Single dose doxycycline for treatment of tick bite only prevents Lyme disease rash

Man taking doxycycline which will only prevent Lyme disease rash.

In a review entitled “Lyme Disease: Emergency Department Considerations,” Applegren et al. recommend using a one-time, single dose of doxycycline for the prophylactic treatment of a tick bite, [1] despite the fact that there has been only one study exploring the effectiveness of such a limited dosage. The article also neglects to mention that there are doctors who take a different approach and advise against a one-time, single dose. [3]

In the article, the authors reference the 2006 Infectious Diseases Society of America (IDSA) guidelines when making their recommendation that “individuals be treated with a single dose of doxycycline (4 mg/kg in children ≥8 years of age to a maximum 200 mg and 200 mg in adults)”. [1]

Their recommendation applies only to patients meeting the following criteria, “(1) the attached tick is clearly identified as a nymph or adult I. scapularis; (2) the tick has been attached ≥36 hours; (3) local infection rates of ticks with B. burgdorferi is ≥20%; and (4) there are no contraindications to doxycycline.” [2]

The authors fail to mention that the IDSA single dose of doxycycline approach is based on one study, which only found a reduction in the number of erythema migrans (EM) rashes.

“A study by Nadelman et al. found that patients treated with a single dose of doxycycline developed EM manifestation at a lower rate than the placebo group (0.4% compared to 3.2%, respectively),” according to Applegren. 

The review also does not mention the evidence, as put forth by the International Lyme and Associated Diseases Society (ILADS), which finds that a single dose is ineffective in warding off Lyme disease. Such evidence was easily accessible via open access, peer-reviewed journals in PubMed [3], the Journal’s website[4], and the National Guideline Clearing House. [5]

ILADS 2014 guidelines used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to conclude that the evidence for a single, 200 mg dose of doxycycline was “sparse, coming from a single study with few events, and, thus, imprecise.” [3]

There were only 9 EM rashes in the Nadelman study. Nadelman and colleagues were able to reduce the number of rashes from eight to one by prescribing a single 200 mg dose of doxycycline. The “p” value was barely significant at 0.04.

The IDSA guidelines adopted the single, 200 mg dose of doxycycline despite the fact that 3 previous prophylactic antibiotic trials for a tick bite had failed.

Nadelman’s study had several other limitations:

  1. It was not designed to detect Lyme disease if the rash were absent.
  2. The 6-week observation period was not designed to detect chronic or late manifestations of Lyme disease.
  3. It was not designed to assess whether a single dose of doxycycline might be effective for preventing other tick-borne illnesses such as Ehrlichia, Anaplasmosis, or Borrelia miyamotoi.

Today, patients expect to be informed of their treatment options. The recent review in the Journal of Emergency Medicine [1] would have been stronger if the authors had disclosed the evidence against using a single, 200 mg dose of doxycycline for prophylactic treatment of a tick bite.

Updated: August 29, 2022

References:
  1. Applegren ND, Kraus CK. Lyme Disease: Emergency Department Considerations. J Emerg Med, (2017).
  2. Wormser GP, Dattwyler RJ, Shapiro ED et al. The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis, 43(9), 1089-1134 (2006).
  3. Cameron DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Rev Anti Infect Ther, 1-33 (2014).
  4. Cameron DJ, Johnson LB, Maloney EL. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease from Expert Review of Anti-infective Therapy 2014 at https://www.tandfonline.com/doi/full/10.1586/14787210.2014.940900.
  5. Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. National Guideline Clearinghouse. Agency for Health Care Research and Quality. Available from: https://www.guideline.gov/content.aspx?id=49320.

51 Replies to "Single dose doxycycline for treatment of tick bite only prevents Lyme disease rash"

  • Suzanne Meub
    08/30/2022 (8:34 am)
    Reply

    What does the IDSA do all day ? Trying to manage tick born disease with 15 year old recommendation ? and that’s the standard of care ? Ludicrous.

  • Andrew Wheelan
    08/27/2021 (11:10 am)
    Reply

    Dr Cameron, this is going to sound ridiculous, but I had over 5000 larval Lone Star Ticks on me on weds. I have been finding conflicting information on the ability of larval ticks to carry disease. They are so small, that it’s an almost guarantee that I have been bitten. I have no associated rash, etc and have been prescribed 14 days of doxy 100 mg. Does this course of action seem prudent, even though they are larvae? I currently have a trash bag full of my clothes and thousands of ticks, do you know of any researchers that may be interested in them? This is on Block Island, RI , where the Loan Star Tick is purportedly a new arrival.

    • Dr. Daniel Cameron
      08/30/2021 (7:03 pm)
      Reply

      I don’t know of any doctors who are studying this issue. Your doctor has to determine the best treatment.

    • Brenda
      09/24/2022 (4:33 pm)
      Reply

      Try UMASS they were testing and making a log of where ticks with Lyme were. Perhaps they would be interested?

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