English Language Guidelines on Lyme disease

None of the guidelines incorporates all the published knowledge on Lyme disease and because of the lack of quality European clinical trials, 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

Points to note:

  • Balanced summary of clinical features, diagnosis and management.
  • Describes diagnostic tests available.
  • Comments that the 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.

Clinical Knowledge Summaries CKS

Points to note

  • Only includes treatment recommendations for erythema migrans: if neurological, cardiac or joint involvement is suspected, immediate referral for specialist advice is recommended.
  • For people with erythema migrans and possible tick exposure, states that laboratory confirmation of infection is not necessary.

The British Infection Association (BIA) has a position statement on Lyme disease.

Points to note:

  • The BIA represents microbiologists and infectious diseases consultants, but there is no information on who, or how many, participated in this document.
  • This is not a set of guidelines and has therefore not been drawn up using NHS Evidence accreditation procedures for guidelines.
  • The full BIA paper an be read on the HPA website, where it is presented as if it is a set of proper guidelines.
  • The statement appears to be a presentation of evidence to support an already confirmed view, rather than a discussion of the present state of knowledge concerning Lyme disease.
  • Lyme Disease Action has some serious concerns about this position statement and has issued a detailed comment paper.

The Health Protection Agency (HPA) has some pages on its website

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)

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.

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.
  • Most recommendations are based on opinion because of the lack of evidence.
  • Recognises that studies show significant treatment failure rates, but makes no recommendation as to further treatment.

DBG (The Deutsche Borreliose-Gesellschaft: German Borreliosis Society)

This is a multidisciplinary medical society. Its members are scientists and physicians who are concerned with Lyme and associated diseases.

Points to note:

  • Contains recommendations on longer term treatment but points out the lack of trials to provide evidence for these.
  • Contains treatment recommendations for co-infections.

 

USA Guidelines

IDSA (Infectious Diseases Society of America)

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.

 

ILADS (International Lyme and Associated Diseases Society)

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.
  • The UK HPA issued a criticism of these guidelines – the report can be read here.

 


Be Aware!

Because of the lack of quality European clinical trials, there is significant disagreement across European guidelines on both diagnosis and treatment. Although tests can help to confirm Lyme disease, no blood test can rule it out: diagnosis should be on the basis of clinical symptoms and the elimination of other conditions.