IDSA Lyme Practice Guidelines: LYME DISEASE PREVENTION

I've been reviewing a lot of criticism of the IDSA Lyme Practice Guidelines, which has been helpful to me in understanding the issues within the controversy and has helped me provide suggestions to others as they begin their lyme diagnosis/treatment journeys and I thought I would share. I'll post sections of the Guidelines in a series so it's a more manageable amount of info!


IDSA LYME PRACTICE GUIDELINES cid.oxfordjournals.org/content/43/9/1089.full

According to the IDSA Lyme Practice Guidelines, the point after which a person has experienced possible exposure to the Borrelia burgdorferi microbe (or in other words, removed an attached tick according to all the criteria listed below) as "possible infection" and recommends the following to "prevent lyme disease":

Did you know that all this takes is one 200mg dose of doxy?

Also, according to one statement in the IDSA Lyme Practice Guidelines, if you have an EM rash, no further testing is required and an MD can diagnose you w/ LD and start abx prophylaxis. However, elsewhere the Guidelines state other requirements than just having the EM rash... leaving both MD and patient confused...

"Thus, a bite from an I. scapularis tick may lead to the
development of Lyme disease, human granulocytic
anaplasmosis (HGA, formerly known as human granulocytic
ehrlichiosis), or babesiosis as a single infection or, less
frequently, as a coinfection. Clinical findings are sufficient
for the diagnosis of erythema migrans, but clinical findings
alone are not sufficient for diagnosis of extracutaneous
manifestations of Lyme disease or for diagnosis of HGA or
babesiosis. Diagnostic testing performed in laboratories
with excellent quality-control procedures is required for
confirmation of extracutaneous Lyme disease, HGA, and
babesiosis." ---IDSA Guidelines • CID 2006:43 (1 November) • 1089

What this means: If you show up to an MD's office with a very obvious and classic bullseye rash, he/she can diagnose lyme infection. But joint problems or any other symptoms don't qualify and testing is then required.

HOWEVER...
You then need to qualify for treatment to prevent the lyme infection from turning into lyme disease, which is a single 200mg dose of doxy. PRESTO, you're cured.

"For prevention of Lyme disease after a recognized tick bite,
routine use of antimicrobial prophylaxis or serologic testing is
not recommended (E-III). A single dose of doxycycline may
be offered to adult patients (200 mg dose) and to children
greater than or equal to 8 years of age (4 mg/kg up to a
maximum dose of 200 mg) (BI) when all of the following
circumstances exist:

(a) the attached tick can be reliably identified as an adult or
nymphal I. scapulars tick that is estimated to have been
attached for greater than or equal to 36 h on the basis of the
degree of engorgement of the tick with blood or of certainty
about the time of exposure to the tick;

(b) prophylaxis can be started within 72 h of the time that the
tick was removed;

(c) ecologic information indicates that the
local rate of infection of these ticks with B. burgdorferi is
greater than or equal to 20% (with the exception of the west coast I. pacificus ticks, because "...rates of infection with Bb in these ticks is low" but if your LOCAL area has a rate of infection greater than or equal to 20%" then you might qualify for one dose of doxy, as long as you meet all other requirements; and

(d) doxycycline treatment is not contraindicated.

The time limit of 72 h is suggested because of the absence
of data on the efficacy of chemoprophylaxis for tick bites
following tick removal after longer time intervals. Infection
of greater than or equal to 20% of ticks with B. burgdorferi
generally occurs in parts of New England, in parts of the
mid-Atlantic States, and in parts of Minnesota and
Wisconsin, but not in most other locations in the
United States. Whether use of antibiotic prophylaxis after
a tick bite will reduce the incidence of HGA or babesiosis
is unknown." --- IDSA Guidelines • CID 2006:43 (1 November) • 1090

What this means is:
MDs might refuse to give you even one dose of doxy unless you meet all four conditions listed above:

a) You need to be able to describe that yes, you identified the right tick (you may need to help the MD know what these look like) and yes, the tick was attached for at least 36 hours (based on when you were outside and when you took a shower and felt it on your shoulder, etc.) and

b) yes, you're showing up in the MDs office within the 36-72 hr window (I hope you can get into the MD's office without an appt...) and

c) yes, you live in an endemic area - although you may have to prove this to the MD if he/she isn't familiar with current statistics of the area in which they are practicing in (this is pretty common) and

d) no, you're not pregnant or nursing, a child under 8, you're not on any other meds or have an allergy to doxy.

If you do have contraindication with doxy, you won't get any substitutes because something like amoxicillin might require more than one dose, and even if it does develop into "lyme disease" you'll be fine due to the, "...the excellent efficacy of antibiotic treatment of Lyme disease if infection were to develop, and the extremely low risk that a person with a recognized bite will develop a serious complication of Lyme disease (D-III)."

OR - you can go to a dermatologist and ask for a long-term (literally, months, years) prescription for the same abx at the same daily dose... for acne. You're MUCH more likely to get that than treatment for lyme disease.

OR - you can find a qualified LLMD/ND.

Also, MDs are discouraged from treating you with additional courses of abx or from doing any testing--of you OR the ticks. The Guidelines don't explain this but my guess is these restrictions help distinguish between Bb infections and manifestation of lyme disease... for surveillance purposes. However, the CDC has been pretty clear about not using the CDC's surveillance case definition criteria for diagnosis or treatment purposes. The IDSA ignores this and the CDC ignores that the IDSA ignores this. I'd like to see them defend this in a court of law.

MDs are then encouraged to monitor the patient for 30 days and watch for EM rash and/or viral symptoms. The patient is encouraged to seek immediate medical attention if either of these symptoms develop "1 month after removing an attached tick". ---IDSA Guidelines • CID 2006:43 (1 November) • 1091

The above criteria also applies to people who received the lyme vaccine and those who had previously diagnosed lyme.

++++++

Next in the series: "How to qualify for Early Lyme''

-p

Post Edited (Pirouette) : 7/16/2016 6:58:05 PM (GMT-6)

Oh YES -

The EM rash is a subject unto itself... so I'm saving it. The Guidelines devotes four whole pages to it later on so I'm saving my rant until I get to that point.

One thing I think this EM discussion should include is a discussion about how EM rash is NOT ringworm and how easily that can be cultured as proof... sheesh.

The EM rash can sometimes not even look like a bullseye or ringworm and can be tough to identify because MDs don't have the right info... But EM identification is critical to diagnosis, according to the CDC surveillance criteria, which is what the entire Guidelines is based on...

Your last paragraph is the sole reason I'm bothering to do all this research on why lyme is now endemic and a review of what the Guidelines really say and I'm also going to include suggestions to refute these statements/recommendations within these summary posts. The BEST way to get diagnosis/treatment right now is to arm ourselves with information. If we can't trust the Guidelines and we can't we can't trust MDs, we need to know everything we can know about lyme.

-p

I HOPE you are right and every educated lymee, one by one, impacts this mess.

It's tough to learn all this stuff starting out--I remember when I first was diagnosed and started treatment, I could BARELY get through the day, much less learn a bunch of complicated stuff. But hopefully if it's broken down into manageable bites and also interpreted into language we can all understand, and if I can pull in relevant information that helps us get more accurate dx and tx, at least our suffering is less...

-p

The problem is that many more species of ticks carry the Bb (Lyme) bacteria than just those two types of ticks (I. scapulars & I. pacificus), they can pass the infection on to a person with the very first stage of saliva (this has been proven scientifically or in articles - sorry, I'm not quite awake yet) and so on.

IDSA is so far behind in what they will admit to that we simply can't rely on them to actually be of help - especially if they stick to the "must be attached for 36 hours" part. I've never had a tick attach for that long, yet I have had these infections for many years now.

So the news that we need to spread to every person we talk with is to be aware that these are old, outdated guidelines - kind of like when AIDS was thought to be confined to homosexuals and monkeys!!! It's just goofy (and stupid) that these people believe that science can't change.

Great break down, P!!

It all went very wrong with the IDSA Dearborne conference in 1994 on Lyme disease. With your research, you likely have discovered this.

For those that aren't sure, these articles are also very helpful to understand some of the controversy:

ILADS vs IDSA:
www.clinicaladvisor.com/controversy-continues-to-fuel-the-lyme-war/article/117160/

archinte.jamanetwork.com/article.aspx?articleid=226373

www.ncbi.nlm.nih.gov/pmc/articles/PMC2901226/

Exactly - and it shows just how corrupt our 'guiding agencies' can be!!

I think that's a good idea, as most people don't want a history lesson, but specific information as to how to heal and how to talk to their doctors and such.

Thank you for all of your hard work on this!!

Little Bear –

I agree! Nearly everything I read has a different attachment period requirement. Crazy. The source is one reason, as IDSA promotes a long period, ILADS a shorter one. But as I got into this more, I began to understand the origin of that requirement and why everyone suggests different ranges.

There is much more to this and I continue to come across new studies but the following are very diverse excerpts from an Institute of Medicine Lyme Workshop held back in 2010 that was supposed to be a neutral zone for discussions about Lyme but as I read through a 500 page notes from it (!!) the bulk of it was repetitive synopsis of all the things left to research and update and VERY LITTLE new information was shared. So disappointing. And ILADS boycotted because there were too many IDSA-influenced speakers, which is also frustrating.

Anyway, the origin of the minimum attachment criteria seems to be the previous science that assumed that Bb existed only in the NE and only in few ticks and only in the tick’s mid-gut, etc. So the IDSA's 36-hr requirement is really an "amalgamation of risk."

When originally studied, the Bb microbe took a specific period of time to work into the salivary glands and only then when the tick started sucking blood, was there a possibility that it might get ingested. Of course, that is OLD science. Studies now find Bb in the salivary gland, confirmed by Burgdorfer, himself.

So, for LYME, attachment duration requirements or “predictive risk index” includes the following components:
• geographic area (whether it is endemic, large or small forest fragment, population density, etc.) which contributes to the likelihood that ticks carry the microbe
• season
• life stage (although unlike other vectors, ticks need blood meals at all 3 life stages (larval, nymph, adult and previous science suggested larval ticks hatch uninfected but newer science now shows the mother tick can pass Bb onto larva)
• feeding patterns

FYI – Rickettsia, which I didn’t really cover, requires only 6-8 hrs… I am still looking into why these rates or so diverse.

Excerpt from
NATURAL HISTORY OF TICKS: EVOLUTION, ADAPTATION, AND BIOLOGY, Tom G. Schwan, Ph.D., Laboratory of Zoonotic Pathogens, National Institute of Allergy and Infectious Diseases

“…Ixodid ticks have a life cycle of 1 to 3 years and are typically less able to fast and survive without a blood meal... These ticks are able to fast for long periods of times between blood meals...

Ticks can be three-, two-, or one-host arthropods. For three-host ticks, larvae feed on a host, fall off, and molt into a nymph. The nymph then attaches to another host, feeds, and falls off, and finally the adult attaches to a third host and feeds. This group includes the hard tick I. scapularis, the vector for Lyme disease Borrelia…
(My note: btw, there have been studies showing a white-footed mouse can have as many as 300 ticks attach over its lifetime)

… Infected ticks can also pass an organism from one development stage to subsequent stages in its life cycle, which is termed transstadial transmission. Because ticks feed on blood at every stage, live a long time, and can transmit pathogens to their offspring or next life cycle, they are capable of sustaining pathogens for long periods of time and they are exquisitely adapted to serve as reservoirs for pathogens and as effective transmitters. Moreover, all TBDs in North America are zoonoses—transmitted from animals to humans.”


Excerpt from
A1 THROUGH A GLASS, DARKLY: THE GLOBAL INCIDENCE OF TICK-BORNE DISEASES (Christopher D. Paddock, M.D., M.P.H.T.M., and Sam R. Telford III, Sc.D.
Infectious Diseases Pathology Branch, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, Division of Infectious Diseases, Department of Biomedical Sciences, Tufts University Cummings School of Veterinary Medicine; Corresponding author: Christopher D. Paddock, CDC)

“…Currently applied entomological risk indices include only the prevalence of infection in host-seeking ticks and the number of ticks collected in an hour (Piesman et al., 1987). However, an epidemiologically predictive risk index will require information on the species of ticks infesting humans, how frequently these attach, and the actual duration of attachment. Although B. burgdorferi typically infects 20% of host-seeking nymphal deer ticks in northeastern United States, the median annual incidence of Lyme disease from 9 prospective studies in the most intensely enzootic communities is only 2% (range, 0.4% - 4.0%) (Hanrahan et al., 1984; Steere et al., 1986; Lastavica et al., 1989; Alpert et al., 1992; Shapiro et al., 1992; Krause and Telford, unpublished; Wormser et al., 1998; Steere et al., 1998; Sigal et al., 1998).
(My note: IDSA Guidelines authors)

In addition, fewer than 10% of all Lyme disease cases in the northeastern United States are reported during the fall or winter months when adult deer ticks are most active, even though as many as 50% -75% of host seeking adult ticks contain spirochetes (Piesman et al., 1986). These apparent paradoxes can be answered by entomology: most tick-borne bacterial pathogens require a period of ‘reactivation’ before they attain infectivity (Spencer and Parker, 1923; Piesman et al. 1987; Katavolos et al., 1997).
(My note: how do they prove this?)

The probability of infection is directly proportional to the duration of feeding and may differ by life stage of the tick, so that 24-48 hours of attachment are generally required for B. burgdorferi to be transmitted by nymphal deer ticks; in contrast, adult deer ticks require approximately 3-5 days of attachment to transmit B. burgdorferi to a susceptible host (Telford, unpublished)…”


Excerpt from
VECTOR- AND HOST-TARGETED STRATEGIES FOR PREVENTION OF TICKBORNE DISEASES, Jose M.C. Ribeiro, M.D., Ph.D., National Institute of Allergy and Infectious Diseases

“…During a blood meal, ticks have evolved to be highly adaptive to remain attached to a host’s skin for several days, and ingest blood during the entire time. When a tick first attaches to a host, the ticks are coming out of a dormant state. As they start to inject a cementing protein, their metabolism begins to increase. Transcription of various proteins increase, and this new metabolic state likely triggers the pathogen. The feeding phases can be characterized as a slow feeding phase when the metabolic system is increasing followed by a rapid feeding phase. This is the primary reason for targeting tick removal in the first 24 hours.
(My note - if the target for tick removal is within the first 24 hours, it's logical that a 24-hr attachment period is more than sufficient for any pathogen transmission--particularly if Bb is in the salivary gland)

During the feeding process, a tick faces its host’s barrier of the hemostasis, a highly redundant process consisting of blood clotting, platelet aggregation, and vasoconstriction at the site of the attachment. To counter these obstacles, the tick produces a complex salivary potion that neutralizes these host defenses. The site of a tick bite is in an immunosuppressed state as tick saliva contains proteins that will block the activation of histamine, ATP, serotonin, bradykinin, and leukotriene B4, which trigger pain and itching in the hosts, thus the attached tick can go unnoticed unless that person happens to develop an allergy to one or more of its salivary proteins. In brief, tick saliva has antihemostatic, anti-inflammatory, and immunosuppressive properties.

Furthermore, the attachment site is high in interleukin 4, for example, and has substances which inhibit the maturation of dendritic cells and the activation of lymphocytes. This environment protects pathogens during transmission…
(My note: for this reason, a person can sometimes not produce an EM rash right away and this is also the reason serology testing is not recommended until at least 2 wks after the bite).

… Future research needs to identify which proteins provide a protective response for the transmission of tick-borne pathogens, including identification of early salivary antigens that might lead to an antibody that trigger a local reaction and alert the vaccinated person to detect and detach the tick soon after attachment. As spirochetes are transmitted 24 hours after exposure, an immediate or even a few hours of a delayed reaction to tick saliva could alert an individual to the need to remove a tick."
(My note: if this 24 hr period is good enough for the science in developing a potential vaccination approach, it's good enough to be used as diagnostic criteria.)

During the discussion after the presentation a “…participant questioned why it takes 24 hours for a tick to begin to transmit pathogens. Ribeiro noted that studies using fluorescent spirochetes did not see evidence of pathogen in the salivary glands until 48 hours after attachment (Ribeiro et al., 2006; De Silva and Fikrig, 1995). The pathogen resides in the tick gut and once the tick attaches to feed, the Borrelia begins to multiply. They increase in size and begin to be seen in the hemocele by 24 hours, and then by 48 hours, they are present in the salivary gland.”

I’ve seen this reference several times although Burgdorfer was pretty clear that he found Bb in the salivary glands and/or in saliva.

-p

great info! thanks!

For scientific articles showing that mosquitoes not only carry but transmit active bacteria, here are a few articles:

"Groups of 113 field-collected mosquitoes of Aedes canadensis and 43 Aedes stimulans were placed in cages with uninfected Syrian hamsters. Of these, 11 females of both species contained B. burgdorferi and had fed fully or partially from the hamsters. No spirochetes were isolated from the hamsters, but antibodies were produced in one test animal."
www.ncbi.nlm.nih.gov/pmc/articles/PMC266646/


"Targeting two specific borrelial genes, flaB and ospA encoding for the subunit B of flagellin and the outer surface protein A, the results show that DNA of Borrelia afzelii, Borrelia bavariensis and Borrelia garinii could be detected in ten Culicidae species comprising four distinct genera (Aedes, Culiseta, Culex, and Ochlerotatus). Positive samples also include adult specimens raised in the laboratory from wild-caught larvae indicating that transstadial and/or transovarial transmission might occur within a given mosquito population."
www.sciencedirect.com/science/article/pii/S1877959X15300327


I can't get in to see this article without paying for it, but here is the title:
"Erythema chronicum migrans (Afzelii) associated with mosquito bite."
Author: Hard S.
www.ncbi.nlm.nih.gov/pubmed/4163724