A tick bite leads to an infection with B. burgdorferi s.l. in less than 5% of the cases.

Therefore, there is no indication to administer an antibiotic therapy after a tick bite with no clinical signs appearing after a few days. Only symptomatic patients with evocative clinical signs after a tick bite or at least after a tick exposure will be treated.

The type of antibiotic treatment given will depend on the clinical manifestation but also on antibiotic strategies in different parts of Europe. The choice of drugs is governed by local policies concerning availability of drugs in different countries, on economical considerations and on national guidelines aimed at preventing the development of drug resistance.

The following information on Lyme borreliosis treatment reports current practice in Europe (Table 1). It is not all-inclusive, and minority strategies are excluded. These minority strategies often include longer periods than is normally recommended and are not based on controlled studies. Controlled studies indicate that shorter treatment regimens are preferable to longer ones (Klempner, et al.,2001, New Eng. J. Med. 345, 85-92, Wormser et al., 2001, Wiener. Klin. Wochenschr. 114, 613-615).

In a small proportion of patients symptoms do not appear to respond satisfactorily to antibiotic therapy. Occasionally relapses occur, especially if unrecommended antibiotics such as the majority of the macrolides, are used and in such cases a second course of antibiotics may be required. Occasionally patients show persistent synovitis months or years after 2-3 months of antibiotic therapy. This so-called antibiotic-refractory Lyme arthritis, which is more frequent in the US, is thought to be due to a form of autoimmunity. Patients with post-Lyme borreliosis syndrome show symptoms such as musculoskeletal pain, neurocognitive symptoms and/or fatigue, similar to chronic fatigue syndrome or fibromyalgia, which persist more than 6 months after a well-administered antibiotic therapy according to guidelines. These symptoms may have severe repercussions on quality of life. There is rarely evidence for the presence of spirochaetes in these cases and it is thought to be partly due to pro-inflammatory imbalance. Symptomatic therapy is generally recommended as well as physical rehabilitation and cognitive behavioral therapy.

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Drug	Route	Dose
		Adults	Children	Duration
Erythema migrans* and borrelial lymphocytoma†
Doxycycline‡	Oral	2 x 100 mg	age-restricted use‡	14 days (10–21 days)
Amoxicillin	Oral	3 x 500–1000mg	25–50 mg/kg	14 days (10–21 days)
Cefuroxime axetil	Oral	2 x 500 mg	30–40 mg/kg	14 days (10–21 days)
Penicillin V	Oral	3 x 1.0–1.5 Mio	0·1–0·15 Mio/kg	14 days (10–21 days)
Azithromycin†	Oral	2 x 500 mg 1 x 500 mg	20 mg/kg 10 mg/ kg	First day Next 4 days
Neuroborreliosis#
Ceftriaxone§	iv	2 g	50–100 mg/kg	14 days (10–30 days)
Penicillin G	iv	20 Mio	0·25–0·5 Mio/kg	14 days (10–30 days)
Doxycycline‡	Oral	2 x 100 mg or 200 mg	age-restricted use‡	21 days (14–30 days)
Arthritis and cardioborreliosis§
Doxycycline‡	Oral	2 x100 mg	age-restricted use‡	21 days (14–30days)
Amoxicillin	Oral	3 x 500–1000 mg	25–50 mg/kg	21 days (14–30 days)
Ceftriaxone§	iv	2 g	50–100 mg/kg	21 days (14–30 days)
Acrodermatitis chronica atrophicans
Ceftriaxone§	iv	2 g	50–100 mg/kg	21 days (14–30 days)
Doxycycline‡	Oral	2 x 100 mg	age-restricted use‡	21 days (14–30 days)
Amoxicillin	Oral	3 x 500–1000 mg	25–50 mg/kg	21 days (14–30 days)

Penicillin V = Phenoxymethylpenicillin, Mio = million units, iv = intravenous
*Treatment for multiple erythema migrans (secondary, relapsing EM) as for acute neuroborreliosis
†Azithromycin is primarily considered as an alternative treatment for children and pregnant or breast-feeding women who are allergic to penicillin or doxycycline.
‡Doxycycline can now be used in children younger than 8 years-old (depending on the dosage form under 6 years-old) and in pregnant or breastfeeding women.
#Use of doxycline is usually restricted to early neuroborreliosis. For late neuroborreliosis parenteral treatment for 2 to 4 weeks is recommended.
§Other third-generation cephalosporins such as cefotaxime are also effective.

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