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Lyme disease - Management
What antibiotics should I prescribe for erythema migrans (pregnancy and breastfeeding)?

  • For women who are breastfeeding and present with erythema migrans alone (that is, there is no evidence of neurological, cardiac, or joint involvement), the following antibiotic regimens can be started in primary care:
    • Amoxicillin 500 mg three times daily, by mouth, for 14 days.
    • If amoxicillin is contraindicated, treat with cefuroxime axetil 500 mg twice daily, by mouth, for 14 days.
      • Between 0.5% and 6.5% of people who are hypersensitive to penicillins are also hypersensitive to cephalosporins. Do not prescribe to people with a history of anaphylaxis to a penicillin.
    • If erythema migrans cannot be reliably distinguished from bacterial cellulitis, treat with one of the following:
      • Co-amoxiclav 500/125 mg three times daily, by mouth, for 14 days (avoid co-amoxiclav in women with hepatic impairment, or a history of hepatic dysfunction associated with co-amoxiclav, because of the risk of cholestatic jaundice).
      • Cefuroxime axetil 500 mg twice daily, by mouth, for 14 days.
      • Amoxicillin 500 mg three times daily, by mouth, for 14 days plus flucloxacillin 500 mg four times daily, by mouth, for 7–14 days.
  • Warn women prescribed any antibiotic for Lyme disease that they may develop a Jarisch–Herxheimer reaction in the first 24 hours of treatment.
    • This reaction, arising from a release of toxins following the death of the bacteria, consists of a worsening of fever, chills, muscle pains, and headache. Tachycardia, hyperventilation, vasodilation with flushing, and mild hypotension may occur.
    • People may mistake this for an allergic reaction and stop their antibiotics. Provided the symptoms are not severe and there is no evidence of an allergic reaction (such as urticaria), they can be advised to continue the antibiotic.
  • For pregnant women who present with erythema migrans alone (that is, there is no evidence of neurological, cardiac, or joint involvement):
    • Treat with antibiotics as for women who are breastfeeding, and inform an obstetrician.
    • You may wish to contact an obstetrician prior to starting treatment; there is a theoretical possibility that a Jarisch–Herxheimer reaction could precipitate uterine contractions, although there are no reports of this occurring in women treated for Lyme disease.
    • Reassure the woman that maternal Lyme disease is associated with a very low risk of adverse pregnancy outcome, particularly if treated with suitable antibiotics, but that the obstetrician may wish to plan additional monitoring during the pregnancy.

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