Topic: Impact of long-term antibiotic therapy on symptoms evocative of chronic lyme disease
Vermont_Lymie
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Clinical Microbiology and Infection, Volume 11, Supplement 2, 2005
Impact of long-term antibiotic therapy on symptoms evocative of chronic lyme disease
J. Clarissou, J. Salomon, D. Guillemot, C. Bernede, F. Ader, L. Bernard, C.M. Perronne (Garches, Paris, F)
Objectives: chronic lyme disease (CLD) could be partly due to the persistence of Borrelia. The aim of our study is to determine the effect of long term antibiotic therapy on heterogeneous symptoms evocative of CLD.
Methods: 100 patients (pts) (65% female, mean age 45 y) with a diagnosis of CLD were included in an open study.
A clinical score was designed based on the following items: erythema migrans (56% of cases), positive serology for Borrelia (51%), tick bite (69%), combination of categories of signs or symptoms: systemic (88%), neurologic (94%), articular (91%), cutaneous (76%), psychiatric (77%), cardiorespiratory (73%) or muscular (67%).
Diagnosis was classified as very probable (67%), probable (25%) or uncertain (8%), according to the clinical score.
An antibiotic therapy was given for 3 to 6 months (penicillin G, ceftriaxone, amoxicillin, doxycycline or clarithromycin). The number (No) of subjective symptoms (SS) and objective signs (OS) was measured at day 0 (D0), month 3 (M3) and M6.
Results: The No of pts with 4 or more categories of signs or symptoms was 82% at D0, 34% at M3 and 31% at M6. The mean No of SS was 12 at D0, 6 at M3 and 5 at M6. The mean No of OS was 2.7 at D0, 1.4 at M3 and 1 at M6. The differences were significant for very probable or probable cases (p < 0.001).
Conclusion: This study shows an important improvement of the clinical conditions of pts with CLD treated with a prolonged course of antibiotic. A controlled randomized trial with a strict case definition and a follow up longer than 3 months is needed.
***
OK, so doctors/medical researchers in France AND England AND Italy are recommending and/or studying long-term abx for lyme borreliosis, according to just a couple of abstracts and articles I've posted recently.
And that is just a small sample of evidence for the efficacy of long-term abx for lyme.
And yet, some flat-earth folks affiliated with the IDSA seem to be fighting hard to deny lyme patients access to proper treatment!!
I just do not get it. What is in it for Steere, Wormser and their ilk to deny lyme patients proper treatment??
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Greatcod
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Good find. There are times when I wonder if Steere and Wormser have anything that resembles a conscience. As "doctors" their concern ought to be patient wellbeing, and open to studies like this one. Instead they mock us. Sickening, in more ways than one.
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I don't think anyone here in England is studying the effects of long-term antibiotics on chronic lyme though? Do you have any studies in England showing this?
The reason why I ask, is the Health protection agency here in England is completely against the idea that Lyme disease needs long term antibitoics. Infact, the person incharge of the Lyme disease unit helped make the IDSA guidelines, and she is in close contact with Shapiro, etc! They keep telling us there are no studies showing long term antibiotics are effective - what a load of rubbish! We do definitely need more studies to prove this though, then we will have a much stronger case against the IDSA and HPA, etc.
I missed the other articles you posted recently, could you repost them in this thread please?
Thanks.
Posts: 263 | From UK | Registered: Mar 2006
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Vermont_Lymie
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Hi ChrisB from England:
Actually, it was the (London) Times article that I posted, written by a doctor, that states that long-term antibiotics are needed if lyme is not caught at an early stage right after the tick bite.
I was very impressed by this -- is that a major newspaper in the UK? I think so! And the NY Times would not print such a statement.
I will find the article and repost it for you, later today. Yes, there are not a whole lot of studies on this, and hopefully columbia/fallon's research will help fill in the gaps someday soon.
Meantime, here is the Italian doctor's correspondence, suggesting the long-term use of minocycline for neuroborreliosis based on their treatment of neurosphyillis with nine months of mino:
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]Posts: 2557 | From home | Registered: Aug 2006
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quote:Originally posted by Vermont_Lymie: [QB] Hi ChrisB from England:
Actually, it was the (London) Times article that I posted, written by a doctor, that states that long-term antibiotics are needed if lyme is not caught at an early stage right after the tick bite.
I was very impressed by this -- is that a major newspaper in the UK? I think so! And the NY Times would not print such a statement.
I will find the article and repost it for you, later today.
Thanks. Yes, The Times is a very big newspaper in the UK. I had people phone me up after they read the article to tell me. It was a good article and apparently the doctor who wrote the article is VERY well known and has been doing medical articles in magazines and newspapers for something like 20 years. I was trying to contact him but couldn't find any details. It could be great if you could post that article. I really look foward to see the studies that Fallon, etc will be doing. Do you know how long it will be until they start doing these studies and publishing the results?
Posts: 263 | From UK | Registered: Mar 2006
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Tried to PM you in response to your PM but your box is full!
I'll try again...
Julie
Posts: 307 | From Byfield, MA | Registered: Jan 2004
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Vermont_Lymie
Frequent Contributor (1K+ posts)
Member # 9780
posted
Reposted, as promised. I was very happy to see the London Times get it right about lyme disease.
Chris, sorry to hear the lyme 'controversies' are on your side of the Atlantic too. I hoped that with a different institutional context and set of political constraints, perhaps doctors are more honest in the UK about appropriate lyme treatment than most ID ducks in the US.
it will probably take some time for Fallon to publish further studies, I would guess. He is still collecting data. The Columbia lyme center has a good website and is worth reading for their unpublished data!
Julie, thanks, will clean up the old mailbox!
****
Why is it that the newspapers in England can actually get it right about lyme?
when American newspapers miss so many important features of the story? Or, are the British papers just more honest?
***
The Times (London)
May 14, 2007, Monday Times2; Pg. 10
HEADLINE: Deer tick with cruel bite
BY: Dr Thomas Stuttaford
Lyme disease is spread by ticks and can lead to severe illness,
says DR THOMAS STUTTAFORD
After working in a Norfolk practice it was a surprise to find that patients in Whitechapel, East London, regarded the British countryside as a place of peril.
They weren't frightened of being attacked by angry beasts, whether bullocks on the marshes or rats in the yard.
But they feared the silence of the night, the emptiness of the fens or marshes and, inevitably, the vulnerability of any lonely country house to burglary and spiders.
The countryside doesn't seem hazardous to those brought up in it. Unless someone has arachnophobia and expects a spider to drop down on to their pillow or bath, the rural natural world is relatively innocuous.
However, it seems that the urban fear of spider-like creatures is not entirely unwarranted.
It is not spiders that we should be careful about but the relatively benign-looking, spider-like deer tick that spreads Lyme disease. This small tick lives on deer and other animals whose habitat is grass, scrubby woodland, heath and moorland.
When Lyme disease was first described 30 years ago, it was thought that it was essentially an American problem.
Now it has become apparent that the disease is endemic throughout Britain. Although still comparatively rare it has apparently been here for 150 years.
Unfortunately, research indicates that the ticks that carry it are either becoming more abundant or that doctors are more aware of the disease and fewer cases are misdiagnosed.
Ten years ago only ten cases of Lyme disease were found in Scotland; last year there were 177.
It is suggested that the warmer weather has led to a lush growth of grass that continues to flourish late into autumn and in some places even during the winter months so that the deer population, and their ticks, have flourished.
Smaller mammals, usually rodents, that live among the dead leaves and dying grass are hosts for a different stage of the deer tick's complicated life cycle.
Lyme disease is spread from ticks to human beings through tick bites. The tick is brushed off undergrowth on to a person's clothes and it is often hours before they bite their victim.
*** Borrelia burgdorferi is the organism responsible for Lyme disease, but it often coexists with other tick-born diseases so that the clinical picture is complex.****
**** The complication is increased because the bacteria decreases the patient's immunity to all diseases and may also cause a resurgence of previous troubles such as shingles or herpes simplex.****
The first sign of Lyme disease is -in between 50 to 75 per cent of cases (estimates vary) -a red, raised skin lesion, usually found in the area of the initial bite.
The rash that appears from three days to a month after the bite is commonly found on the upper legs, buttocks or the upper arm.
The red rash expands concentrically, and the centre of it may become ulcerated or blistered. The lymph glands near by are often enlarged and tender.
The rash is associated with general malaise, lack of joie de vivre, headaches and muscular aches and pains.
*** Days or weeks after the initial symptoms, the patient may develop severe localised symptoms that could last for weeks or months, and very occasionally may prove fatal.****
Fifteen per cent of patients suffer severe neurological abnormalities including meningitis, encephalitis, Bell's (facial) palsy or peripheral nerve weakness.
Eight out of ten who progress to serious complications develop heart troubles and, if left untreated, about 60 per cent of patients who have had Lyme disease develop severe arthritis.
Diagnosis is difficult and requires a host of specialised tests.
*** Treatment is with antibiotics that are used in large doses for a long time.****
The earlier it is started the less likely a patient is to develop severe later complications.
HOW TO SPOT TICKS AND AVOID GETTING BITTEN
* Ticks attach themselves when people or animals brush past tall grass, shrubs, bushes or tree branches.
* Walk in the middle of paths and check yourself after sitting on logs or leaning against tree trunks.
* If you picnic, use a light-coloured blanket to sit on so that you can examine the underside more easily.
* Wear long-sleeved shirts, trousers tucked into socks, shoes not sandals.
* Change when back from a walk and brush any ticks off clothing and stamp on them.
* Check warm areas of body for ticks: armpits, elbows, groin, behind the knees and ears.
* Check pets for ticks when they come into the house and keep them off furniture, especially bedding.
Use insect repellents.
HOW TO REMOVE A TICK: DO'S AND DON'TS
DO
* Use tweezers to grasp the tick as close to the skin as possible without squeezing the tick's body; pull the tick out without twisting.
* If you don't have tweezers, use a cotton thread. Tie a single loop of cotton around the tick's mouthparts, as close to the skin as possible, then pull gently upwards and outwards.
* Cleanse the bite site and tweezers with antiseptic before and after removal.
* Save the tick in a container in case of later symptoms (label with date and location).
DO NOT
* Squeeze or twist the body of the tick as this may cause the head and body to separate, leaving the head embedded in your skin.
* Use your fingernails to remove a tick. Infection can enter via any breaks in your skin, eg, close to the fingernail.
* Try to burn the tick off, apply petroleum jelly, nail polish or other chemical.
* Any of these methods can cause discomfort to the tick, resulting in regurgitation or saliva release.
* Use vinegar or Vaseline to kill the tick -they won't work.
USEFUL WEBSITES
The tick alert campaign: masta-travel-health.com/tickalert/index.html
The Health Protection Agency is currently running a scheme to investigate ticks: lymediseaseaction.org.uk/information/tick.htm
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