Lyme disease, treatment

A recently filed case in Pennsylvania illustrates a possible new face for liability (Cassidy v. SmithKline Beecham, 1999). The plaintiff claims that the manufacturer of a vaccine for Lyme disease should have warned physicians and patients in its advertisements that 30% of the population ran the risk of developing "treatment-resistant Lyme arthritis" because their particular genotype interacted adversely with the vaccine. This duty to warn is based not in product liability doctrine, but on negligence. 

Two tetracyclines have sufficiently distinctive features to warrant separate mention. Doxycycline, with its longer half-hfe and lack of nephrotoxicity, is a popular choice for patients with preexisting renal disease or those who are at risk for developing renal insufficiency. The lack of nephrotoxicity is related mainly to biliary excretion, which is the primary route of doxycycline elimination. Doxycycline is the preferred parenteral tetracycline Doxycycline is a potential first-hne agent in the prophylaxis of anthrax after exposure. Doxycycline is the treatment of choice for the primary stage of Lyme disease in adults and children older than 8 years. 

Answer C. The primary stage of Lyme disease is readily treatable with oral antibiotics. Doxycycline is considered to have the best activity against Lyme disease, so it the drug of choice for treatment in adults unless there is a history of allergy or intolerance to doxycycline. 

Unlabeled Uses Treatment of Lyme disease and typhoid fever... 

Uniabeled Uses Treatment of atypical mycobacterial infections, gonorrhea, malaria, rheumatoid arthritis prevention of Lyme disease prevention or treatment of traveler s diarrhea. 

Unlabeled Uses Systemic Treatment of acne vulgaris, chancroid, Campylobacter enteritis, gastroparesis, Lyme disease, diabetic gastroparesis Topical Treatment of minor bacterial skin infections... 

I Unlabeled Uses Some penicillins, such as amoxicillin, have been used in the treatment of Lyme disease and typhoid fever. 

PCR amplification has led to more sophisticated and accurate diagnostic techniques regarding diseases. This allows earlier detection of the disease compared to conventional methods, making earlier treatment possible. For example HIV (human immunodeficiency virus) may be detected by searching for the DNA sequence unique to this virus. Amplifying samples and searching for DNA associated with the bacteria responsible for the condition has identified infectious bacterial diseases. Lyme disease, certain stomach ulcers, and middle ear infections have been detected in this manner. 

Although the clinical usefulness of tetracyclines is limited for most of the common microbial pathogens, they remain drugs of choice (or very effective alternative therapy) for a wide variety of infections caused by less common pathogens. These include brucellosis rickettsial infections such as Rocky Mountain spotted fever, typhus, and Q fever Mycoplasma pneumonia cholera plague Ureaplasma urethritis Chlamydia infections and Lyme disease. Oral doxycycline, 100 mg orally twice a day for 7 days, is a recommended treatment for chlamydial sexually transmitted disease. 

The causative agent in Lyme disease is a spirochetal bacterium (Borrelia burgdorferi) that is transmitted directly through the bite of a deer tick. Optic neittopathy can occur due to Lyme disease and manifests as papillitis, retrobulbar neuropathy, or ischemic optic neiu-opathy. Serologic testing may help to identify Lyme infection by use of indirect immunofluorescent assay and enzyme-linked immunosorbent assay.The treatment of Lyme disease includes oral or intravenous peniciUin, doxycycUne, erythromycin, or ceftriaxone. 

Lyme disease, caused by the spirochete Borrelia burgdorferi, incites a variety of ocular manifestations, the most common being a conjunctivitis that occurs in up to 10% of patients with early disease. Although the characteristics of the conjunctivitis have not been clearly defined, several reports have described fitlhcular conjunctivitis. Increased antibody titers to B. burgdorferi indicate the presence of Lyme disease. A history of tick bite or erythema chronicum migrans should alert the clinician to consider Lyme disease in the differential diagnosis in areas of the country where this disease is prevalent. Treatment of Lyme disease conjunctivitis should include topical tetracycline as an adjunct to oral doxycycline, 100 mg twice daily for 2 to 3 weeks, which is used to treat the systemic infection. 

Wormser GP, Dattwyler RJ. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplas-mosis, and babesiosis clinical practice guidelines by the Infectious Diseases Society of America. Chn Infect Dis 2006 43 1089-1134. 

Territo, J., and D.V. Lang. Coping With Lyme Disease A Practical Guide to Dealing With Diagnosis and Treatment. New York Henry Holt, 1997. 

Feder, H.M., Jr., and M.S. Hunt. Pitfalls in the Diagnosis and Treatment of Lyme Disease in Children. Journal of the American Medical Association 274 (July 5, 1995) 66-8. 

Genese C, Finelli L, Parkin W, Spitalny KC. From the Centers for Disease Control and Prevention. Ceftriaxone-associated biliary complications of treatment of suspected disseminated Lyme disease—New Jersey, 1990-1992. JAMA 1993 269(8) 979-80. 

Suspicions were expressed in the Mealey Publication s Drug and Medical Device Report that the Lyme disease vaccine LYMErix could cause an incurable form of autoimmune arthritis. It was hjrpothesized that blood concentrations of OspA after three doses of vaccine place vaccinees classified by genetic type HLA-DR4-I- at risk of developing treatment-resistant Ljme arthritis. The premarket trials for the vaccine were assessed by an independent advisory committee, which found no link between Ljme disease immunization and autoimmune arthritis (10). However, the committee stressed the need for long-term surveillance and further studies in those over 70 years and in children, and the effect of the vaccine in patients with chronic arthritis the possible development of autoimmunity deserves further study (11). After licensing of the vaccine, more than 1 rmlfion Americans received it and no unusual adverse effects were reported to the manufacturer (10). 

Clinical usage Tetracylines are effective for sexually transmitted diseases caused by chlamydia and syphilis. They are also commonly used for the treatment of community-acquired pneumonia, Lyme disease, and Rocky Mountain spotted fever, and in combination with other agents for Helicobacter pylori. 

Important drugs have been derived from two plants common in the woodlands of the eastern United States. One is etoposide (an anticancer drug) based on the podophyllotoxin found in Podophyllum peltatum,415 The second is sanguinarine (from Sangulnarla canadensis), which is used for treatment of periodontal disease. A common fence lizard of the western United States, Sceloporus occidentalis, has something in the blood that kills the bacteria responsible for Lyme disease.416... 

For skin and soft tissue infections, roxithromycin is an effective and well-tolerated therapy for erysipelas and acne [162, 163]. As with other macrolide antibiotics, its immunomodulatory effects make it useful as an adjunctive therapy of psoriasis vulgaris [164]. Despite its in vitro activity against Borrelia burgdorferi, monotherapy with this macrolide was not effective for the treatment of Lyme borrelio-sis [165]. However, a small, nonrandomized, open prospective clinical study of 17 patients with confirmed late Lyme disease (stage n/III) showed a 76% complete recovery rate from a therapeutic combination of roxithromycin 300 mg... 

H. pylori [269]. Multiple studies investigating azithromycin in combination with one or two other drugs (amoxicillin, metronidazole, tinidazole, tetracycline, bismuth subsalicylate, and/or a PPl) revealed that the more effective azithromycin-containing regimens involved triple therapy [270-275]. In contrast to clarithromycin, azithromycin is not FDA approved for treatment of H. pylori disease. The role of azithromycin in the treatment of H. pylori remains to be defined. Several in vitro and animal studies have suggested that azithromycin may be clinically active in the treatment of early Lyme disease (LD) [276-278], Several clinical trials of treatment of early Lyme disease performed in the United States and Europe comparing azithromycin vs. doxycycline, oral penicillin, amoxicilUn/ probenicid, or oral amoxicillin revealed no significant difference in clinical outcome [279-283]. The precise role and dose of azithromycin in the treatment of early LD remains to be established. 

Dattwyler, R. J., Gmnwaldt, E and Luft, B. J. (1996). Clarithromycin in treatment of early Lyme disease A pilot study. Antimicrob. Agents Chemother. 40,468-469. 

---