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Pt w/ typical Lyme sx (erythema migrans, carditis, arthritis, neuro sx, lymphocytoma, acrodermatitis chronica atrophicans)
Needs dx and/or initial tx Pt w/ early localized Lyme sx (erythema migrans) Pt w/ early disseminated Lyme sx (inflammatory arthritis, meningitis, cranial neuritis, carditis, lymphocytoma) Awaiting initial tx for Lyme arthritis Awaiting initial tx for neurologic Lyme (facial palsy, neuritis, meningitis, encephalitis) Awaiting initial tx for Lyme carditis Awaiting initial tx for Borellial lymphocytoma
Pt w/ late disseminated Lyme sx (chronic arthritis, acrodermatitis chronica atrophicans, encephalopathy, polyneuropathy)
Pt w/ persistent sx after initial tx
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Asymptomatic pt, bitten by tick Prompt tick removal is important to ↓ Lyme risk. Don’t test tick, nor asymptomatic pt, for B burgdorferi. Don’t diagnose Lyme dz in asymptomatic pts.1 Abx ppx indicated in certain pts, while watch & wait is appropriate for others - Remove attached ticks ASAP by mechanical means using clean, fine-tipped tweezer (or a comparable device) inserted btwn tick body and skin;2 transmission occurs after 36-48h of attachment3,4
- Don’t use heat/match, nail polish, petrolatum, or other chemicals to force tick to detach; this may delay removal3 or cause tick to regurgitate and potentially ↑ risk of pathogen transmission4
- Send tick to lab for species ID, per IDSA;4 CDC makes no recommendation re: lab ID3,5
- Don’t test tick for B burgdorferi;3,4 (+) result poorly predicts clinical infxn or asymptomatic seroconversion3
- Provide abx ppx w/in 72h of removal, only to pts w/ an identified high-risk tick bite:6,7 doxycycline 200 mg PO x1 for adults or 4.4 mg/kg/dose (max 200 mg) for children;4,5,* watch & wait appropriate for pts w/ low or equivocal risk4,5
- Monitor for erythema migrans (EM) or other s/sx of tick-borne infxn in wks following tick bite; avg onset of EM: 7 days after bite (range: 3-90 days);1,3 STARI rash looks similar but occurs slightly earlier, after Amblyomma americanum bite;8 an earlier inflammatory reaction may wax & wane at bite site w/in first 48h, not representative of EM or Lyme1,5
Ticks that commonly bite humans:5 Footnotes 1 NICE 2018. Lyme Disease - NICE Guideline (NG95). National Institute for Health and Care Excellence. Published 4/11/18. Last updated 10/17/18. Accessed 5/31/23
2 CDC 2022. Tick removal technique:
• Use clean, fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible.
• Pull upward w/ steady, even pressure. Don’t twist or jerk the tick; if mouth-parts break off and remain in the skin, remove the mouth-parts w/ tweezers. If unable to remove the mouth easily w/ tweezers, leave it alone and let the skin heal.
• After removing the tick, thoroughly clean the bite area and your hands w/ rubbing alcohol or soap and water.
• Dispose of a live tick by putting it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet.
Lyme Disease: Tick removal and testing. Last reviewed 5/13/22. Accessed 6/21/23
3 CDC 2022. Lyme Disease. Last reviewed 1/19/22. Accessed 6/20/23
4 IDSA/AAN/ACR 2020. Lantos PM, 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. Clin Infect Dis. 2021. Jan 23;72(1):1-8. Accessed 5/31/23
5 CDC 2021. Ticks. Last reviewed 10/21/21. Accessed 6/21/23
6 IDSA/AAN/ACR 2020. High-risk tick bite (all must be true): the tick bite was from (a) an identified Ixodes spp. vector species, (b) it occurred in a highly endemic area, and (c) the tick was attached for ≥36h.
Lantos PM, 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. Clin Infect Dis. 2021. Jan 23;72(1):1-8. Accessed 5/31/23
7 CDC 2021. High-risk tick bite (all must be true):
(a) the tick bite occurred in a state where Lyme dz incidence is high, or in an area where >20% of ticks are infected w/ Borrelia burgdorferi;
(b) the attached tick can be identified as an adult or nymphal blacklegged tick;
(c) the estimated time of attachment is ≥36h based on degree of tick engorgement w/ blood ( CDC image) or likely time of exposure to the tick.
Guidance for Clinicians: Caring for Patients after a Tick Bite. December 14, 2021. Accessed 6/21/23
8 CDC 2018. Southern Tick–Associated Rash Illness: STARI or Lyme? Last reviewed 11/19/18. Accessed 6/21/23
* ILADS 2014. ILADS diverges from CDC & IDSA guidance, recommending against single-dose doxycycline, instead recommending: “Clinicians should promptly offer abx ppx for all 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 doxycycline 100–200 mg bid x20 days. Other treatment options may be appropriate on an individualized basis.” They cite very low-quality evidence, and differing values leading to a differing conclusion upon evaluation of that evidence.
Cameron DJ, et al. Evidence Assessments and Guideline Recommendations in Lyme Disease: The Clinical Management of Known Tick Bites, Erythema migrans Rashes and Persistent Disease. Expert Rev Anti Infect Ther. 2014. Sept;12(9):1103-1135. Free full-text PDF @ PubMed® Central
Numerous groups, incl the Infectious Diseases Society of America (IDSA), have raised concern about the quality, validity, and inherent bias of International Lyme and Associated Diseases Society (ILADS) guidance, which does not meet epocrates editorial standards. We include their recommendations here not as an endorsement of their validity but to provide context when confronted w/ pt questions arising from ILADS recommendations.
Pt w/ other conditions or sx atypical for Lyme dz In endemic area, consider Lyme dz in pts w/ certain sx or conditions, even in absence of distinct tick bite - Use combo of clinical presentation (sx, h/o possible tick exposure) and lab testing to guide dx & tx of pts w/o erythema migrans (EM);1,2 consider starting tx while awaiting labs2
- Consider Lyme (or other tick-borne illness)3 in absence of EM in pts w/ acute onset of multiple sx: fever, sweats, lymphadenopathy, malaise, fatigue, neck pain/stiffness, migratory joint or muscle pain, cognitive impairment, HA, paresthesia;* inquire about possible tick exposure; also consider Lyme in pts w/ eye sx (eg, uveitis, keratitis)2
- Perform 2-tier testing when Lyme being considered in absence of EM: initial ELISA1,2 or IFA,1 then Western immunoblot (or FDA-approved 2nd EIA4) if 1st test is (+) or equivocal; don’t r/o dx if tests are (-) but there’s high clinical suspicion of Lyme dz2
- In pts w/ potential tick exposure in a Lyme dz–endemic area who have 1+ skin lesions suggestive of, but atypical for, EM, consider Ab testing performed on an acute-phase serum sample, followed by a convalescent-phase serum sample (2-3wk later) if initial result is (-)5
- Don’t use unaccredited labs or unvalidated tests for Lyme dx2,6,**
Consider testing for Lyme dz in limited pts being evaluated for other conditions - If appropriate epidemiologic setting, test for Lyme in pts w/ unexplained carditis; in pts w/ chronic cardiomyopathy, IDSA suggests against routine testing for Lyme5
- Don’t test pts w/ amyotrophic lateral sclerosis, relapsing-remitting multiple sclerosis, Parkinson dz, dementia or cognitive decline, new-onset seizures, or other atypical neuro conditions for Lyme5,***
- Don’t test adults w/ psych illness for Lyme, per IDSA (NICE says to consider doing so);* consider not testing kids w/ developmental, behavioral, or psych disorders5
- In pts w/ nonspecific white matter changes on brain imaging w/o hx of other clinical or epidemiologic support for the dx of Lyme dz, IDSA suggests against testing for Lyme, while NICE suggests testing can be considered
Footnotes 1 CDC 2022. Lyme Disease. Last reviewed 1/19/22. Accessed 6/20/23
2 NICE 2018. Lyme Disease - NICE Guideline (NG95). National Institute for Health and Care Excellence. Published 4/11/18. Last updated 10/17/18. Accessed 5/31/23
3 CDC 2021. Ticks: Symptoms of Tickborne Illness. Last reviewed 8/5/21. Accessed 6/22/23
4 CDC 2019. Mead P, et al. Updated CDC Recommendation for Serologic Diagnosis of Lyme Disease. Morb Mortal Wkly Rep. 2019;68:703. PDF
5 IDSA/AAN/ACR 2020. Lantos PM, 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. Clin Infect Dis. 2021. Jan 23;72(1):1-8. Accessed 5/31/23
6 CDC 2023. Examples of unvalidated tests include:
• Capture assays for antigens in urine
• Immunofluorescence staining, or cell sorting of cell wall–deficient or cystic forms of B burgdorferi
• Lymphocyte transformation tests
• Quantitative CD57 lymphocyte assays
• “Reverse Western blots”
• In-house criteria for interpretation of FDA-cleared tests
• IgM or IgG tests w/o previous enzyme immunoassay
Lyme Disease: Laboratory tests and practices that are not currently recommended. Last reviewed 2/9/23. Accessed 6/20/23
* ILADS 2021. ILADS diverges from IDSA and CDC, recognizing “chronic Lyme disease” as an active infxn lasting years (or decades) and causing common sx such as: fatigue, cognitive dysfxn, HA, sleep disturbances, migratory arthralgia & myalgia, numbness & tingling, neuropathic pain, anxiety & depression, and musculoskeletal problems.
Lyme Disease Basics for Providers: A Brief Primer by International Lyme and Associated Diseases Society. Accessed 5/31/21
Numerous groups, incl the Infectious Diseases Society of America (IDSA), have raised concern about the quality, validity, and inherent bias of International Lyme and Associated Diseases Society (ILADS) guidance, which does not meet epocrates editorial standards. We include their recommendations here not as an endorsement of their validity but to provide context when confronted w/ pt questions arising from ILADS recommendations.
** ILADS 2021. ILADS diverges from CDC and NICE guidance, supporting “emerging testing modalities” that “present new opportunities for addressing the challenges faced in lab eval of Lyme dz.”
Numerous groups, incl the Infectious Diseases Society of America (IDSA), have raised concern about the quality, validity, and inherent bias of International Lyme and Associated Diseases Society (ILADS) guidance, which does not meet epocrates editorial standards. We include their recommendations here not as an endorsement of their validity but to provide context when confronted w/ pt questions arising from ILADS recommendations.
*** ILADS 2021. ILADS diverges from IDSA guidance, claiming that Lyme should be considered in the diff dx of rheumatologic and neurologic conditions, as well as chronic fatigue syndrome, fibromyalgia, somatization disorder, and “any difficult-to-diagnose multi-system illness.”
Numerous groups, incl the Infectious Diseases Society of America (IDSA), have raised concern about the quality, validity, and inherent bias of International Lyme and Associated Diseases Society (ILADS) guidance, which does not meet epocrates editorial standards. We include their recommendations here not as an endorsement of their validity but to provide context when confronted w/ pt questions arising from ILADS recommendations.
No sx or concerns, pt wants to prevent Lyme dz Use personal protective measures, repellants, & tick checks to ↓ risk of tick exposure & infxn w/ tick-borne illness - Wear light-colored, long-sleeved/legged clothing to make ticks more apparent before attachment1,2
- Tuck pants into socks to prevent ticks from attaching to skin of ankles & legs; keep to center of trail, avoid wooded & brushy areas w/ high grass and leaf litter1-3
- Perform full-body tick check after being outdoors;3 bathing/showering w/in 2h of outdoor activity significantly ↓ risk of Lyme dz2,3
- Put clothes in hot dryer for 10min, or wash clothes in hot (not warm or cold) water, to kill ticks2,3
- Check gear,1 companion animals, for unattached ticks1,2
- Repellants recommended for skin & clothing: N,N-Diethyl-meta-toluamide (DEET),4 picaridin, ethyl-3-(N-n-butyl-N-acetyl) aminopropionate (IR3535), oil of lemon eucalyptus (OLE),5 p-methane-3,8-diol (PMD),5 2-undecanone3
- Permethrin spayed on or impregnated in clothing kills ticks on contact, is more effective than DEET2,3
- Not recommended: botanical agents & essential oils (eg, essential oils of rosemary, cinnamon leaf, lemongrass, geraniol, nootkatone, and carvacrol)2
Full-body tick check points3 Footnotes 1 CDC 2017. Travelers’ Health: Diseases Spread by Ticks. Last reviewed 10/23/17. Accessed 6/22/23
2 IDSA/AAN/ACR 2020. Lantos PM, 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. Clin Infect Dis. 2021. Jan 23;72(1):1-8. Accessed 5/31/23
3 CDC 2019. Lyme Disease: Preventing Tick Bites on People. Last reviewed 9/30/19. Accessed 6/22/23
4 IDSA/AAN/ACR 2020. The EPA has approved DEET for use on children, w/ no age restriction. Because of a lack of safety data, however, the AAP & CDC only recommend DEET for children >2 mo of age.
Lantos PM, 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. Clin Infect Dis. 2021. Jan 23;72(1):1-8. Accessed 5/31/23
5 IDSA/AAN/ACR 2020. The AAP, CDC, and EPA do not recommend OLE and PMD for children <3 yo.
Lantos PM, 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. Clin Infect Dis. 2021. Jan 23;72(1):1-8. Accessed 5/31/23
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