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Published guidelines for the treatment of Lyme disease A Literature Review

By Dr. Wolfgang Klemann, Internist, Pforzheim

History

1st A first guideline for the treatment of Lyme disease was in 1991 by Rahn and Malawista the Annals of Internal Medicine published in (1). It is an attempt to bring order to the already conflicting data situation. Already in 1991 the disease was diagnosed increased. The treatment time was mainly based on empiricism.

Second in 1997 by a further guideline was Burrascano Conn's Current Therapy (2) published in. Here is the first time addressed the problem of chronic and refractory Lyme disease.

Two more of guidelines were published, both of which raise the claim evidencebasiert, (ie evidence-based) to be.

First, these are the "Practice Guidelines for the treatment of lyme disease" of the Infectious Diseases Society of America (IDSA) in 2001 (3).

Second, these are the "Evidence-based guidelines for the management of Lyme disease" of the International Lyme and Associated Diseases Society (ILADS), published in spring 2004 (4).

Why there are now two competing guidelines?

This can best be understood in the medical history:

  • First , the IDSA guidelines, which were first published, recommended, in principle, the unique short-term therapy for patients with early disease.
  • 2nd Most Lyme sufferers can by one, 2-4 weeks of antibiotic treatment to be cured, especially with early diagnosis and indications for antibiotic therapy.
  • 3rd Special attention is IDSA Guidelines for the ultimately selected randomly, "major symptom" of Lyme to be addressed in the "meningitis, meningoencephalitis, pericarditis, or recurrent attacks of arthritis (> 2 weeks) include any.
  • Fourth treatment success is defined by IDSA as disappearance of the "major symptom.
  • 5th A certain, but not in such a small percentage of treated patients, but this "standard treatment" not by symptoms, but complained sustained "minor symptoms" such as joint pain, chronic fatigue, muscle pain, encephalopatische symptoms, generalized pain syndrome, etc.
  • 6th This group of patients, the IDSA guidelines do not ultimately satisfy, this population is not really considered it.
  • 7th The call by many practitioners to treatment guidelines that take into account this group of patients led to the development and publication of the ILADSGuidelines in spring 2004.
  • 8th ILADS this publication do not regarded as a completed process, but as a continually evolving process (based on studies with a high level of evidence) to the treatment of chronic, recurrent or refractory first glance appears to improve the disease.
  • 9th In some ways this was a (further) split in the medical profession created.
  • 10th The views on the value of persistent symptoms or "consequences" of the disease, which occur when a part of the patients, but also socio-medical purposes is controversial in medical.
  • 11th authors or doctors, which they consider more the side of the IDSA see represented in the "minor symptoms of lyme" at best an indication for symptomatic therapy. Another antibiotic therapy appears to them not useful.
  • 12th The other group of doctors believes that called negligible consequences as "minor symptoms of lyme, but significantly debilitating chronic symptoms are not. After her talk, many of these patients experience repeated / prolonged antibiotic therapy on.

A comparison of the two guidelines appear worthwhile:

Various statements about Erythema migrans (EM) are noteworthy:

With IDSA found this one: rash "on The great majority of Lyme patients present with EM." According to the IDSA shows the vast majority of Lyme disease sufferers to an EM.

In ILADS found this one: An EM occurs in less than half the cases. Studies, an increased frequency of the EM postulating that are questionable called: because the EM inclusion criterion for these studies represented one, would really vicious circle before one. Will result seronegative, but also seropositive patients, each of which no EM, but other early symptoms, such as such as fever, flu-like symptoms, muscle or joint pain, paresthesia or encephalopathische symptoms have not covered, since they restrictive "Center for Disease Control inclusion criteria (note to see next section) do not meet. Furthermore, patients with advanced disease, whose diagnosis was delayed because for example no EM initially occurred, such studies excluded. The exclusion of these patients leads to a falsely high estimate of the frequency of the EM.

Explanation of the Center for Disease Control (CDC) criteria:

At this point it is noted that the CDC diagnostic criteria of the IDSA has taken over to scientific purposes. Clinicians who strictly follow the diagnostic criteria of the U.S. CDC stick, but may succumb to a diagnostic error: the CDC itself explicitly describes this diagnostic criteria for epidemiological (surveillance) purposes as provided. This course observations are scientific studies of disease incidence as well as intended! It is noteworthy, then, that the CDC clinical diagnosis of the actual determination of these criteria should not: "not intended to be used in clinical diagnosis." (5), (6)

Various statements about serologic testing seem noteworthy:

The IDSA guidelines are concerned with the laboratory diagnosis is not explicitly deal. "Present serological assays for Lyme disease have substantial limitations" The IDSA guidelines relate mainly to the therapy.

In ILADS found to be: ...... Serological tests are particularly important in the late phase of the disease is not reliable. Serological tests should be used for clinical diagnosis "based on" one, but should not replace the clinical assessment of the treating physician to come.

Various statements about chronic Lyme disease appear noteworthy:

With IDSA found to be:

Persistent (chronic) Lyme disease is very rare, there are symptoms of a standard treatment continued after, then a "post-lyme syndrome" spoken, persistent symptoms are a postulated autoimmune process and / or fibromyalgia, a chronic-fatigue syndrome, psychiatric disorders or simply stress assigned.

In ILADS found to be:

According to the ILADS persistent symptoms after standard treatment suggest a persistence of infection indicates, in cases of delayed diagnosis or delayed start of treatment, etc. in particular. In molecular biology research, which could explain Erregerpersistenz one, is pointed. Longer treatment regime for chronic, recurrent, and refractory to treatment at first glance appearing recommended, especially Lyme disease.

Various statements about long-term antibiotic treatment seem noteworthy:

With IDSA found to be:

IDSA does not recommend long-term antibiotic therapy, rather, the existence of chronic Lyme disease called into question. Since no study results available to the subject, no long-term therapy should be performed. It is assumed that symptoms until months after treatment, some disappear. Therefore, attitude is in many cases a "wait and justified.

In ILADS found to be:

In symptomatic patients supports the ILADS the prolonged use of antibiotics. The common practice of waiting for a spontaneous cure is not recommended. Treatment of chronic Lyme disease must be designed individually, depending on the severity of the disease, since then the response to treatment measures, etc.

Common to the Guidelines

Recommendations for the treatment of erythema migrans:

Both companies recommend the earliest possible treatment for 3 weeks. If necessary, arthritis, according to two guidelines, the repeated treatment of Lyme indicated (IDSA: "... we recommend repeat treatment with another four-week course of oral antibiotics or with a 2 - to 4-week course of ceftriaxone iv).

Conclusion

The IDSA guidelines follow a rather rigid, systematic approach to diagnosis, especially in therapeutic ways. The IDSA guidelines actually refer to a selected patient population with EM as the main diagnostic criterion. Contrast is found in the ILADS guidelines great flexibility in the treatment of individual patients to the variable course of the disease to take into account. It will be here early to late stages of the disease both at diagnosis and the therapy takes into account both.

View

Especially for the late manifestations of Lyme disease, the data situation is not satisfactory. To understand the persistent Lyme disease further research efforts are needed.

Pforzheim, Germany, in September 2006

Literature

1st Rahn DW, Malawista SE: Lyme disease: recommendations for diagnosis and treatment. Ann Intern Med 1991 Mar 15; 114 (6) :472-81

2nd Burrascano JJ. Lyme desease. In Conn's Current Therapy. WB Saunders Company, PA, USA 140-143

3rd Wormser GP, Nadelman RB, Dattwyler RJ, Dennis DT, Shapiro ED, Steere AC, Rush TJ, Rahn DW, Coyle PK, Persing DH, Fish D, air BJ (2000). "Practice guidelines for the treatment of Lyme disease. The Infectious Diseases Society of America" (PDF). Clin Infect Dis 31 ((Suppl 1)): 1-14.

4th Cameron D, Gaito A, Narris N, Bach G, Bellovin S, Bock K, Bock S, Burrascano J, Dickey C, Horowitz R, Phillips S, sea-Scherrer L, Raxlen B, Sherr V, Smith H, Smith P, Stricker R; ILADS Working Group (2004). "Evidence-based guidelines for the management of Lyme disease". Expert Rev Anti Infect There 2 ((1 Suppl)): S1-13.

5th CDC Case Definitions for Infectious Conditions under Public Health Surveillance. Retrieved on 2006-03-15.

6th CDC Testimony before the Connecticut Department of Health and Attorney General's Office. CDC's Lyme Prevention and Control Activities. Retrieved on 2006-03-15.