Lyme disease guidelines updated

By Nelson Sigelman - October 5, 2006

The Infectious Diseases Society of America (IDSA) on Monday released updated guidelines on the diagnosis and treatment of Lyme disease. The report is expected to be of great interest to Vineyard physicians and residents who must contend with the significant community health risks posed by tick-borne diseases.

The most significant changes in the society's updated clinical practices guidelines, originally published in 2000, is the addition of information on additional tick-borne diseases, antibiotic dosage recommendations for high risk patients who do not exhibit Lyme symptoms, and an expanded discussion of so called chronic or post Lyme syndromes.

IDSA is a professional organization based in Alexandria, Virginia, with more than 8,000 members, including physicians, scientists, and other health-care professionals who specialize in infectious diseases. According to the IDSA, its purpose is "to improve the health of individuals, communities, and society by promoting excellence in patient care, education, research, public health, and prevention relating to infectious diseases."

The IDSA said the guidelines were updated in response to growing concern and confusion about Lyme disease, in order to provide guidance to physicians and patients based on the latest scientific evidence. They were developed by a panel of infectious disease specialists chaired by Gary P. Wormser, Chief, Division of Infectious Diseases and Vice Chairman of the Department of Medicine, New York Medical College, who also was the lead author.

"We worked to make the guidelines as comprehensive as possible based on a thorough review of all credible scientific literature," said Dr. Wormser.

The guidelines are now available on the IDSA web site (www.idsociety.org) and will be published in the Nov. 1 edition of the journal, Clinical Infectious Diseases.

Vineyard concern about Lyme disease was evident in April during a weekend conference and public forum that featured a panel of specialists in the field of tick-related diseases. An evening seminar for physicians and health-care providers attracted an overflow crowd to hear the panelists discuss their latest research and current understanding of tick-borne diseases, and the emotionally charged topic of Lyme treatment, including arguments for and against a diagnosis of chronic Lyme disease.

Lyme guidelines

Although Lyme disease is the most commonly known tick-borne infection, the updated guidelines now contain information on two other tick-related diseases, HGA and babesiosis, a disease seen with increasing frequency on the Vineyard and Nantucket. Although the routine preventive dispensing of antibiotics is not recommended for individuals with tick bites and no symptoms of disease, one substantive change in IDSA's treatment recommendations is that some selected, high-risk tick bites may be treated with a single dose of the antibiotic doxycycline but only under certain conditions.

Those conditions include a reliable identification that the bite came from a deer tick that has been attached for 36 hours or longer; and if preventive treatment can be started within 72 hours of the time the tick was removed.

IDSA states that most patients who develop Lyme disease are cured with a single course of 10 to 28 days of antibiotics, depending on the stage of their illness. Occasionally a second course of treatment is necessary. More prolonged antibiotic therapy is not recommended and may be dangerous, according to Dr. Wormser.

One of the topics taken up in the guidelines is chronic Lyme disease and Post-Lyme Disease Syndromes, terms used to describe a variety of medical conditions that stem from what some contend is an established and untreated Lyme disease infection. It is a topic that has ignited fierce debate among the public and medical community regarding treatment options and the extent of the condition.

The updated IDSA guidelines contain greater detail in the discussion of post-Lyme disease syndromes. As in the past, the guidelines do not recommend ongoing antibiotic therapy for those with chronic symptoms who have completed the recommended initial course of treatment for Lyme disease.

"After a thorough review of the literature, the panel concluded there is no convincing biologic evidence for symptomatic, chronic Borrelia burgdorferi (Lyme) infection after completion of the recommended treatment for Lyme disease," the guidelines state.

Furthermore, long-term antibiotic therapy may be dangerous and it also can lead to complications for the patient, such as blood stream catheter infection (for those on intravenous antibiotics) and Clostridium difficile colitis (a potentially severe infection of the bowel). Long-term antibiotic therapy may also foster the development of drug-resistant superbugs that are difficult to treat, said one of the panelists.

Dr. Wormser said. "People who continue to have symptoms that persist after appropriate antibiotic treatment for Lyme disease should talk to their physicians about whether the diagnosis was accurate or if they may have a different or new illness to be certain they get the proper medical care."

Local view

Martha's Vineyard and Nantucket are considered hot spots for tick-borne illnesses. As a result, Island physicians are generally well versed in the symptoms associated with a variety of diseases and the islands are a focus of outside research.

Sam Telford 3rd, associate professor of infectious diseases at the Tufts University School of Veterinary Medicine, has been conducting research on ticks on both islands for many years. Contacted by e-mail and asked to comment on the report, he said the IDSA report has been a long time in gestation and is very welcome because it sorts through the vast literature that has accumulated and would allow average doctor to "cut right through the nonsense."

Noting that he is not a physician and therefore his comments only reflect his knowledge of the biology of the agent and whether that is compatible with the report, Mr. Telford said he expects that the guidelines will only further inflame the "Lyme activist community."

In particular he cited references to post-Lyme syndrome which he said suggest that folks really should wonder if their persisting signs and symptoms are really more unusual than what many people experience every once in a while or more frequently as we age.

Jumping into the debate about chronic symptoms, Mr. Telford said it took fortitude to suggest that people really should wonder if their persisting signs and symptoms are really more unusual than what everyone experiences every once in awhile or more frequently as we age. He said, "The IDSA report now provides guidance for the physician confronted with a patient who has some subjective complaints compatible with aging or stress.

"If they had been objectively diagnosed with Lyme once, then further testing and perhaps treatment for Lyme may be undertaken. If they had not previously been diagnosed, but live in an endemic area, they could be tested. But if they come up negative in the hands of a good lab, then it is not Lyme. (And yes, there are good tests and bad tests, and good labs and bad labs.)

"Folks should then move on and entertain other diagnoses, including, in my opinion, change their diet, do more exercise, drink more red wine, watch more Three Stooges, go fishing, think positively. (I can hear it now, 'easy for you to say, you've never been infected.')"

Mr. Telford added that the good news is that the majority of those with acute or late Lyme who are treated according to the IDSA guidelines will improve and become well. "The words in the IDSA report are based upon a careful review of the peer-reviewed scientific literature by individuals with an aggregate of 250 years or more of clinical experience with Lyme disease among the 13 infectious disease doctors (not all the authors are physicians)," he said. "This is as authoritative a statement as they come from an evidence-based medicine approach."