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Guidelines on Lyme disease

None of the guidelines incorporates all the published knowledge on Lyme disease and there is significant disagreement on both diagnosis and treatment. All these references should be read in this context.

UK Guidelines

There are no specific UK guidelines, but the NHS provides the following :

The Map of Medicine provided under NHS Choices

http://healthguides.mapofmedicine.com/choices/map/lyme_disease1.html

Points to note:

Balanced summary of clinical features, diagnosis and management
Describes diagnostic tests available
Comments that two current NHS 2 tier testing “has a combined specificity with ELISA of 99% but a poor sensitivity of 56%”
Says that there is evidence for both ILADS and IDSA views (see their guidelines below) and longer treatment may be necessary in consultation with a Lyme disease expert

The Health protection Agency has some pages on its website

http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/LymeDisease

Points to note:

Not very balanced view on treatment: IDSA supported, ILADS denounced
Antibiotic recommendations differ from ECDC guidelines
Contains epidemiological information for England and Wales
Brief description of UK diagnostic tests available

European Guidelines

ECDC (European Centre for Disease Prevention and Control)

http://ecdc.europa.eu/en/healthtopics/tick_borne_diseases/lyme_disease/basic_facts/Pages/factsheet_health_professionals.aspx

Points to note:

No laboratory tests are required in the diagnosis of erythema migrans, which depend on a clinical evaluation and an assessment of tick exposure risk.
Treatment guidelines differ from HPA recommendation
Acknowledges key areas of uncertainty: Areas for further research include more detailed knowledge of the ecological aspects of Lyme borreliosis on a local, regional and EU scale, including distribution and prevalence of pathogenic and non-pathogenic genospecies, and more data on the epidemiology of Lyme borreliosis. Further improvements in diagnostic tests are also required.

EFNS (The European Federation of Neurological Societies)

November 2009 - EFNS guidelines on the diagnosis and management of European Lyme neuroborreliosis. Mygland A, Ljøstad U, Fingerle V, Rupprecht T, Schmutzhard E, Steiner I. Eur J Neurol. 2010;17:8-16.
http://www.efns.org/Guideline-Archive.389.0.html

Points to note:

Deals with neuroborreliosis only
Contains recommendations on treatment but points out the lack of European treatment studies and controlled trials on treatment length.
Recognises that studies show significant treatment failure rates, but makes no recommendation as to further treatment

USA Guidelines

IDSA (Infectious Diseases Society of America)

http://www.journals.uchicago.edu/doi/pdf/10.1086/508667

Points to note:

Recommends repeat treatment if objective symptoms persist or recur
Attributes continuing symptoms beyond 3 separate courses of antibiotics to an unknown cause
An IDSA review panel recommended changes to the current guidelines: these can be read here http://www.lymediseaseaction.org.uk/releases/lda_40.pdf

ILADS (International Lyme and Associated Diseases Society)

http://www.ilads.org/lyme_disease/treatment_guidelines.html

Points to note:

Recognises that laboratory tests can not be used to exclude Lyme disease
Recommends that duration of treatment should be guided by clinical response