Clinical Infectious Diseases 2007;44:1134-1135 © 2007 by the Infectious Diseases Society of America.
All rights reserved.
Lyme Disease Guidelines-It's Time to Move Forward
Sam T. Donta
Falmouth Hospital, Falmouth, Massachusetts
Reprints or correspondence: Dr. Sam T. Donta, Falmouth Hospital,
Ter Heun Dr., Falmouth, MA 02540 (email@example.com).
TO THE EDITOR-
The recommendations in the Infectious Diseases Society of America's guidelines  regarding the chronic form of Lyme disease-referred to as posttreatment Lyme disease-seem to be encumbered by our inability to better define chronic Lyme disease itself. We should not be debating the existence of persisting or relapsing symptoms. There is ample evidence for their existence [2-4]. Rather, we should be moving forward, discussing the nature of the chronic form of the illness and possible pathophysiologic mechanisms underlying it-that is, determining whether it is a prsisting infection, whether autoimmunity is involved, and whether there are postinfectious sequelae.
The various types and combinations of symptoms do not resemble the typical aches and pains of daily living, but are unique in the vast majority of patients who experience them, regardless of whether they have received prior antibiotic treatment. The use of the term "post-Lyme" implies that infection is no longer present; however, it is not currently possible to determine whether infection persists.
Indeed, even in patients who have more obvious symptoms and signs of Lyme disease that persist beyond the initial erythema migrans phase and who have robust serologic responses to Lyme disease bacterial proteins, it is not currently possible to isolate the bacteria. It would appear that patients with the chronic form of Lyme disease do not have the same robust serologic responses as patients with oligoarthritis [5-7], perhaps indicating inadequate host responses or bacterial factors that allow for the establishment of persisting infection. Patients who have had known tick bites or Lyme disease-related rashes who subsequently developed chronic symptoms of Lyme disease were not included in the original studies of serologic responses of patients with Lyme disease . In our experience, as well as in the experience of others, these patients have poorer and altered immunologic responses [5-7].
Our findings, which were based on careful observations of several thousand patients over the past 20 years, strongly support infection> as the probable cause of chronic symptoms. Antibiotic regimens consisting of tetracycline-not doxycycline  or the combination of a macrolide antibiotic and lysosomotropic agent -appear to yield the
best outcomes, including apparent cures or marked, stable improvements in 75% of patients; however, these treatments require that they be administered for a number of months to achieve good outcomes, depending on the duration of illness.
Our findings are also consistent with a persisting intracellular localization of the infection. The few controlled clinical trials that have been conducted thus far have employed different antibiotic regimens (i.e., intravenous ceftriaxone and doxycycline ) and treatments of shorter duration that have not been as effective as tetracycline or macrolide-lysosomotropic regimens. It would be important to validate our observations with additional controlled trials, although measuring end points in patients who have chronic symptoms and few, if any, objective signs is fraught with limitations.
Until there are better, specific markers of disease activity, we should acknowledge that there are patients who are affected by Lyme disease to varying degrees that range from mildly symptomatic to severely debilitating and who depend on the expertise of the members of the Infectious Diseases Society of America for diagnosis and treatment. In addition, we should move forward with plans to better understand the nature of this illness and to develop better ways to diagnose and treat the disease.
Potential conflicts of interest. S.T.D.: no conflicts
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IDSA:n näkemystä edustavat lääkärit ovat aloittaneet "kampanjan" edistääkseen näkemystään kroonisen borrelioosin hoidosta. Näkemyksessä ei ole tullut esiin mitään uutta viimeisten kuukausien/vuosien aikana. Heidän mukaansa muutaman viikon hoito parantaa ja oireiden jatkuessa kyse on jostakin muusta kuin borreliabakteerista.
AAN Practice Parameter: Antimicrobial Therapy of Neuroborreliosis
Experts provide evidence-based recommendations for the treatment of Lyme disease and discuss the evidence against persistent infection in "post-Lyme syndrome."
Ongoing controversy surrounds the choice of antibiotic for the treatment of neurologic Lyme disease, the appropriate duration of treatment, and whether or not chronic symptoms of "post-Lyme syndrome" are due to persistent or relapsing infection.
A panel of experts from the U.S. and Europe, who have published extensively about Lyme disease, developed this evidence-based review of the treatment of neurologic Lyme disease for the American Academy of Neurology.
The panel performed a literature search of studies published from 1983 to 2003. From the resulting 353 citations, 122 potentially relevant articles were reviewed in detail, of which 37 ultimately were used for the analysis.
There were sufficient data to conclude that neurologic Lyme disease in adults and children age ≥8 years is effectively treated with a 2-week course of parenteral penicillin, ceftriaxone, or cefotaxime.
There was no evidence of antibiotic resistance in Borrelia burgdorferi. European studies provided substantial evidence that oral doxycycline is as efficacious as parenteral antibiotics in patients who have Lyme-associated meningitis, facial nerve palsy, or radiculitis.
Evidence from three trials suggested a lack of benefit from prolonged antibiotic treatment of "post-Lyme syndrome" (symptoms persisting or recurring after appropriate treatment in the absence of evidence of ongoing infection).
Comment: Misunderstanding of Lyme disease has created a demand by patients with pain, fatigue, and perceived cognitive trouble to seek prolonged parenteral treatment for Lyme disease and "post-Lyme syndrome."
This study provides evidence-based recommendations for appropriate types and duration of antimicrobial therapy for neurologic Lyme disease. It also provides reassurance that the disease can be treated and highlights the lack of evidence that post-Lyme syndrome is due to active B. burgdorferi infection that would require prolonged antibiotic therapy.
? Karen L. Roos, MD
Dr. Roos is John and Nancy Nelson Professor of Neurology, Indiana University School of Medicine, Indianapolis.
Published in Journal Watch Neurology October 2, 2007
Halperin JJ et al. Practice Parameter: Treatment of nervous system Lyme disease (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2007 Jul 3; 69:91.
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