Efficacy and safety of pharmacological treatments for Lyme neuroborreliosis: An updated systematic review

Abstract

BackgroundEvidence‐based recommendations for treatment of Lyme neuroborreliosis (LNB) should rely on the available literature. As new data emerges, close review and evaluation of the recent literature is needed to build evidence‐based recommendations to inform clinical practice and management of LNB. We performed an update of a previous systematic review on treatment of LNB.MethodsA systematic literature search of Medline and CENTRAL was performed for published studies from 2015‐2023 to update a previous systematic review. Randomized controlled trials (RCTs) and non‐randomized studies (NRS) were evaluated. Risk of bias was assessed using the Cochrane risk of bias tools for RCTs, NRS were assessed using the ROBINS‐I‐tool. Quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Data was integrated in existing meta‐analysis of the available literature.ResultsAfter screening 1530 records, 2 RCTs and 5 NRS with new and relevant data were additionally identified. Meta‐analysis showed no statistically significant difference between doxycycline and beta‐lactam antibiotics regarding residual neurological symptoms after 12 months. Meta‐analysis showed no benefit of extended antibiotic treatment of LNB. Three NRS show no benefit for additional steroid use in LNB with facial palsy.DiscussionAdditional incorporated recent research corroborates existing guideline recommendations for treatment of LNB. New RCTs add to the certainty of previous analysis showing similar efficacy for doxycycline and beta‐lactam antibiotics in LNB. Available evidence shows no benefit for extended antibiotic treatment in LNB. NRS do not suggest a role for steroids in facial palsy due to LNB.

Why Is the Duration of Erythema Migrans at Diagnosis Longer in Patients with Lyme Neuroborreliosis Than in Those without Neurologic Involvement?

“…Only approximately one-quarter of study subjects had completed the appropriate 10–14-day course of antibiotic treatment for EM before the diagnosis of LNB and could therefore be interpreted to represent treatment failure. However, almost 80% of the patients who had received antibiotic treatment already had symptoms suggestive of the presence of LNB at the time of initiating the antibiotic treatment, and none of them had received doxycycline in an adequate dose for 14 days, as recommended for the treatment of early LNB in Europe [ 29 ]. The large majority of untreated patients appreciated the presence of skin redness but did not realize that their skin redness was EM and/or were not aware that it should be treated promptly to prevent the progression of infection or simply ignored the risk, while a few (<5%) were misdiagnosed by their personal physicians.…”