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NICE: GPs 'should consider' antibiotics for Lyme disease without test result

GPs should consider starting antibiotics in suspected lyme disease patients without the characteristic circular red rash or confirmed test results, according to the new NICE guidelines.

NICE also informed GPs not rule out Lyme disease in people with ‘no clear history of tick exposure’ if they have potential symptoms, and to diagnose and treat patients presenting with erythema migrans, without further testing.

The new guidelines, which were drafted last year, have told GPs to consider Lyme disease in people presenting with several symptoms such as fever and sweats, fatigue, neck pain or stiffness and headache, as it is a ‘possible but uncommon’ cause.

They said that if there is clinical suspicion of Lyme disease but no erythema migrans, GPs should offer an enzyme-linked immunosorbent assay test and ‘consider starting treatment with antibiotics’ while waiting for the results.

GPs were also told not to ‘rule out the possibility of Lyme disease’ in people with symptoms but ‘no clear history of tick exposure’.

NICE centre for guidelines director Professor Mark Baker said that the advice will lead to earlier diagnosis and ‘provide people with prompt treatment’.

He said: ‘Our committee reviewed the best available evidence and identified gaps in what we know about prevalence in this country and the benefit of long-term treatment options. Further research into Lyme disease should be a high-priority area in the UK so we can continue to improve care.’

Chair of the NICE guideline committee Professor Saul Faust, who specialises in paediatric immunology and infectious diseases at the University of Southampton, added: ‘This new guideline gives more clarity on how clinicians can spot Lyme disease and provide early treatment. It guides through when to use tests and what antibiotics to prescribe according to symptoms.’

Isle of Arran GP and Chair of the Rural GP Association of Scotland Dr David Hogg has welcomed the guidelines, which he said appear to offer ‘clear and pragmatic guidance’ on the assessment of tick bites, and the ‘appropriate treatment steps’.

He said: ‘GPs in rural Scotland see frequent presentations of tick bites, and so far there has been a lack of consistent and helpful guidance on how to manage these cases beyond the consideration of erythema chronica migrans, and early antibiotic use when that is indicated’.

This comes as Pulse revealed that more than 8,000 GPs received a personalised letter informing them that they are over prescribing antibiotics and PHE announced their ambition to half inappropriate antibiotic prescribing by 2020.

Guidelines in full

Consider the possibility of Lyme disease in people presenting with several of the following symptoms, because Lyme disease is a possible but uncommon cause of:

  • fever and sweats
  • swollen glands
  • malaise
  • fatigue
  • neck pain or stiffness
  • migratory joint or muscle aches and pain
  • cognitive impairment, such as memory problems and difficulty concentrating (sometimes described as 'brain fog')
  • headache
  • paraesthesia

Do not rule out the possibility of Lyme disease in people with symptoms but no clear history of tick exposure.

Do not diagnose Lyme disease in people without symptoms, even if they have had a tick bite.

Take into account that people with Lyme disease may have symptoms of cognitive impairment and may have difficulty explaining their symptoms. For adults, follow the recommendations in NICE's guideline on patient experience in adult NHS services.

Diagnose and treat Lyme disease without laboratory testing in people with erythema migrans.

Use a combination of clinical presentation and laboratory testing to guide diagnosis and treatment in people without erythema migrans. Do not rule out diagnosis if tests are negative but there is high clinical suspicion of Lyme disease.

If there is a clinical suspicion of Lyme disease in people without erythema migrans:

  • offer an enzyme-linked immunosorbent assay (ELISA) test for Lyme disease and
  • consider starting treatment with antibiotics while waiting for the results if there is a high clinical suspicion

If the ELISA is positive or equivocal:

  • perform an immunoblot test for Lyme disease and
  • consider starting treatment with antibiotics while waiting for the results if there is a high clinical suspicion of Lyme disease

Source: NICE

Readers' comments (10)

  • I had a patient with memory problems who couldnt remember if he had been bitten by a tick. I treated him for Lyme Disease then got a rude letter about my antibiotic prescribing.(/s).

    If General Practise and NICE guidance werent so bloody tragic I would almost laugh.

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  • Every patient presenting with cold/flu has “several” of the listed symptoms, so now you can be sued for missing Lyme Disease as well as sepsis. So what do you want, a stiff letter re your antibiotic prescribing or years being persecuted by the GMC for failing to follow Lyme Disease guidelines? Deferred antibiotic scrips for everyone, it’ could save the (very) occasional life........and your career,

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  • Well this is a joke

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  • Why not just do the Immunoblot test first? This guideline implies avoiding several visits to the doctor before the diagnosis is made (which the Daily Mail will no doubt make a headline from).
    We really are between the devil and the deep blue sea with NICE exhorting to use antibiotics for vague symptoms and the Chief Medical Officer telling us not to.

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  • Correction to Sentence 2 above: "guideline implies making several visits"

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  • I used to work down on the New Forrest where Lyme is endemic. We used to treat such presentations with good history for Lyme (eg walking trip, bird, flu) with antibiotics anyway. It’s worth noting that the rash is only seen in a minority. The powers that be need to stop issuing proclamations and let us get on with the time honoured tradition of taking a history and examining patients for what is likely rather than what is rare.

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  • Vinci Ho

    Oh dear
    Purely on the rash , erythema migrants ( enlarging ring , hence , migrating) is a differential diagnosis of the bigger group , erythema annulare centrifuging. That can be often idiopathic but also associated with infections , drugs including penicillins and even cancers). Of course , annular skin lesions can be tricky , in general (annular eczema , psoriasis, sarcoidosis etc . Not always ring worm!).
    Of course , history and examination are fundamentally essential.

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  • Vinci Ho

    Erythema annulare centrifugum

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  • More guidance. Just what we need.

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  • Took Early Retirement

    fever and sweats
    swollen glands
    malaise
    fatigue

    That sounds nasty to me: potentially, yet we are to use.....antibiotics??????

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