II. HOW ARE TICKBORNE DISEASES USUALLY TREATED?

LYME DISEASE

The treatment of Lyme Disease usually depends upon a few factors: the symptoms that the child displays, diagnostic tests, age of the child, and if the child has any allergies to any medications. Based upon these factors antibiotic therapy will be given either orally (by mouth) or intravenously (through a vein) for more severe disease. 

Lyme Disease and Body Systems Affected

The most common type of Lyme Disease, that which has some flu like symptoms and usual rash is generally treated with 2 to 3 weeks of oral antibiotics.

If children have any signs that the disease may be affecting the nervous system the physician will often need to rule out meningitis.  If meningitis is ruled out, the child may be able to receive oral antibiotics but if not intravenous antibiotics (or sometime oral doxycycline) are generally needed.  The duration of therapy for this is usually 2 to 4 weeks. 

Although rare, Lyme Disease affecting the heart can occur, and is treated with 2 to 3 weeks of antibiotics.  In children with less severe disease oral therapy may be okay. Most recommend intravenous antibiotics for children with more severe disease that requires hospitalization. 

If a child has Lyme Disease affecting the joints (i.e. arthritis), they will usually need 4 weeks of oral antibiotics.  Lyme arthritis is one of the few conditions that sometimes will require a repeat course of oral therapy or a trial of a few weeks of intravenous antibiotics.  This second course is generally used if the child does not respond to the initial 4 oral therapy. 

Antibiotic Therapies Recommended for Treatment of Lyme Disease:

Oral Therapy

For children at least 8 years old, doxycycline is the preferred oral therapy.  Because the bacteria that causes Lyme Disease also responds to other antibiotics, doxycycline is not generally recommended for children less than 8 years old.   The oral antibiotics recommended for young children include amoxicillin and cefuroxime.  If a child cannot receive doxycycline, amoxicillin or cefuroxime a macrolide (azithromycin, clarithromycin, or erythromycin) may be considered.  The reason that the macrolide is only used if they cannot receive the other agents is because it may be less likely to work.

Intravenous Therapy 

Ceftriaxone is usually the preferred intravenous therapy for the treatment of Lyme Disease.  Other antibiotics that are also efficacious, but need to be administered more frequently are cefotaxime and penicillin G.    

ROCKY MOUNTAIN SPOTTED FEVER 

The CDC suggests that because these diseases are often severe, doxycycline is the preferred drug in children of all ages. Treatments can be either oral or intravenous depending on the severity.  Duration of therapy is usually between 5 to 14 days. Longer therapies are sometimes needed for more severe disease. 

MEDICATION SUMMARY

• For all of medications you should give your child all of the doses prescribed.
• If your child has any concerning reactions (rash, throat swelling, severe or bloody diarrhea, etc) contact your physician right away. 
• If your child is given the medication as a liquid – shake well before giving each dose and ask your pharmacist for a measuring device. 
• If there is any drug remaining after the course is done, throw it away. 
• Many of these drugs may have interact with other medications, please let your pharmacist know if your child takes any prescription, over the counter medication, or herbal supplements. 

Penicillins

Amoxicillin (oral)

• Amoxicillin should not be used in children that have an allergy to penicillins.
• You should talk to your child’s doctor if your child has an allergy to cephalosporins it is possible that your child will also be allergic to amoxicillin. 
• Could cause tooth discoloration that is lessened by brushing your child’s teeth well. 

Penicillin G (intravenous)

• Penicillin should not be used in children that have an allergy to penicillins.
• You should talk to your child’s doctor if your child has an allergy to cephalosporins your child may also be allergic to penicillin. 

Cephalosporins

Cefuroxime axetil (oral)

• Cefuroxime should not be used in children that have an allergy to cephalosporins.
• You should talk to your child’s doctor if your child has an allergy to penicillins as there is a chance that your child will also be allergic to cefuroxime.
• Cefuroxime axetil liquid should be taken with food.
• Cefuroxime axetil tablets can be taken with food to make it less likely to cause upset stomach.  

Ceftriaxone or cefotaxime (intravenous)

• Ceftriaxone or cefotaxime should not be used in children that have an allergy to cephalosporins.
• You should talk to your child’s doctor if your child has an allergy to penicillins as  there is a chance that your child will also be allergic to either ceftriaxone or cefotaxime. 

Tetracyclines

Doxycycline (oral)

• Your child should try to avoid prolonged exposure to sunlight and tanning because this can lead to a bad reaction. 
• This medication can cause tooth discoloration in young children. 
• This drug can discolor skin and/or fingernails.
• This drug should be spaced at least 2 hours from iron, calcium, antacids, or dairy products. 
• If tolerated this medication should be taken on an empty stomach.
• If your child is taking a tablet or capsule it should be swallowed whole with a full glass of water. 

 Macrolides

Azithromycin, clarithromycin, or erythromycin (oral)

·     Space antacids at least two-hours from taking the medication. 

·     If your child is taking a tablet or capsule it should be taken whole. 

·     Clarithromycin and azithromycin should be stored at room-temperature, not in the refrigerator. 

·     Some types of erythromycin are stored in the refrigerator while others can be kept at room-temperature. 

·     Erythromycin is best taken, if it does not cause stomach upset, on an empty stomach.

·     Clarithromycin extended-release tablets should be taken with food. 

Others

Atovaquone (oral)

·     The drug should be administered with a high fat meal. 

·     Let your child’s doctor know if your child has diarrhea.

Clindamycin (oral)

·     Do not refrigerate solution. 

·     Take capsules with a full glass of water.

Quinine (oral)

• Let your child’s doctor know if you child has a heart condition.
• Do not crush capsules. 

 III. Prevention of Tick Borne Illnesses in Children

How do I protect my child from a tick borne illness?

·       The best way to protect your child from a tick borne illness is to keep your child away from areas where ticks may be found (for example: wooded areas, fields, infested animals).

·       If you can’t keep your child away from a tick infested area, then protective clothing should be worn. 

• Your child should wear light colored clothing (so ticks can be seen on the clothing and removed before they attach to the child’s skin).
• Your child should also wear long sleeve shirts, long pants and a hat to limit a tick’s access to your child’s skin.
• Pants should be tucked in to your child’s boots or socks and shirts should be tucked in to your child’s pants.

·         Products that contain DEET (like Cutter’s® and Deep Woods Off®) or permethrin (like Sawyer®) can be sprayed onto your child’s clothing to repel and/or kill ticks.         

·       DEET and permethrin should not be used in infants less than 2 months of age.

·       Products that contain DEET may also be applied to exposed skin.  Avoid spraying or applying DEET to your child’s face to avoid getting DEET in your child’s mouth or eyes.  For younger children, you may want to apply DEET to your hands then rub your hands on any exposed areas of your child’s skin.  Do not apply DEET to the hands of young children since they may rub their eyes or stick their hands in their mouths. 

·       Permethrin should never be applied to the skin. 

·       After your child has returned from an area that may be infested with ticks, check his/her body and clothing for any ticks.  Be sure to check your child’s hair and behind his/her ears.  Remove any ticks you find on your child.

·       If you have pets in your household, they should also be kept free of ticks.  Your veterinarian can help you pick a product that will keep your pets tick-free.

If I find a tick on my child, how do I safely remove the tick?

To remove a tick:

1. Use a pair of tweezers (not your bare hands) to grasp the tick as close to your child’s body as possible.
2. Steadily pull the tick straight out from the body without twisting your hand.  Do not crush or squeeze the tick.  If you cannot remove the entire tick, do not panic.  Simply clean and disinfect the area as noted below.
3. After removing the tick, clean and disinfect the area with soap and water, a chlorhexidine wash, an iodine wash or rubbing alcohol. 
4. Be sure to wash your hands thoroughly after you remove the tick from your child.
5. The CDC recommends that you save the tick in a sealed plastic bag (like a Ziplock® baggie) stored in your freezer in case your child later becomes sick.  You should write the date of the tick bite on a piece of paper placed inside the plastic bag.

 If my child is bitten by a tick, will he/she need antibiotics?

·       In general, antibiotics are not recommended for most people who are bitten by a tick.  Usually, your doctor will ask you to watch your child closely for signs of a tick borne infection, like a skin rash or flu-like symptoms, for one month after the tick bite happened.  In states where tickborne illnesses are most common, your doctor may give your child a single dose of doxycycline.

·       If your child does develop a skin rash or flu-like symptoms (low fever, tired, achy joints/muscles), then your child should be seen by his/her doctor as soon as possible.

References

1.     American Academy of Pediatrics. Prevention of Mosquitoborne Infections. In: Pickering LK, ed. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:193-195.  Available at: http://aapredbook.aappublications.org/cgi/content/full/2009/1/2.14.  Accessed September 30, 2009.

2.     American Academy of Pediatrics. Prevention Of Tickborne Infections. In: Pickering LK, ed. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009:191-193.  Available at: http://aapredbook.aappublications.org/cgi/content/full/2009/1/2.13.  Accessed September 30, 2009. 

3.     Center for Disease Control and Prevention. Department of Health and Human Services. Lyme Disease: A Public Information Guide. May 2007.

4.     Centers for Disease Control and Prevention.  Learn About Lyme Disease.  http://www.cdc.gov/ncidod/dvbid/Lyme/.  Accessed September 30, 2009.

5.     Centers for Disease Control and Prevention.  Prevention and control.  http://www.cdc.gov/ticks/prevention.html.  Accessed June 17, 2009.

6.     Centers for Disease Control and Prevention.  Removing ticks. http://www.cdc.gov/ticks/tick_removal.html.  Accessed June 17, 2009.

7.     Centers for Disease Control and Prevention.  Rickettsial Diseases.  Questions and Answers.  What is Rocky Mountain spotted fever?   http://www.cdc.gov/ticks/diseases/rocky_mountain_spotted_fever/faq.html.  Accessed September 30, 2009.

8.     Centers for Disease Control and Prevention.  Tickborne Rickettsial Diseases.  http://www.cdc.gov/ticks/transmission.html.  Accessed September 30, 2009.

9.     Chen LF, Sexton DJ.  What’s new in rocky mountain spotted fever? Infect Dis Clin North Am 2008;22:415-432.

10.  Feder HM Jr.  Lyme disease in children.  Infect Dis Clin North Am 2008;22:315-326.

11.  Nelson’s Pocket Book of Pediatric Antimicrobial Therapy.  16^th Ed.  J Bradley and J Nelson, eds. Alliance for World Wide Editing, Buenos Aires, Argentina.

12.  Pediatric Dosage Handbook.  15^th Ed. C Taketoma, J Hodding and D Kraus, eds. Lesi-Comp. Hudson, OH.

13.  Treatment of Lyme disease. The Medical Letter 2007;49:49–51.

14.  Wormser GP, Dattwyler RJ, Shapiro ED, et al.  The clinical assessment, treatment, and prevention of lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America.  Clin Infect Dis 2006:43;1089-134.