Doxycycline, amoxicillin, or cefuroxime axetil for 10-14 days adequate for early cutaneous Lyme disease

Reference

Torbahn G, Hofmann H, Rucker G, et al. Efficacy and safety of antibiotic therapy in early cutaneous Lyme borreliosis: A network meta-analysis. JAMA Dermatology 2018;154(11):1292-1303.

Synopsis

Early cutaneous LB is characterized by the presence of a target lesion and evidence of a recent tick bite (generally with adherence to the skin by the tick for at least 12 to 24 hours). The CDC recommends the following options for LB in adults: doxycycline 100 mg twice daily for 10 days to 21 days, cefuroxime axetil 500 mg twice daily for 14 days to 21 days, or amoxicillin 500 mg 3 times daily for 14 days to 21 days. Treatment failure has been reported, so this study performed a network meta-analysis to identify and compare all studies of the early treatment of LB. A network meta-analysis creates a web of comparisons, with both direct comparisons (drug A vs drug B in a single study) and indirect comparisons (drug A vs drug B in study 1 and drug A vs drug C in study 2, allowing an indirect comparison of drugs B and C). This was a well-done systematic review with an appropriate search and assessment of study quality. The authors identified 19 randomized trials that compared 2 antibiotics (no studies compared antibiotics with placebo), of which 17 were included in the analysis. Drugs studied included (most commonly) amoxicillin, azithromycin, cefuroxime axetil, ceftriaxone, doxycycline, penicillin V, and various combinations. Study quality was mixed, suffering from inadequate randomization (n = 5) and failure to mask (n = 4), with only 5 of the 17 studies both adequately randomizing and masking participants and outcome assessors. On the basis of a careful review of this mixed bag of studies, the authors conclude that no antibiotic therapy was significantly better or worse than doxycycline (which was typically given for 14 days). There was no clear difference between different antibiotics or classes of antibiotics, and no difference between longer and shorter durations. Penicillin had the lowest rate of adverse events, while doxycycline was (not surprisingly) associated with skin-related adverse events. The overall treatment response at 12 months was greater than 80%.