Lyme Disease - Antibiotic Prescribing

Comments from the Expert Advisory Committee

  • Testing for Lyme disease should only be performed by an accredited laboratory that use validated tests and participate in a formal external quality assurance programme.
  • Laboratory tests are necessary to confirm a diagnosis of later stage infection. Antibodies to B. burgdorferi are usually detectable within 4-8 weeks of infection. Patients with late-stage infection are rarely seronegative and usually have very strongly positive antibody tests.
  • The occurrence of false-positive tests in patients with other infections or conditions such as autoimmune diseases, can lead to misdiagnosis and inappropriate treatment. Other specialised investigations may be necessary for confirmation of a positive result.
  • Symptoms of Lyme disease may take months or years to resolve even after treatment for several reasons, including alternative diagnoses, reinfection, treatment failure, immune reaction, and organ damage caused by Lyme disease.


Early onset / erythema migrans without evidence of neurological or cardiac manifestations:

  • Early onset is a Clinical diagnosis – presence of ‘bull’s eye’ skin lesion and assessment of tick exposure risk
  • Diagnose Lyme disease in people with erythema migrans -a red rash that increases in size and may sometimes have a central clearing.
  • It is not usually itchy, hot, or painful. It becomes visible from one to four weeks (but can appear from 3 days to 3 months) after a tick bite and lasts for several weeks at the site of a tick bite.
  • Be aware that a rash that is not erythema migrans can develop as a reaction to a tick bite. This rash usually develops and recedes within 48 hours from the time of the tick bite
  • No laboratory test required

Screenshot 2020-11-27 162223

lyme table 2020

Post exposure prophylaxis: tick2

  • If tick remains on the skin, carefully remove it. Link to instructions
  • If patient presents with an attached tick or within 3 days (72 hours) of removal of a tick they should be offered doxycycline 200mg single dose as prophylaxis in the absence of any contraindication to doxycycline.
  • For those people where there is a contraindication to doxycycline, including children under 8 years old, there is insufficient evidence on which to make a recommendation of an alternative agent.

Later stage infection

Post-Lyme disease syndrome

  • Antibiotics not recommended where Lyme disease has previously been adequately treated – no demonstrable clinical benefit from prolonged antibiotic therapy
  • Supportive management, e.g. for management of chronic pain, fatigue, depression

Useful information

Safe Prescribing (visit the safe prescribing page)

Reviewed December 2020