Diagnosis and therapy of chronic systemic co-infections in Lyme disease and other tick-borne infectious diseases

Townsend Letter for Doctors and Patients, April, 2007 by Garth L. Nicolson

A major problem in the treatment of LD is finding effective treatments of the late chronic stage, especially when they involve the CNS. Table 1 shows the antibiotics useful for treating LD based on the clinical situation. (13-15) Since with time (late stage), Bb infections occur intracellularly as cystic or persistent forms, Plaquenil, Falgyl, or Tinidazole should be added along with a macrolide (azithromycin, Biaxin, or Dynabac) and/or fluoroquinolones (ciprofloxacin, gatifloxacin, levofloxacin, ofloxacin). (13-17) With antibiotic treatment, Herxheimer reactions (or "die-off" reactions involving chills, fever, night sweats, muscle aches, joint pain, short-term memory loss, and fatigue or a general worsening of symptoms) usually occur for days to weeks due to release of bacterial cell wall degradation products and stimulation of interleukins or chemical messengers that cause worsening of some signs/symptoms. (16,17)

To overcome Herxheimer reactions or other adverse responses, IV antibiotics have been used for a few weeks--followed by oral antibiotics. Oral Benadryl (diphenhydramine, 50 mg) taken at least 30 minutes before antibiotics, and lemon/olive drink (one blended whole lemon, one cup fruit juice, one tablespoon olive oil--strain and drink liquid) have proved useful. (16) This period usually passes within a few weeks and differs from allergic reactions that can cause immediate rashes, itching, swelling, dizziness, breathing trouble, and other problems. For LD, the dosing for pediatric use has been worked out. (2)

Antibiotic Therapy for Co-Infections of Borrelia, Mycoplasma, Babesia, and Others

For patients with co-infections of Borrelia plus Mycoplasma species, the therapy should be the same as in Table 1 (with doxycycline), but the duration of therapy must be increased. The reason for this is that slow-growing mycoplasmal infections are not readily susceptible to antibiotics, and thus the therapy must be more gradual. (6,16,17) Some patients with Mycoplasma co-infections may benefit from combinations of antibiotics other than those listed in the table, such as adding additionally azithromycin or a floxacin, especially if there are limited responses. (16) These can be worked into the regimen slowly over weeks, if necessary. The protocol for infections involving Borrelia plus Mycoplasma species should be continued for at least six months. (17)

When Babesia infections are present as co-infections with Borrelia, patients can be treated with quinine (Quinamm) and clindamycin (cleocin). (9) For co-infections with Mycoplasma or Ehrlichia species, doxycycline should be added to the antibiotic regimen. (3) Dr. Richard Horowitz has presented a scheme for treating co-infections in LD, (19) and I have added advice on Mycoplasma/Ehrlichia co-infections (Table 2). If Chlamydia pneumoniae is also present, then two penetrating antibiotics active against these microorganisms should be considered, such as doxycycline plus a fluoroquinolone (levofloxacin, ofloxacin, or gatifloxacin).