When Are Antibiotics For Lyme Disease Medically Necessary?

As good weather brings people outdoors and into the woods, it also exposes them to tick bites that can result in Lyme disease, one of the fastest growing infectious diseases in the United States. A microscopic bacterial organism, Borrelia burgdorferi, carried by the Ixodes tick causes the Lyme infection. Although the incidence of Lyme disease remains low -- about 100,000 cases each year -- that's a big jump over the 16,000 cases the Center for Disease Control (CDC) noted in 1999.

The CDC and Infectious Diseases Society of America (IDSA) have de-emphasized antibiotics in the treatment of Lyme disease.

"The IDSA released guidelines that are more restrictive about using antibiotics in the three stages of Lyme disease," said Dr. Skip Freedman, Executive Medical Director at AllMed Healthcare Management, a leading independent review organization.

According to Freedman, doctors should consider other diagnostic possibilities first. Prior to diagnosing Lyme disease, they must verify that a patient has recently been in a place where the disease is epidemic -- usually the coastal northeast, mid-Atlantic region, Wisconsin, Minnesota or northern California. Then doctors should follow the current CDC and IDSA guidelines for prescribing courses of antibiotic treatment.

During the first stage of the disease, infected patients may develop a bull's-eye rash. In the second stage, they may show multiple skin lesions that coincide with flu-like symptoms, followed by nonspecific muscular, skeletal, arthritic, neuralgic, psychiatric and even cardiac symptoms.

"A diagnosis of Lyme disease should never be made based on initial blood test screening alone," Freedman said. Doctors must run more specific serologic tests, including an enzyme-linked immunoassay and a Western blot test to check if Lyme disease antibodies are present.

Once doctors determine that a patient is in stage one or two of the disease, it can be easily treated with a two- to four-week course of oral antibiotics. Most doctors prescribe doxycycline, (for adults and children over eight years old) or amoxicillin or cefuroxime (for adults and children under eight). Usually -- but not always -- an early course of antibiotic treatment cures the disease. Even with proper treatment, patients who have Lyme disease may develop symptoms consistent with fibromyalgia or chronic fatigue syndrome. An active infection, however, often isn't the source of such symptoms.

Doctors unfamiliar with Lyme disease often misdiagnose it as multiple sclerosis, rheumatoid arthritis, fibromyalgia, chronic fatigue syndrome or other autoimmune and neurological diseases. Misdiagnosis, as well as delayed or inadequate treatment, may lead to the persistent third stage of the disease.

Without early and medically necessary antibiotic treatment, 10 to 15 percent of Lyme disease patients may display arthritic or even neurological complaints. And 80 percent of patients with Lyme disease develop malaise and fatigue similar to chronic fatigue syndrome. They also may display other symptoms unrelated to Lyme disease.

The current recommendations for diagnosis and care require either the bull's-eye rash or positive specific laboratory tests and only recognize false negatives during the early stages of the disease. The recommendations also suggest that post-Lyme disease syndromes don't respond to long-term antibiotic use.