Category: Lyme Transmission and Prevention
How do I know whether I have received a sufficiently long course of antibiotic therapy?
Obviously if a person is no longer having symptoms, that is a good sign that the duration of treatment was adequate. However a large number of patients continue to have symptoms after a course of antibiotic therapy, particularly in the later stages of Lyme Disease. Some doctors believe that the symptoms will clear up over time without antibiotics or that the residual symptoms reflect residual damage or an autoimmune response that would no longer respond to antibiotic therapy. Other doctors believe that persistent symptoms require longer courses of antibiotic therapy and that the antibiotics themselves should not be stopped until the signs and symptoms of disease are gone. A middle-of-the-road approach might be to advocate a repeated course of antibiotic therapy if the symptoms haven't cleared up after 3-4 months. Most valuable would be to use objective markers to measure change in response to treatment, such as neuropsychological testing or neuroimaging before and after the repeated course of treatment. The use of these objective tests allows the clinician to determine whether physiological and cognitive changes occurred, and it allows insurance companies who pay for the treatment to see that their investment was worthwhile. Neuropsychological testing before and after re-treatment was reported in a pilot study at Columbia (see Fallon et al, Journal of Spirochetal Diseases, v 6: 94-102, 1999....this article is available on Medscape); the results indicated that patients given a repeated course of IV antibiotic therapy showed considerable cognitive improvement. This however was an uncontrolled study. There have now been 4 controlled studies of chronic Lyme disease. Two studies (Klempner et al) using the same treatment approach (1 month of IV and 2 months of Doxy) showed no benefit with repeated treatment. One study (Krupp et al) using one month of IV ceftriaxone showed improvement in fatigue at 6 months to a greater extent in the drug treated group than in the placebo treated group; this finding was replicated in a later study by Fallon et al. Finally, the fourth study (Fallon et al, 2008) found a temporary benefit in overall cognition after 10 weeks of IV ceftriaxone but this improvement was lost when patients were off antibiotics for another 14 weeks; this study also reported that patients who had more pain or physical dysfunction at the start of the study were more likely to show improvement in these domains if given IV ceftriaxone compared to IV placebo and that this improvement was sustained even after being off of antibiotics for 14 weeks.
Taken together, these study results suggest that repeated antibiotic therapy may be beneficial for a subgroup of patients. However all of these studies also reported troubling adverse effects associated with the IV antibiotic therapy. Given these potentially dangerous risks, it is clear that other safer and more durable treatments are needed for patients with persistent symptoms.
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