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Lyme disease - Management
Basis for recommendation

These recommendations are based on guidance from the UK Health Protection Agency (HPA) [HPA, 2009e], US [Wormser et al, 2006] and European [Brouqui et al, 2004; Mygland et al, 2010] guidelines, case definitions on clinical features of Lyme disease by the European Union Concerted Action on Lyme Borreliosis [EUCALB, 2008], and narrative reviews [Hengge et al, 2003; Hytonen et al, 2008].

  • The recommendation to consider Lyme disease not only in people with a history of a recent tick bite but also in people with a history of possible exposure to ticks (work or recreation in a forested, heathland, or moorland area, or even in suburban parkland) is based on HPA guidance [HPA, 2009e] and on evidence from a systematic review [Tibbles and Edlow, 2007]. The systematic review reported that a history of a known tick bite was present in only 64% (95% CI 52 to 74) of people with erythema migrans in European studies, and in just 26% (95% CI 18 to 37) of people in US studies.
  • The recommendation to make a clinical diagnosis of Lyme disease on the basis of the presence of erythema migrans in people with a history of a tick bite or possible exposure to ticks is derived from a US guideline, produced by the Infectious Diseases Society of America [Wormser et al, 2006] which has been endorsed by the HPA [HPA, 2009b], and from a European guideline [Brouqui et al, 2004].
  • The recommendation to suspect but not diagnose Lyme disease when suggestive symptoms are present but erythema migrans is absent is based on the US guideline [Wormser et al, 2006]. Reports from observational studies in the US of the proportion of people with Lyme disease without erythema migrans vary from 10% to 16% [Krause et al, 2002; Steere et al, 2003].
  • The list of flu-like symptoms is derived from HPA guidance [HPA, 2009e] and a systematic review of history and physical examination findings for the diagnosis of erythema migrans [Tibbles and Edlow, 2007].
  • The recommendation to consider other tick-borne diseases, and the possibility of co-infection, is derived from HPA guidance [HPA, 2009e].

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