Q&A: Lyme disease guidelines updated for first time in 14 years
New Lyme disease guidelines published in Arthritis & Rheumatology were co-authored by the Infectious Diseases Society of America, American Academy of Neurology and American College of Rheumatology.
The document features 43 guidelines for diagnostic testing, testing scenarios, Lyme carditis and information regarding "chronic Lyme disease."
Healio spoke with Paul G. Auwaerter, MBA, MD, clinical director of infectious diseases and professor of medicine at Johns Hopkins Medicine, who said the guidance was based on input from a “wide range” of experts.
Q: What are the major diagnostic testing recommendations, and what’s new?
A: From a diagnostic standpoint, I would say they remain rooted in the clinical diagnosis of a rash consistent with erythema migrans. If there are other signs of objective illness, serology remains the cornerstone for securing a diagnosis. That includes the two-tier Borrelia burgdorferi serologic testing that many people are familiar with but also includes the modified two-tier testing that had been approved by the FDA in 2019.
The guidance also states if you are uncertain of the diagnosis, an acute and convalescent serologic test should be employed to search for a change.
Q: What are the major treatment recommendations, and what’s new?
A: The treatment recommendations have no had radical changes. One that I think is important to know is that for erythema migrans in early Lyme disease, 10 days of doxycycline is sufficient, whereas 14 days is recommended for amoxicillin or cefuroxime.
The important recommendation is that, in concert with recommendations from the CDC for Rocky Mountain spotted fever, and also from the Red Book and the American Academy of Pediatrics, we suggest doxycycline is acceptable for short-course therapy in children aged younger than 8 years, which does not stain dental enamel.
Q: What do the guidelines have to say about “chronic Lyme disease”?
A: The recommendations remain that patients who have persistent symptoms following standard treatment of Lyme disease should not get additional antibiotic therapy, if they lack objective evidence of reinfection or treatment failure.
The guideline does not specifically address chronic Lyme disease in its formal recommendations other than to say that that entity is poorly described and used for patients who may have nonspecific symptoms such as fatigue, chronic musculoskeletal pain, cognitive impairments and others. We would suggest that objective findings as well as positive serological tests are used together to make a clinical diagnosis. That is a limited recommendation.
Q: When were the guidelines last updated, and what prompted this update?
A: The catalyst for this was that they required an update, as they were last updated in 2006. The distinguishing feature here is that we now have three societies that have come together to produce these guidelines — the IDSA, The American Academy of Neurology and the American College of Rheumatology. This update was also prompted by the National Academy of Medicine's recommendations for guidelines, which included the GRADE [grading of recommendations assessment, development and evaluation] system of weighing evidence.
Lastly, we sought to be as inclusive as possible to have a wide range of specialties, not only from the societies that are supporting this but also emergency medicine, cardiology, pediatrics and patients. Even the ticks were represented by a member from the American Entomological Society.
Q: Do you think it would it be more helpful to have “living guidelines” for Lyme disease?
A: I do, and in fact the IDSA has taken to having guidelines looked at on a frequency of every 2 years, with updates as required, instead of waiting 5 to 10-plus years in between guidelines. That is something that is already part of the new and updated IDSA guidelines process.