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July 2012 New York City Department of Health and Mental Hygiene Vol.3(3):17-24
 

IN THIS ISSUE

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Preventing and Managing Lyme and Other Tick-borne Diseases
  • Advise patients to use tick checks, DEET, and showers to avoid tick bites; if a tick is attached, it should be removed promptly and safely.

  • Ask patients with suggestive symptoms such as fever, headache, malaise, and/or rash about travel history, as most tick-borne infections are acquired outside of New York City.

  • Follow recommended testing protocols, including repeat testing if indicated, because symptoms may be nonspecific and immune response is often delayed.

 

TREATMENT

Treatment is more likely to be effective if started early in the course of disease. For most tick-borne diseases, diagnostic tests based on the detection of antibodies will frequently appear negative in the first 7 to 10 days of illness, so prompt treatment must be based on clinical suspicion alone. Begin treatment (see Table 2) at clinical diagnosis for all tick-borne diseases except babesiosis, which should be confirmed by evidence of active parasitemia.5 See Tick-borne Diseases in the New York City Area: A Physician's Reference Manual for detailed information.

TABLE 2. TREATMENT OF TICK-BORNE INFECTIONS5,10
Infection Adults Children Comments
Lyme diseasea Doxycyclineb 100 mg BID × 10-21 days,
OR
Cefuroxime axetil 500 mg BID × 14-21 days,
OR
Amoxicillin 500 mg TID × 14-21 days

Age <8 years: Amoxicillin 50 mg/kg/day in 3 divided doses × 14-21 days,
OR
Cefuroxime axetil 30 mg/kg/day in 2 divided doses × 14-21 days
Age ≥8 years: Doxycycline 4 mg/kg/day in 2 divided doses × 10-21 days

Consider possible coinfection with
B. microti
and/or
A. phagocytophylum
in patients with especially severe or persistent symptoms despite treatment.
Babesiosisc Oral atovaquone 750 mg every 12 h × 7-10 days, AND
oral azithromycin 500-1000 mg on
day 1, and 250 mg orally QD thereafter,
OR
Clindamycin 300-600 mg every 6 h IV or 600 mg every 8 h orally AND
oral quinine 650 mg every 6-8 h ×
7-10 days
Atovaquone 20 mg/kg every 12 h AND oral azithromycin 10 mg/kg QD on day 1, 5 mg/kg QD thereafter,
OR
Clindamycin 7-10 mg/kg every 6-8 h IV or orally AND oral quinine 8 mg/kg every 8 h × 7-10 days
Consider possible coinfection with
B. burgdorferi
and/or
A. phagocytophylum
in patients with especially severe or persistent symptoms despite treatment.
Anaplasmosisd Doxycyclineb
100 mg BID orally or IV × 10 days

Age ≥8 years with moderate illness: doxycycline 4 mg/kg/day orally or IV in 2 divided doses × 10 days
Age <8 years with severe illness who are not coinfected with Lyme disease: doxycycline 4 mg/kg per day orally or IV in 2 divided doses × 4-5 days or approx. 3 days after resolution of fever and clinical improvement is noted
Age <8 years with severe illness who are coinfected with Lyme disease:
doxycycline 4 mg/kg/day orally or IV in 2 divided doses × 4-5 days. Follow with either amoxicillin 50 mg/kg/day in 3 divided doses
OR
cefuroxime axetil 30 mg/kg/day in 2 divided doses to complete a 14-day course of antibiotic therapy.

Failure to respond in 3 days suggests infection with a different agent or coinfection with
B. microti
.
Ehrlichiosis Doxycyclineb
100 mg BID orally or IV × 10 days
Age ≥8 years: doxycycline 4 mg/kg/day orally or IV in 2 divided doses × 10 days
Age <8 years:
doxycycline 4 mg/kg/day orally or IV in 2 divided doses × 4-5 days OR approx. 3 days after resolution of fever and clinical improvement is noted
Failure to respond in 3 days suggests infection with a different agent.
Rocky Mountain spotted fever Doxycyclineb
100 mg/day BID orally or IV for at least 3 days after fever subsides and until evidence of clinical improvement (typically 5-7 days)
Weight ≥100 lbs (45.5 kg): doxycycline 100 mg/day BID orally or IV for at least 3 days after fever subsides and until evidence of clinical improvement (typically 5-7 days). Consult a pediatric infectious disease specialist.
Weight <100 lbs (45.5 kg): doxycycline 2.2 mg/kg body weight/dose BID orally or IV for at least 3 days after fever subsides and until evidence of clinical improvement (typically 5-7 days). Consult a pediatric infectious disease specialist.
If infection is suspected or petechial rash appears on palm or sole, treat immediately, without laboratory confirmation of diagnosis.

aFor patients intolerant of amoxicillin, doxycycline, and cefuroxime axetil, the macrolides azithromycin, clarithromycin, or erythromycin may be used and the patient should be closely observed to ensure resolution of clinical manifestations. For treatment of later-stage Lyme disease, see Infectious Diseases Society of America Guidelines at http://cid.oxfordjournals.org/content/43/9/1089.long.
bDoxycycline is the drug of choice in adults and children for anaplasmosis, ehrlichiosis, RMSF, and in most cases of Lyme disease. Limited courses of doxycycline do not result in tooth staining in children. While tetracyclines are usually contraindicated for use in pregnancy, they may be warranted for life-threatening situations with a high clinical suspicion or documentation of anaplasmosis, ehrlichiosis, or RMSF.
cImmunocompromised patients: azithromycin 600-1000 mg/day.
d
Patients with mild illness for whom doxycycline treatment is contraindicated may be treated with rifampin for 7-10 days at a dosage of 300 mg BID orally for adults and 10 mg/kg BID for children (maximum, 300 mg per dose).

See Tick-borne Diseases in the New York City Area: A Physician's Reference Manual at www.nyc.gov/html/doh/downloads/pdf/ehs/tick-borne-dx-physician.pdf for detailed information.

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