Lymenet

A Guide to Lyme Disease for Doctors III – Treatment

  • 2026 June 11.
  • 1219 megtekintés

The treatment of Lyme disease is one of the most complex and controversial areas of medicine, particularly in cases involving late-stage, disseminated or protracted symptoms. Although antibiotic therapy remains the primary treatment for the infection, clinical experience and research in recent years have increasingly highlighted that the management of the disease requires a far more complex approach. Lyme borreliosis is not merely a simple bacterial infection, but a multifactorial disease process that can activate immunological, neurological, inflammatory and, in some cases, autoimmune mechanisms. For this reason, the success of treatment is not determined solely by the type of antibiotic or the duration of the course, but also by numerous other factors, including the duration of the infection, the presence of co-infections, the state of the immune system, the patient’s nutritional and hormonal status, and the body’s ability to regenerate.

Antibiotic treatment remains the cornerstone of Lyme disease therapy. In cases of recent infection, minocycline/doxycycline, amoxicillin, ciprofloxacin or cefuroxime are generally effective, although the choice of antibiotic requires individualisation to the specific case: the most reliable results can be achieved with combination therapy, and based on knowledge of the antibiotic sensitivity of the Borrelia species causing the infection. Treatment is particularly likely to be successful if the diagnosis is made at the onset of the infection, i.e. whilst early symptoms, such as erythema migrans, are still present. However, erythema migrans does not always indicate a recent infection; in many cases, it develops independently of a tick bite, as a result of changes in the immune system or the effects of antibiotic treatment. If a rosette-like, spreading redness develops around the site of a known tick bite, it is more likely that a fresh infection is (also) present. According to the latest expert opinions, the redness may also be an immune response or an allergic skin reaction in an individual who has previously encountered the infection, particularly if it develops very quickly, within a few days. It is therefore important to seek medical advice to determine whether the symptoms consistently point to a recent infection, or whether there are also symptoms suggestive of a chronic infection.

Most cases detected early can be cured without residual symptoms with appropriate treatment. The problem arises primarily in patients in whom the infection remains undiagnosed for months or even years. In such cases, Borrelia is able to persist in various tissues, and the infection can sustain not only local but also systemic inflammatory processes.

It is also important to clarify a terminological debate here. The ‘outlined’ mechanism of infection spread previously published in the literature describes ‘early localised’, ‘early disseminated’ and ‘late disseminated’ Lyme disease. This may give the treating physician a false sense of security that the infection does not initially spread throughout the body, and is therefore easily treatable. In contrast, the facts show that 1. 4–6 hours after a tick bite, the pathogen enters the bloodstream directly, 2. the tick’s saliva inhibits the immune response, whilst Borrelia blocks both the innate and specific immune responses as well as the formation of germinal centres, thus allowing the pathogen to spread unhindered, 3. within a maximum of 2 weeks after the bite, the infection reaches its first peak in almost every part of the body examined, 4. within 1–2 weeks, the infection may present with systemic symptoms. Therefore, the time window between early and disseminated infection is measured in weeks.

The treatment of disseminated Lyme disease is often considerably more difficult. In cases of neurological involvement, the use of intravenous ceftriaxone or cefotaxime, in combination, may become necessary, whilst prolonged oral antibiotic therapy is used for joint or chronic symptoms. There has long been debate in the literature as to whether standard short courses of antibiotics are sufficient in all cases. A recent review study has been published showing that Borrelia can still be detected in the body even in treated patients: the review lists 32 human clinical publications, in addition to animal studies. Several clinical observations and publications suggest that, in certain patients, longer or combined treatment may yield more favourable results, particularly if the infection has been present for a longer period or affects multiple organ systems. This is because Borrelia is characterised by its ability to employ various survival mechanisms. The bacterium can persist intracellularly or develop slow-metabolising persister forms. These mechanisms may contribute to certain patients not responding adequately to conventional monotherapy.

In the case of Borrelia, which is one of the most diverse bacteria in terms of both its genetics and its antigens, it is important to find an effective therapy in the first instance; otherwise, the pathogen’s resistance may increase. An article on Lyme therapy published in Orvosi Hetilap emphasises that the aim of combined antibiotic treatments may be to simultaneously inhibit multiple different targets. The combination of antibiotics with different mechanisms of action may, in theory, increase the effectiveness of treatment, a finding confirmed by both in vitro and clinical studies. Some combinations bring together agents that inhibit cell wall synthesis, block protein synthesis, and are also effective intracellularly. In vitro studies have demonstrated synergistic effects in several cases, a finding increasingly confirmed by clinical research reports. However, the use of combination therapies requires increased caution, as the risk of side effects, drug interactions and changes to the gut microbiome may also increase significantly. The Lyme Borreliosis Foundation’s combined therapy, containing synergistic antibiotics that have been tested in vitro and clinically, has been validated by a 5-year follow-up of 250 patients. With the use of this complementary therapy, side effects are minimal, although the treatment requires a calm lifestyle and avoidance of extreme physical exertion and heavy workloads.

Antibiotic treatment alone is often insufficient for full functional recovery. Due to the inflammatory processes, oxidative stress and immune system dysregulation associated with Lyme disease, supportive therapies are becoming increasingly important. The three main pillars of treatment are targeted therapy against the infection, preparing the body for treatment, and supporting gradual recovery and convalescence. This is because a long-standing infection can significantly deplete the body’s energy reserves and place a strain on the liver, the digestive system and the immune system, meaning that recovery does not end with the completion of the course of antibiotics.

One of the most important elements of supportive care is the protection of the gut microbiome. Prolonged antibiotic therapy can significantly alter the normal gut flora, which can lead to digestive complaints, malabsorption, immunological problems and opportunistic infections. For this reason, the use of probiotics is recommended during almost all prolonged courses of treatment: experts primarily recommend enteric-coated capsules containing as many different probiotic strains as possible; the use of liquids and powders is not recommended due to their passage through the stomach, and the intake of antibiotic-resistant strains is also contraindicated. Proper nutrition is also of paramount importance. An anti-inflammatory diet, adequate protein intake, limiting simple carbohydrates, and a diet rich in antioxidants can contribute to recovery and the restoration of the immune system’s balance. A natural diet helps reduce inflammation; in particular, one should avoid processed foods, vegetable fats and oils (except extra virgin olive oil), margarines, starches, sugar substitutes (e.g. stevia, aspartame, maltodextrin, sucralose, etc.), and preservatives. Complex processed foods containing more than 5–10 ingredients should be treated with suspicion.

Addressing vitamin and trace element deficiencies can also be an important part of complex therapy. Béres drops are a long-established combined preparation for replenishing trace elements. The supplementation of vitamins and minerals is best recommended as part of the diet or in a complex preparation, as preparations containing individual minerals separately may lead to an imbalance in the ionic balance, and vitamins . Vitamin C can also be administered as an injection, even in higher doses, but in this case it must be mixed into an infusion solution (some studies indicate a tolerance of up to 60,000 mg, provided the risk of kidney stones has been ruled out). The immunomodulatory effect of vitamin D has long been known, and several studies suggest that its deficiency may be linked to the persistence of chronic inflammatory conditions – the maximum recommended dose of vitamin D3 in cases of severe illness may be as high as 50,000 IU per week for a short period.  Supplementation with other minerals or vitamins is only recommended as part of a complex formulation. Magnesium deficiency can exacerbate muscle pain, neurological symptoms and fatigue, whilst B vitamins play a key role in the regeneration of the nervous system. In some patients, the intake of omega-3 fatty acids (primarily through diet) or the use of antioxidants may also have a beneficial effect in reducing oxidative stress and supporting cellular regeneration.

The issue of detoxification also deserves special attention. Although the concept of ‘detoxification’ is often overused and presented in a scientifically inaccurate manner, supporting the liver and the excretory systems can indeed be important during the treatment of Lyme disease. Inflammatory substances released during the destruction of bacteria, as well as prolonged medication use, can exacerbate the body’s inflammatory response. Some patients may experience a temporary worsening of symptoms during treatment. Adequate fluid intake, a liver-supporting diet, possibly preparations containing milk thistle, antioxidants, and avoiding excessive physical exertion may help alleviate symptoms at this time.

The effectiveness of treatment can be significantly influenced by co-infections spread by ticks. This is because ticks often carry several pathogens at once, so infection with Babesia, Bartonella, Ehrlichia or Anaplasma species alongside Borrelia is not uncommon. These co-infections can alter the clinical picture, exacerbate symptoms and reduce the effectiveness of antibiotic treatment. Babesia, for example, is a protozoan infection that can cause fever, night sweats, shortness of breath and haemolytic symptoms. Bartonella is often associated with neurological, vascular and psychiatric complaints, whilst Ehrlichia and Anaplasma can trigger flu-like symptoms, haematological abnormalities and immunological disorders.

Recognising co-infections is particularly important in cases where the patient does not respond adequately to standard Lyme therapy. In such cases, treatment often needs to be modified, and targeted combination therapy may become necessary. However, diagnosis is not always straightforward, as the sensitivity of laboratory tests varies and symptoms often overlap. For this reason, clinical experience and the assessment of the patient’s overall condition are of paramount importance.

In forms of Lyme disease presenting with chronic symptoms, dysfunction of the immune system may also play a significant role. Borrelia is capable of employing immune evasion mechanisms, modifying its surface proteins and influencing the functioning of the immune response. In some patients, a persistent inflammatory state may develop, in which the symptoms are no longer directly caused by the active infection, but rather by the immune system’s excessive or abnormal response. This may explain why, in certain cases, fatigue, joint pain or neurocognitive symptoms may persist even after antibiotic treatment, although based on experience and the available literature, these may (also) be signs of a persistent infection in most cases.

Rehabilitation and convalescence are therefore crucial. Due to persistent fatigue and reduced physical capacity, many patients require gradual rehabilitation. Overly intense physical activity often worsens symptoms, so a gradual reintroduction of exercise is recommended. In cases of neurological involvement, physiotherapy, neurorehabilitation, speech therapy or psychological support may also be necessary. The psychological burden of chronic illness can be significant, particularly for those who have lived for years without a diagnosis or whose symptoms were attributed to psychological causes.

One of the most important insights regarding the treatment of Lyme disease is that there is no single therapeutic model that can be applied equally to all patients. The course of the infection is extremely variable, so treatment must also be individualised. The patient’s general condition, immunological status, co-infections, hormonal and metabolic status, as well as psychological stress, can all influence the chances of recovery. For this reason, successful treatment often requires multidisciplinary collaboration between infectious disease specialists, neurologists, rheumatologists, immunologists, rehabilitation specialists and dietitians.

Overall, it can be said that the treatment of Lyme disease is a far more complex process than one limited solely to the use of antibiotics. Although targeted antibiotic treatment remains essential, the modern approach is increasingly shifting towards a complex, patient-centred approach. Combined therapies, the identification of co-infections, support for the immune system, the reduction of inflammation, protection of the gut flora and conscious support for convalescence can all contribute to the patient not only recovering in a microbiological sense, but also regaining their quality of life and physical capacity functionally.

Sources

(C) Lyme Borreliosis Foundation

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