, swollen glands, malaise, fatigue, neck pain or stiffness, migratory joint or muscle aches and plain cognitive impairment, such as memory problems and difficulty concentrating (sometimes described as 'brain fog'), headache, paraesthesia.

Do not rule out the possibility of Lyme disease in people with symptoms but no clear history of tick exposure.

Do not diagnose Lyme disease in people without symptoms, even if they have had a tick bite.

Follow usual clinical practice to manage symptoms, for example, pain relief for headaches or muscle pain, in people being assessed for Lyme disease.

B.Laboratory investigations to support a diagnosis

NICE has also produced a visual summary of the recommendations on testing for Lyme disease.

Diagnose and treat Lyme disease without laboratory testing in people with erythema migrans.

Use a combination of clinical presentation and laboratory testing to guide diagnosis and treatment in people without erythema migrans. Do not rule out diagnosis if tests are negative but there is high clinical suspicion of Lyme disease.

If there is a clinical suspicion of Lyme disease in people without erythema migrans: offer an enzyme-linked immunosorbent assay (ELISA) test for Lyme disease and consider starting treatment with antibiotics while waiting for the results if there is a high clinical suspicion.

Test for both IgM and IgG antibodies using ELISAs based on purified or recombinant antigens derived from the VlsE protein or its IR6 domain peptide (such as C6 ELISA).

If the ELISA is positive or equivocal:

perform an immunoblot test for Lyme disease and

consider starting treatment with antibiotics while waiting for the results if there is a high clinical suspicion of Lyme disease.

3.Management

Emergency referral-Follow usual clinical practice for emergency referrals, for example, in people with symptoms that suggest central nervous system infection, uveitis or cardiac complications such as complete heart block, even if Lyme disease is suspected.

Specialist advice-Discuss the diagnosis and management of Lyme disease in children and young people under 18 years with a specialist, unless they have a single erythema migrans lesion and no other symptoms. Choose a specialist appropriate for the child or young person's symptoms dependent on availability, for example, a paediatrician, paediatric infectious disease specialist or a paediatric neurologist.

Antibiotic treatment

For adults and young people (aged 12 and over) diagnosed with Lyme disease, offer antibiotic treatment according to their symptoms as described in table 1.For children (under 12) diagnosed with Lyme disease, offer antibiotic treatment according to their symptoms as described in table 2.

Table 1 Antibiotic treatment for Lyme disease in adults and young people (aged 12 and over) according to symptoms ^a

Symptoms	Treatment	First alternative	Second alternative
Lyme disease without focal symptoms
Erythema migrans and/or Non-focal symptoms	Oral doxycycline: 100 mg twice per day or 200 mg once per day for 21 days	Oral amoxicillin: 1 g 3 times per day for 21 days	Oral azithromycin: 500 mg daily for 17 days
Lyme disease with focal symptoms
Lyme disease affecting the cranial nerves or peripheral nervous system	Oral doxycycline: 100 mg twice per day or 200 mg once per day for 21 days	Oral amoxicillin: 1 g 3 times per day for 21 days	–
Lyme disease affecting the central nervous system	Intravenous ceftriaxone: 2 g twice per day or 4 g once per day for 21 days (when an oral switch is being considered, use doxycycline)	Oral doxycycline: 200 mg twice per day or 400 mg once per day for 21 days	–
Lyme disease arthritis	Oral doxycycline: 100 mg twice per day or 200 mg once per day for 28 days	Oral amoxicillin: 1 g 3 times per day for 28 days	Intravenous ceftriaxone: 2 g once per day for 28 days
Acrodermatitis chronica atrophicans		Oral amoxicillin: 1 g 3 times per day for 28 days	Intravenous ceftriaxone: 2 g once per day for 28 days
Lyme carditis^b	Oral doxycycline: 100 mg twice per day or 200 mg once per day for 21 days	Intravenous ceftriaxone: 2 g once per day for 21 days	–
Lyme carditis and haemodynamically unstable	Intravenous ceftriaxone: 2 g once per day for 21 days (when an oral switch is being considered, use doxycycline)	–	–
^a For Lyme disease suspected during pregnancy, use appropriate antibiotics for a stage of pregnancy. ^b Do not use azithromycin to treat people with cardiac abnormalities associated with Lyme disease because of its effect on QT interval.

Table 2 Antibiotic treatment for Lyme disease in children (under 12) according to symptoms ^{a, b, c}

Symptoms	Age	Treatment	First alternative	Second alternative
Lyme disease without focal symptoms
Erythema migrans and/or Non-focal symptoms	9–12 years	Oral doxycycline for children under 45 kg: 5 mg/kg in 2 divided doses on day 1 followed by 2.5 mg/kg daily in 1 or 2 divided doses for a total of 21 days For severe infections, up to 5 mg/kg daily for 21 days	Oral amoxicillin for children 33 kg and under: 30 mg/kg 3 times per day for 21 days	Oral azithromycin^, for children 50 kg and under: 10 mg/kg daily for 17 days
Erythema migrans and/or Non-focal symptoms	Under 9	Oral amoxicillin for children 33 kg and under: 30 mg/kg 3 times per day for 21 days	Oral azithromycin^{, e} for children 50 kg and under: 10 mg/kg daily for 17 days	–
Lyme disease with focal symptoms
Lyme disease affecting the cranial nerves or peripheral nervous system	9–12 years	Oral doxycycline for children under 45 kg: 5 mg/kg in 2 divided doses on day 1 followed by 2.5 mg/kg daily in 1 or 2 divided doses for a total of 21 days For severe infections, up to 5 mg/kg daily for 21 days	Oral amoxicillin for children 33 kg and under: 30 mg/kg 3 times per day for 21 days	–
	Under 9	Oral amoxicillin for children 33 kg and under: 30 mg/kg 3 times per day for 21 days	–	–
Lyme disease affecting the central nervous system	9–12 years	Intravenous ceftriaxone for children 50 kg and under: 80 mg/kg once per day for 21 days	Oral doxycycline for children under 45 kg: 5 mg/kg in 2 divided doses on day 1 followed by 2.5 mg/kg daily in 1 or 2 divided doses for a total of 21 days For severe infections, up to 5 mg/kg daily	–
Lyme disease affecting the central nervous system	Under 9	Intravenous ceftriaxone for children 50 kg and under: 80 mg/kg once per day for 21 days	–	–
Lyme arthritis or Acrodermatitis chronica atrophicans	9–12 years	Oral doxycycline for children under 45 kg: 5 mg/kg in 2 divided doses on day 1 followed by 2.5 mg/kg daily in 1 or 2 divided doses for a total of 28 days For severe infections, up to 5 mg/kg daily for 21 days	Oral amoxicillin for children 33 kg and under: 30 mg/kg 3 times per day 28 days	Intravenous ceftriaxone for children 50 kg and under: 80 mg/kg once per day for 28 days
Lyme arthritis or Acrodermatitis chronica atrophicans	Under 9	Oral amoxicillin for children, 33 kg and under: 30 mg/kg 3 times per day for 28 days	Intravenous ceftriaxone for children 50 kg and under: 80 mg/kg once per day for 28 days	–
Lyme carditis (both haemodynamically stable and unstable)^e	9–12 years	Oral doxycycline for children under 45 kg: 5 mg/kg in 2 divided doses on day 1 followed by 2.5 mg/kg daily in 1 or 2 divided doses for a total of 21 days For severe infections, up to 5 mg/kg daily for 21 days	Intravenous ceftriaxone for children 50 kg and under: 80 mg/kg once per day for 21 days	–
Lyme carditis (both haemodynamically stable and unstable)^e	Under 9	Intravenous ceftriaxone for children 50 kg and under: 80 mg/kg once per day for 21 days	–	–
At the time of publication (April 2018), doxycycline did not have a UK marketing authorization for this indication in children under 12 years and is contraindicated. The use of doxycycline for children aged 9 years and above in infections where doxycycline is considered the first line in adult practice is accepted the specialist practice. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Discuss management of Lyme disease in children and young people with a specialist, unless they have a single erythema migrans lesion with no other symptoms, see recommendation : Children weighing more than the amounts specified should be treated according to table 1. At the time of publication (April 2018), azithromycin did not have a UK marketing authorization for this indication in children under 12 years. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information. Do not use azithromycin to treat people with cardiac abnormalities associated with Lyme disease because of its effect on QT interval

For more details click on the link: https://www.nice.org.uk/guidance/ng95/history

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Dr. Kamal Kant Kohli Kohli