Treatment

Discover THE TREATMENT OPTIONS FOR lYME AND PANDAS

Treatment of Lyme Disease

Early Treatment

  • Many patients with early Lyme disease treated with short antibiotic courses (< 20 days) recover.

  • However, clinical experience and scientific literature both show that a significant proportion do not return to pre-Lyme health after such short courses.

ILADS Recommendations:

  • For patients with erythema migrans (EM):

    • 4–6 weeks of doxycycline, amoxicillin, or cefuroxime

    • ≥21 days of azithromycin is also acceptable (especially effective against European Borrelia strains).

  • For non-EM early disease: treatment is similar to EM protocols.

  • For disseminated disease: longer courses or antibiotic combinations may be required.

Treatment Response and Persistence

  • 10–20% of patients remain ill following antibiotic therapy for early Lyme disease.

  • The clinical course and treatment response should guide further management.

  • Follow-up is essential:

    • If symptoms persist, recur, or new symptoms appear, persistent infection should be considered.

    • Borrelia burgdorferi has demonstrated the ability to survive antibiotics in laboratory, animal, and human studies.

    • Current testing cannot confirm eradication of the bacteria.

Chronic and Persistent Lyme Considerations

  • Persistent infection and co-infections must be considered in patients with ongoing symptoms.

  • Extended antibiotic therapy may be necessary when the risk of untreated infection outweighs the risks of long-term treatment.

  • Risks of long-term antibiotics exist but can be reduced with careful management.

  • Providers should engage in shared decision-making with patients:

    • Options for therapy

    • Risks and benefits of treatment

    • Risks of untreated persistent Lyme

Relapse vs. Re-Infection

  • Patients may be repeatedly infected with Lyme disease.

  • Both relapse and re-infection should be considered when symptoms recur after treatment.

Patient-Centered Care

ILADS emphasizes:

  • Person-specific, individualized care

  • Careful assessment and re-assessment of the full clinical picture

  • Treatment decisions guided by both the initial presentation and the course of illness if symptoms persist or return

Lyme disease

(Borrelia burgdorferi s.l.)

First-line (conventional) antibiotic therapy

Regimens below reflect the 2020 AAN/ACR/IDSA guideline and CDC clinical pages; tailor to age, pregnancy, allergies, and manifestations. IDSA+1CDC

Early localized (erythema migrans):
doxycycline 100 mg PO BID × 10 days; or amoxicillin 500 mg PO TID × 14 days; or cefuroxime axetil 500 mg PO BID × 14 days. Azithromycin only if others can’t be used. CDC

Early disseminated—cranial neuropathy (e.g., facial palsy): oral doxycycline × 14–21 days. CDC

Neuroborreliosis (meningitis/radiculoneuritis): doxycycline 200 mg/day PO or IV ceftriaxone 2 g QD × 14–21 days (choose route by severity/enteral tolerance). CDC

Carditis (atrioventricular block/myocarditis):
Outpatient, mild: oral agents (doxycycline/amoxicillin/cefuroxime/azithro) × 14–21 days.
Hospitalized or high-grade block: start IV ceftriaxone, switch to oral when improving; total 14–21 days. Temporary pacing is rarely needed; conduction usually recovers in days. IDSAOxford Academic

Lyme arthritis: oral doxycycline/amoxicillin/cefuroxime × 28 days; if minimal response, consider 2–4 weeks IV ceftriaxone or a second oral course, then transition to non-antibiotic arthritis management if synovitis persists despite adequate antibiotics. AAFP

Post-exposure prophylaxis (PEP)

For a high-risk Ixodes bite, consider single-dose doxycycline 200 mg (4.4 mg/kg up to 200 mg in children) within 72 hours of tick removal if criteria are met (Ixodes species, engorged, in a highly endemic area, etc.). CDC+1

Persistent symptoms after treatment (PTLDS)

Prolonged or repeated long-term antibiotics do not show durable benefit and carry harm in randomized trials; management is supportive and symptom-directed. New England Journal of Medicine

Common tick-borne co-infections (treat concurrently if suspected/confirmed)

  • Anaplasmosis (Anaplasma phagocytophilum): doxycycline (adults & children) 10–14 days (covers possible concurrent Lyme). CDC

  • Ehrlichiosis (Ehrlichia spp.): doxycycline for ≥5–7 days and ≥72 h fever-free with clinical improvement. CDC+1

  • Babesiosis (Babesia microti and others):
    uncomplicated: atovaquone + azithromycin × 7–10 days; severe disease or intolerance: clindamycin + quinine; consider exchange transfusion for high parasitemia/severe hemolysis. Immunocompromised patients often need longer/more intensive therapy. IDSACDC

  • Hard-tick relapsing fever (Borrelia miyamotoi): treat similarly to Lyme: ~14 days doxycycline (or amoxicillin); anticipate possible Jarisch–Herxheimer reaction. Evidence base is mostly case series. CDC

  • Bartonella henselae (cat-scratch disease; debated as an Ixodes co-pathogen): usually self-limited; azithromycin can hasten lymph node resolution; severe/disseminated disease requires specialist-guided combinations (e.g., doxycycline with rifampin), noting limited high-quality evidence. CDC

Clinical pearl: Fever with leukopenia and thrombocytopenia suggests anaplasmosis/ehrlichiosis; hemolytic anemia or parasitemia on smear suggests babesiosis. Co-infections can blunt response to standard Lyme therapy—treat all identified pathogens.

PANDAS/PANS

Definitions:

  • PANDAS = pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (abrupt-onset OCD/tics temporally linked to GAS).

  • PANS = broader, acute-onset OCD/restrictive eating with neuropsychiatric symptoms, infectious or non-infectious triggers.

Guideline landscape & controversy:

  • The PANS Research Consortium (PRC) published 2017 consensus treatment papers (Journal of Child & Adolescent Psychopharmacology):

    Three pillars—

  • (1) treat triggers (often antimicrobials), (2) immunomodulation by severity,

  • (3) manage psychiatric/behavioral symptoms. Liebert Publications

  • The AAP 2025 Clinical Report provides a cautious, non-guideline overview and emphasizes limited evidence and careful differential diagnosis. Expect payer/policy variability and ongoing debate. AAP Publications

Conventional management (commonly accepted)

  1. Treat the trigger/infection

    • GAS pharyngitis/sinusitis/skin infection: treat per standard pediatric guidelines (e.g., penicillin/amoxicillin; macrolide if true allergy). In severe, strep-driven, frequently relapsing cases, some experts consider secondary prophylaxis (practice varies; evidence low–moderate). PPN+1

    • Non-streptococcal triggers (e.g., Mycoplasma, influenza, SARS-CoV-2): manage per usual ID standards; the causal role is less certain.

  2. Psychiatric/behavioral care for OCD/tics/anxiety

    • CBT/ERP is foundational; SSRIs and standard tic/OCD pharmacology as indicated, with careful titration (some children are medication-sensitive during flares). The Heartwood Program

  3. Anti-inflammatory / immunomodulatory therapy

    • NSAIDs and short oral corticosteroid bursts are often used for flares.

    • IVIG (1–2 g/kg) or therapeutic plasma exchange (PLEX) may be considered for moderate–severe, function-threatening cases when there is a convincing immune-mediated presentation and inadequate response to the above. Evidence includes:
      • a 1999 randomized trial showing symptom reductions with IVIG and PLEX in infection-triggered OCD/tics;
      • a 2016 double-blind RCT of IVIG that did not meet its primary endpoint, though some secondary and open-label signals exist;
      • newer observational reports with mixed results. Decisions are individualized, ideally in multidisciplinary care. PubMed+1PMC

Routine tonsillectomy is not recommended solely for PANDAS/PANS; consider only for standard ENT indications.

Non-conventional / adjunctive approaches (what we know)

Important framing: Many are unproven or have only in vitro or small, uncontrolled human data. Discuss risks, interactions, and cost with families; avoid substituting these for indicated antibiotics/immunotherapy.

  • Herbal/“botanical” antimicrobials (e.g., Cryptolepis sanguinolenta, Japanese knotweed/Polygonum cuspidatum, Artemisia annua): demonstrate in-vitro anti-Borrelia or anti-Babesia activity; robust clinical trials are lacking. Quality control and drug–herb interactions are concerns.

  • Disulfiram for persistent Lyme-attributed symptoms: mechanistic rationale and case series/pilot work exist; adverse effects can be significant; no definitive efficacy in large RCTs—use only with specialist oversight or in trials.

  • Hyperbaric oxygen therapy (HBOT): not guideline-recommended for Lyme; evidence limited to small, uncontrolled studies; reputable reviews highlight approved uses vs. unproven claims.

  • Ozone therapy and similar “oxidation” interventions: the FDA states ozone is a toxic gas with no proven safe medical application; avoid.

  • Diet, sleep, graded activity, micronutrient repletion: low risk and sensible as adjuncts to manage fatigue, sleep disturbance, pain, and mood—not disease-specific therapies.

Non-conventional treatment options