is the physician executive who leads the Medical Information Team at epocrates. After training in internal medicine, pulmonary, and critical care specialties, she worked in health care policy before joining the epocrates team in 2006. Her team creates and curates clinical decision support tools for the moments of care.

Anne Meneghetti, MD

Lyme Disease: Picture of a tick on a sign in the woods

(Adobe Stock 480211882 by 24K-Production)

Lyme disease is a bacterial infection caused by 

 1It is transmitted to humans through the bite of infected black-legged ticks, predominantly in the Northeast, mid-Atlantic, and upper-Midwest regions of the US. Early symptoms typically include fever, headache, fatigue, and a distinctive skin rash called 

. If not treated promptly, the infection can spread to the joints, heart, and nervous system, leading to more severe health issues. Lyme disease is usually diagnosed based on symptoms and the likelihood of tick exposure, with laboratory tests providing additional confirmation. Most cases are effectively treated with antibiotics. To further explain, we answer 

: What are the most effective strategies for preventing Lyme disease during the fall months, particularly in areas with high tick populations?

Anne Meneghetti, MD, and Walt Hadikin, MD: 

Lyme disease prevention strategies are important during summer and early fall months in areas in the US where the Ixodes tick is endemic, such as the Northeast, upper Midwest, and northern California.

 The key to prevention is avoidance of tick bites and prolonged tick attachment. This includes avoidance of tick-infested areas (such as tall grass and wooded areas), wearing long sleeves and pants, tucking pants into socks, and opting for light-colored clothing to facilitate tick detection. Insect repellants such as DEET or picaridin are recommended for application to exposed skin areas, while permethrin may be used on clothing (but not skin).

 After exposure to tick habitats, thorough skin checks are advised, focusing on the armpits, groin, scalp, neck, and head. Bathing within 2 hours and drying clothing on high heat for at least 1 hour can also help prevent disease. If a tick is found, it should be promptly removed with tweezers.

: Can you discuss the current recommendations for using antibiotics to treat Lyme disease and the potential risks of antimicrobial resistance associated with these treatments?

Lyme disease treatment varies by stage. Early localized Lyme, characterized by erythema migrans (EM) rash, typically requires 10 days of doxycycline or 14 days of amoxicillin or cefuroxime axetil. Early disseminated Lyme with multiple EM lesions and neurological or cardiac symptoms is treated with 14 to 21 days of doxycycline or intravenous ceftriaxone, cefotaxime, or penicillin G if doxycycline is contraindicated. Isolated facial nerve palsy may be treated with oral amoxicillin or cefuroxime axetil. Lyme carditis patients, if stable, receive 14 to 21 days of oral treatment; severe cases start with IV ceftriaxone, switching to oral therapy to complete 14 to 20 days. Lyme arthritis, a manifestation of late disseminated Lyme, is treated with a 28-day oral doxycycline course or amoxicillin or cefuroxime axetil. Lack of response may indicate the need for 2 to 4 weeks of IV ceftriaxone, with referral advised for no improvement post therapy.

, Lyme’s causative agent, has not been seen, but broad-spectrum antibiotics could promote resistance in other bacteria.

Extended antibiotic courses beyond those that are recommended may promote such resistance. Adhering to guidelines for duration and choice of antibiotics is critical to avoid resistance risks.

For rapid access to guideline-recommended treatment options for the various stages and forms of Lyme disease, check out epocrates’ Lyme Disease Dx & Tx Guideline Synthesis, which is accessible on the mobile app and online.

: What role do infection prevention and control professionals play in educating the public about Lyme disease prevention and the proper use of antibiotics?

Infection prevention and control specialists can be central to public health education about Lyme disease. This may involve educating the public by providing critical information on how to prevent Lyme disease, including avoiding tick-infested areas, using insect repellent, wearing protective clothing, and performing regular tick checks. They can also lead public awareness efforts about the early symptoms of Lyme disease and the importance of seeking timely medical intervention to facilitate early diagnosis and treatment. Infection control professionals can also work with frontline clinicians to promote the proper use of antibiotics when treating Lyme disease to mitigate risks of antimicrobial resistance. 

They may also develop and distribute educational materials outlining practical tips for limiting tick exposure and educating the public about appropriate Lyme disease treatment, including information on posttreatment Lyme disease syndrome that affects a subset of patients (with estimates ranging between 5% and 30%) following Lyme disease treatment. This is especially important when vulnerable patients (and clinicians) are exposed to conflicting information from peers, friends, social media, and myriad other sources.

: How can health care facilities better prepare for and manage increased Lyme disease cases during the fall, especially in preventing the spread of infection and minimizing antibiotic resistance?

As Lyme disease incidence continues its upward trend with no signs of slowing, health care organizations can take several proactive steps to prepare for Lyme disease cases this fall. Campaigns geared toward educating clinicians on the latest guidelines for prevention, diagnosis, and treatment will ensure that clinicians can spot the clinical manifestations of Lyme disease and institute early treatment. Public awareness campaigns will inform the community about preventive measures and the importance of seeking early intervention should signs or symptoms of Lyme disease appear.

Working with public health departments to monitor tick populations and infection rates can help predict possible outbreaks before they occur. Health care systems should encourage the use of preventive measures among the public, especially in high-tick population areas and during peak tick activity months. These actions, along with others such as the development of rapid response protocols, the use of telemedicine to promote early access to care, the maintenance of efficient reporting systems, and community engagement initiatives, will go a long way to addressing needs and gaps in Lyme disease care and control this fall.

: Are there any recent advancements or research findings in preventing, diagnosing, or treating Lyme disease that infection prevention and control professionals should be aware of this fall?

 The US has lacked an FDA-approved Lyme disease vaccine since LYMErix’s 2002 withdrawal. LYMErix, based on B burgdorferi’s outer surface protein A, was pulled due to low sales, safety concerns, and lawsuits. With rising Lyme cases and expanding tick habitats, vaccine development has been reinvigorated in recent years. Pfizer and Valneva’s VLA15 is in late trials, with FDA submission hoped for 2025. (same) Moderna has 2 mRNA vaccines in the pipeline, while University of Massachusetts researchers are exploring passive immunity with annual antibody administration.

CDC recommends 2-step serologic testing for Lyme, with an initial enzyme immunoassay [EIA] followed by a Western blot or another EIA. Early infection may yield false negatives, and persistent antibodies limit reinfection diagnosis. A new test developed at Tufts University detects autoantibodies against a host-derived substance 

 uses for growth, potentially improving diagnosis and treatment monitoring.

Hygromycin A, an antibiotic discovered in the 1950s that selectively inhibits


 is advancing to human trials this year. It’s a targeted Lyme treatment, unlike current broad-spectrum antibiotics, which risk resistance. Tulane University’s research on FGFR inhibitors offers a new approach to treating persistent neurological symptoms post-Lyme treatment.

Among the myths on The Global Lyme Alliance's list: 

: What are the common misconceptions about Lyme disease prevention, and how can infection prevention and control professionals effectively address these misconceptions?

The Global Lyme Alliance [GLA] released a list of common Lyme disease myths. Such misperceptions can impede effective prevention and treatment. Among the myths on GLA’s list: Lyme disease is always associated with erythema migrans rash. In fact, fewer than 50% of patients. See 

Infection control professionals can help address these misconceptions about Lyme disease by educating the public using evidence-based materials, promoting tick-protective measures, including insect repellants and long-sleeved shirts, encouraging regular tick checks after outdoor exposure, and dispelling myths via community outreach initiatives and health education materials.

: What measures can be taken to monitor and track Lyme disease cases during the fall to ensure timely intervention and minimize the impact on public health?

State and local health departments gather Lyme disease reports as part of their legal duties and surveillance efforts. To enhance these efforts and research, the CDC is developing improved platforms that utilize electronic health records from large health care systems in U.S. regions with a high incidence of Lyme disease, particularly the Northeast. The Surveillance-Based Lyme Disease Network collaborates with health care partners in Maine, Massachusetts, Pennsylvania, and Wisconsin. By integrating this data with conventional public health surveillance, the CDC seeks a more profound understanding of Lyme disease’s effects on the community.

Lyme disease: About. CDC. Accessed October 14, 2024. 

https://www.cdc.gov/lyme/about/index.html

Lyme disease: Tick prevention. CDC. Accessed October 14, 2024. 

https://www.cdc.gov/ticks/prevention/index.html

Lyme disease vaccine approved by FDA. American Lyme Disease Foundation. Accessed October 14, 2024. 

https://aldf.com/vaccine/#:~:text=It%20might%20surprise%20you%20to,vaccine%20approved%20by%20the%20FDA

Clinical trials: mRNA-1975/1982-P101. Moderna. Accessed October 14, 2024. 

https://trials.modernatx.com/study/?id=mRNA-1975%2F1982-P101

Research points to potential new medical therapy for Lyme disease. University of Massachusetts Amherst. Accessed October 14, 2024. 

https://www.umass.edu/news/article/research-points-potential-new-medical-therapy-lyme-disease

Lyme disease: Diagnosis and testing. CDC. Accessed October 14, 2024. 

https://www.cdc.gov/lyme/hcp/diagnosis-testing/index.html#:~:text=CDC%20recommends%20a%20two%2Dstep,and%20Drug%20Administration%20(FDA)

Potential new test for diagnosing Lyme disease. Tufts University. Accessed October 14, 2024. 

https://now.tufts.edu/2022/03/15/potential-new-test-diagnosing-lyme-disease

Targeted antibiotic for treating Lyme disease. National Institutes of Health. Accessed October 14, 2024. 

https://www.nih.gov/news-events/nih-research-matters/targeted-antibiotic-treating-lyme-disease

Lyme antibiotic treatment enters human trials. Northeastern University. Accessed October 14, 2024. 

https://news.northeastern.edu/2024/02/28/lyme-antibiotic-treatment-human-trials/

Crystal J. Top ten myths about Lyme disease. Global Lyme Alliance. April 6, 2020.

Articles

Lyme disease, caused by Borrelia bacteria and transmitted by black-legged ticks, demands vigilant prevention, timely diagnosis, and effective treatment to minimize health and public safety risks.

Lyme Disease Prevention and Antibiotic Usage

) is a type of bacteria commonly found in the lower intestine of warm-blooded animals and is 

the most commonly identified organism in urinary tract infections

 is ubiquitous in the gastrointestinal tract of humans and animals, although many strains are nonpathogenic. Uropathogenic 

 (UPEC) strains possess several virulence mechanisms—including structural features like flagella and fimbriae and the production of secreted toxins—that enable them to colonize the urinary tract and cause infection.

 is shed in feces, it can be transferred from the perianal area to the urethral opening during toileting (eg, wiping back-to-front), during sexual activity, or during urinary catheterization. Because the female urethra is shorter than in males and near the perianal area, UTIs are much more common in females.

uncovered a fascinating link between food supply 

and urinary tract infection. Researchers examined genomic “fingerprints” of 

 isolates from Flagstaff, Arizona, hospital inpatients with UTI and compared patterns with 

 strains from raw chicken, turkey, and pork sold in local grocery store chains. While causation isn’t proven from this study, the correlation between strains was compelling: researchers estimate that around 8% of extraintestinal 

 infections in humans, mostly UTIs, are attributable to foodborne zoonotic 

This study highlights the ecosystem's complex interplay between animals, humans, and bacteria.

 are frequent culprits in causing severe disease, including bloody diarrhea. The incubation period is usually 3-4 days post-exposure but may range from 1 to 10 days. Symptoms of STEC infection include severe stomach cramps, diarrhea—often bloody—and vomiting. If there is a fever, it is usually typically less than 101 F/ 38.5 C For most patients, symptoms resolve within 5–7 days. 

Around 5–10% of patients diagnosed with STEC

 infection develop hemolytic uremic syndrome (HUS), which manifests as anemia, low platelets, and kidney failure. While most patients with HUS recover within a few weeks, others may die of this complication or have permanent kidney damage.

 that 265,000 STEC infections occur annually in the US, causing 3,600 U.S. hospitalizations and 30 deaths annually. The most commonly identified STEC in North America is 

 O157:H7 (often expressed simply as 0157), estimated to cause about 36% of STEC infections. Less is known about non-0157 STEC strains; in general, they are less likely to cause severe illness or hemolytic uremic syndrome.

Groups at higher risk for severe illness from STEC include children younger than 5 years old, adults over age 65, and patients with immunocompromise (eg, due to HIV, diabetes, or cancer therapy). However, people of any age can become infected and seriously ill.

 infections begin with swallowing trace amounts of human or animal feces. Environmental sources include contaminated pond water and contact with animals. During the slaughter of farm animals, 

 from their intestinal tracts can contaminate raw meat and poultry; feces can then come into contact with kitchen tools and surfaces during food preparation and may persist in undercooked meat. Other foodborne sources include unpasteurized milk or cider, soft cheese made from raw milk, or contaminated lettuce. Transmissions can occur from eating food prepared by someone whose hands are contaminated with traces of feces from toileting, livestock work, or from touching animals in petting zoos.

During the early years of the COVID-19 pandemic, reports of enteric foodborne infections, in general, were lower than in previous years. However, a 

 confirmed that in 2022, foodborne infection rates returned to pre-pandemic levels—and in the case of Shiga toxin-producing 

 (STEC), the annual incidence was higher than before the pandemic. Examples of 

 outbreaks in 2022 included infections resulting from ground beef shipped in meal kits and frozen falafel.

Wash hands, utensils, and surfaces often. Wash fruits and vegetables before eating, cutting, or peeling them. Thoroughly clean hands after toileting, changing diapers, or touching animals (even in your backyard).

Avoid cross-contamination. Keep foods that won’t be cooked separately from raw foods and their juices, including raw meat, poultry, seafood, and eggs.

Use a food thermometer to ensure food is cooked to a 

Refrigerate perishable food within 2 hours or 1 hour if food is exposed to temperatures above 90°F, such as in a hot car. Thaw food in the refrigerator, not on the counter.

 in the perianal area from entering the urethra, wipe from front to back during toileting. It is recommended to urinate following sexual activity to flush bacteria from urethral tissue. Reduce the use of urinary catheterization when possible and use the proper technique before and during insertion.

To reduce worsening antimicrobial resistance from 

 and other bacteria, clinicians should have ready access to localized susceptibility and resistance data to guide prescribing decisions. Diarrheal infections from STEC, including 0157, are treated supportively—antibiotics have not been shown to be helpful. However, when treating 

 UTIs in hospitalized patients, prescribers should follow guidance based on institutional antimicrobial susceptibility data. For ambulatory patients, geolocated antimicrobial susceptibility data are free in the 

Have foodborne infections returned to prepandemic levels? What information should infection prevention and control personnel offer to patients and staff to prevent an E coli infection? 

Escherichia coli (E coli): What IPC Professionals Should Know 

“Take these pills for 10 days, even if you feel better sooner.” I vividly recall how, in years past, I would impress upon patients the importance of completing an entirely long antibiotic course. My mind’s eye beheld the specter of a half-treated infection raging back in fuller force and powered by newly resistant organisms. Now we know better: The shortest effective course is the way to reduce the risk of patient adverse drug events, antimicrobial resistance, and unnecessary health care costs.

According to the CDC, clinicians prescribed 211 million outpatient antibiotic prescriptions in 2021, which is equivalent to 636 prescriptions for every 1000 individuals, though prescribing rates varied widely by state.

 Once an antibiotic prescription is started, every additional day of use holds the potential for the added risk of adverse events (AEs) for the patient. A study of inpatients with pneumonia

 revealed that antibiotics prescribed at discharge were often excessive in duration, and that each day of excess treatment was linked to a 5% increase in antibiotic-related AEs. Although some AEs, such as anaphylaxis, occur early in a treatment course regardless of intended duration, the risk for AEs, such as hepatotoxicity, nephrotoxicity, and some gastrointestinal effects, changes to the microbiome, and specific drug interactions, can compound over time.

Each additional day of antibiotic exposure also holds the potential to contribute to the emergence of antimicrobial resistance in the patient’s community. More prolonged exposure affords more opportunities for resistance to develop and for natural selection to favor resistant organisms that can then spread to new hosts. Drug-specific pharmacokinetics are also a factor in considering course duration. For example, the elimination half-life for a drug like azithromycin is significantly longer than some other antibiotics so that appropriate courses may be shorter.

New data on the noninferiority of shorter courses emerge yearly for common infections like pneumonia, sinusitis, urinary tract infection, and cellulitis. In 2021, the American College of Physicians

recommended limiting antibiotic durations to 5 days for chronic obstructive pulmonary disease exacerbations and acute uncomplicated bronchitis. They also recommended 5 days for community-acquired pneumonia, considering an extension based on clinical signs.

It takes time for new evidence to translate into practice changes; the lag time between the “lab bench and the bedside” might average 17 years for health care interventions, per one estimate

 or a median duration of 10 days for most conditions studied. Investigators noted that typical durations exceeded those recommended in clinical practice guidelines available at that time, including excessively long courses for sinusitis, community-acquired pneumonia, cellulitis, and cystitis.

Duration of therapy isn’t the only vital component of antibiotic prescribing. The CDC estimates

 that up to half of outpatient antibiotic use is inappropriate in 1 or more ways, including inappropriate duration, dosing, antibiotic choice, as well as unnecessary use of an antibiotic in the first place. In choosing an antibiotic, prescribers are often encouraged to incorporate local antimicrobial resistance and susceptibility patterns into their decision-making. Historically, these data have been hard to find outside the hospital setting. The new Bugs + Drugs feature in the epocrates mobile app offers free geolocalized ambulatory setting antimicrobial susceptibility data on urinary and skin/soft-tissue organisms centered on any zip code in the US.

Indeed, some patients with underlying conditions or other clinical factors may warrant a longer duration of antibiotics. However, long durations—regardless of patient characteristics, infection type, specific antibiotic, and local resistance patterns—are no longer supported by recent evidence. The CDC and major specialty societies concur that the shortest effective antibiotic duration is the one that provides the best outcome for patients and their communities. Reduced AEs translate into reduced unnecessary health care costs. It’s not always the case that a single change in how we practice can benefit individuals and society; this is one of those changes where incentives are well aligned. It’s no wonder that the refrain of “shorter is better” is increasingly inspiring changes to antibiotic prescribing in both inpatient and outpatient settings.

This article is intended for informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment.

Outpatient antibiotic prescriptions — United States, 2020 | antibiotic use | CDC. Published October 24, 2022. Accessed April 14, 2023. https://www.cdc.gov/antibiotic-use/data/report-2021.html

Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a multihospital cohort study. 

. 2019;171(3):153-163. doi:10.7326/M18-3640

Lee RA, Centor RM, Humphrey LL, et al. Appropriate use of short-course antibiotics in common infections: best practice advice from the American College of Physicians. 

. 2021;174(6):822-827. doi:10.7326/M20-7355

Rice LB. The Maxwell Finland Lecture: for the duration-rational antibiotic administration in an era of antimicrobial resistance and clostridium difficile. 

Measuring outpatient antibiotic prescribing. CDC. Reviewed October 5, 2022. Accessed April 5, 2023. 

https://www.cdc.gov/antibiotic-use/data/outpatient-prescribing/index.html

Is it truly beneficial to prescribe longer courses of antibiotics?

Anne Meneghetti, MD

Articles

Lyme Disease Prevention and Antibiotic Usage

Escherichia coli (E coli): What IPC Professionals Should Know

The Duration of Antibiotics: Why Short Is Good in the Long Run