Topic: Long-term minocycline suggested for neuroborreliosis by Italian doctors: 2000
Vermont_Lymie
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posted
Clinical Infectious Diseases 2000;31:846
(Yes, this was published by the IDSA! Don't they read their own literature??)
Possibility of the Use of Oral Long-Acting Tetracyclines in the Treatment of Lyme Neuroborreliosis
SIR--We have read with interest and would like to praise both the well-done study of Dotevall and Hagberg [1] and the ensuing discussion regarding the use of doxycycline versus minocycline for treatment of CNS spirochetal infections [2, 3].
We believe that an additional comment on this discussion may be warranted.
We previously performed an open study on the treatment of neurosyphilis in patients who were allergic to penicillin, using oral minocycline, 100 mg b.i.d. for 14 consecutive days per month for 9 months [4].
We were surprised that no clinically detectable CNS or gastrointestinal side effects were registered over a total of 294 person-days of administration of minocycline, although they were actively sought by means of a follow-up questionnaire and clinical examination.
Our selection of a long-acting tetracycline for treatment of our patients Was made on the basis of tetracycline activity against Treponema pallidum, the satisfactory pharmacokinetics of doxycycline across the blood-brain barrier [5], and the excellent lipid solubility of minocycline [6].
However, we chose minocycline because it was the only tetracycline available in our hospital pharmacy.
Therefore, our experience supports the use of oral minocycline for CNS infections by spirochetes, including not only Borrelia burgdorferi, as suggested by Cunha [2], but also T. pallidum.
In this regard, some of the disadvantages of the use of minocycline--namely, discoloration of the teeth, skin, and nails--are likely to be either irrelevant or not applicable to the majority of patients, because tertiary CNS manifestations of T. pallidum and infection most frequently appear in adults and not in teens and children.
In general, this also applies to most patients with neuroborreliosis. A recent epidemiological study of Lyme disease in Europe [7] showed that the incidence of neuroborreliosis in children aged <15 years [28%] was higher than that in adults [14%].
However, given the higher incidence of Lyme disease among adults [>75%], a semisynthetic tetracycline could have been administered to >70% of the patients with neuroborreliosis.
However, we believe that the real point at issue in the previous discussion [2, 3] is represented by the possibility of safe and effective use of oral long-acting tetracyclines for tertiary manifestations of spirochetal diseases.
This point is not clearly indicated in widely distributed guides for the treatment of infectious diseases [8, 9], in particular with respect to neurosyphilis and the loading dose of doxycycline for neuroborreliosis.
On the basis of clinical experience, it would seem that both doxycycline and minocycline can be used for these conditions.
Until a controlled trial is performed (with, possibly, control of plasma, CSF, and tissue pharmacokinetic parameters) in patients with neurosyphilis or neuroborreliosis, only personal experience and preferences, in addition to adequate clinical monitoring, should be used to instruct the choice of drug.
Andrea De Maria1 and Alberto Primavera2 Departments of 1Internal Medicine and 2Neurology, University of Genova, Genova, Italy
References
1. Dotevall L, Hagberg L. Successful oral doxycycline treatment of Lyme disease- associated facial palsy and meningitis. Clin Infect Dis 1999;28:569-74
2. Cunha BA. Minocycline versus doxycycline in the treatment of Lyme neuroborreliosis. Clin Infect Dis 2000; 30:237-8.
3. Dotevall L, Hagberg L. Adverse effects of minocycline versus doxycycline in the treatment of Lyme neuroborreliosis. Clin Infect Dis 2000; 30:410-1.
4. De Maria A, Solaro C, Abbruzzese M, Primavera A. Minocycline for symptomatic neurosyphilis in patients allergic to penicillin. N Engl J Med 1997;337:1322-3.
5. Yim CW, Flynn NM, Fitzgerald FT. Penetration of oral doxycycline into the cerebrospinal fluid of patients with latent or neurosyphilis. Antimicrob Agents Chemother 1985; 28:347-8.
6. Kapusnik-Uner JE, Sande MA, Chambers HF. Tetracyclines, chloramphenicol, erythromycin and miscellaneous antibacterial agents. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Goodman Gilman A, eds. The pharmacological basis of therapeutics. Vol 1. New York: McGraw- Hill,1996:1123-53.
7. Berglund J, Eitrem R, Ornstein K, et al. An epidemiologic study of Lyme disease in southern Sweden. N Engl J Med 1995;333:1319-24.
8. Bartlett JG. Pocket book of infectious disease therapy. Baltimore: Williams and Wilkins, 1998:309-14.
9. Gilbert DN, Moellering RC, Sande MA. Clinical approach to initial choice of antimicrobial therapy. In: Gilbert DN, Moellering RC, Sande MA, eds, The Sanford guide to antimicrobial therapy. Hyde Park, VT: Antimicrobial Therapy, 1999:1-16.
Reprints or correspondence: Dr. Andrea De Maria, Department of Internal Medicine, Padiglione Maragliano, University of Genova, #10 Largo Rosanna Benzi, Genova, 16132 Italy, [email protected]
*Will add the original cite of publication later!
[ 31. May 2007, 08:16 PM: Message edited by: Vermont_Lymie ]
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posted
Interesting. Is this letter new? When was it first published?
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5dana8
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Thanks for the article vermont_lymie
Wish I could take minio, but it made me very nauseated. More so than the doxy
Guess the meds effects everyone so differently.
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CaliforniaLyme
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Good one Monty*)!*)!!!!!!
-------------------- There is no wealth but life. -John Ruskin
All truth goes through 3 stages: first it is ridiculed: then it is violently opposed: finally it is accepted as self evident. - Schopenhauer Posts: 5639 | From Aptos CA USA | Registered: Apr 2005
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Dave6002
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Intravenous to oral antibiotic switch therapy Author(s): Cunha BA Source: DRUGS OF TODAY 37 (5): 311-319 MAY 2001 Document Type: Review
Abstract: I.v.-to-p.o. switch therapy has become the mainstay of antibiotic therapy for the majority of patients. I.v.-to-p.o. switch therapy is inappropriate for critically ill patients who require i.v. antibiotic therapy and should not be considered in patients who have the inability to absorb drugs. These exceptions constitute a very small percentage of hospitalized patients for which i.v.-to-p.o. switch therapy is ideal. I.v.-to-p.o. switch therapy is best achieved with antibiotics that have high bioavailability that result in the same blood and tissue concentrations of antibiotic as their intravenous counterpart and have few gastrointestinal side effects. Antibiotics ideal for i.v.-to-p.o. switch programs include chloramphenicol, clindamycin, metronidazole, TMP-SMX, fluconazole, itraconazole, voriconazole, doxycycline, minocycline, levofloxacin, gatifloxacin, moxifloxacin and linezolid. Antibiotics that may be used in i.v.-to-p.o. switch programs that have lower bioavailability but are effective include p-lactams and macrolides. For antibiotics with no oral formulation, e.g., carbapenems, equivalent coverage must be provided with an oral antibiotic from an unrelated class. Excluding gastrointestinal malabsorptive disorders, disease state is not a determinant of suitability for i.v.-to-p.o. switch programs. I.v.-to-p.o. switch programs should be used in patients with any infectious disease disorder for which there is effective oral therapy and is not limited to certain infectious diseases. Oral absorption of antibiotics is near normal in all but the most critically ill patients. Therefore, even in sick, hospitalized individuals, p.o. therapy is appropriate. I.v-to-p.o. switch therapy has several important advantages including decreasing drug cost (i.v. vs, p.o.), decreasing length of stay permitting earlier discharge and optimal reimbursement and decreasing or eliminating i.v. line phlebitis and sepsis with its cost implications. Clinicians should consider all patients, except the most critically ill or those unable to absorb oral medications, as candidates for treatment for most or all of their antibiotic treatment with oral antibiotics. (C) 2001 Prous Science. All rights reserved
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