DÄ internationalArchive31-32/2009Lyme Disease—Current State of Knowledge: In reply

Correspondence

Lyme Disease—Current State of Knowledge: In reply

Dtsch Arztebl Int 2009; 106(31-32): 525. DOI: 10.3238/arztebl.2009.0525

Nau, R; Christen, H; Eiffert, H

LNSLNS We welcome the interest expressed in our review article. Repellents, as discussed by Temmesfeld, are effective to only a limited degree. In most cases, the protective effect of repellents against ticks is clearly shorter than that against mosquitoes, so that the available substances have to be re-applied at relatively short intervals. It is of particular importance that bends of joints, interdigital spaces, gluteal folds, and the retroauricular region should be inspected thoroughly after any stay in an area populated by ticks.

As shown by Hunfeld's working group and mentioned by Shah, both in Frankfurt, persistence of culturable Borrelia species in the human organism may occur even after adequate antibiotic therapy for Lyme borreliosis (1). However, after guideline conform treatment this is a rare event, and it is unclear to what proportion the host organism will succeed in completely eliminating the Borrelia species—weakened by the preceding antibiotic treatment—on its own account without repeated treatment with antibiotics. With respect to reinfection by means of a repeated tick bite, we would not withhold a second course of antibiotic treatment, preferably on the basis of available sensitivity tests (2, 3) with ceftriaxone i.v. from any patient with clear clinical disease activity (for example, progressive neurological symptoms plus >6 months of persistent pleocytosis in the cerebrospinal fluid or persistent swollen joints plus positive borrelia polymerase chain reaction in fluid aspirated during puncture of a joint).

We are not in favor of the dosage increase of ceftriaxone to 4 g/d i.v., because after 3 weeks' treatment with this dose the risk of precipitation of calcium-ceftriaxone salt in the gallbladder is high. The minimal inhibitory concentrations of different strains of Borrelia burgdorferi for ceftriaxone are 0.03 to0.06 g/l (2, 3). Even after a single dose of ceftriaxone, ventricular CSF in patients without meningeal inflammation reached maximum concentrations of 0.18 to1.04 mg/l (median 0.43 mg/l) (4). This means that they are one order of magnitude above the minimum inhibitory concentration. The elimination half life of ceftriaxone from CSF is about 17 hours (4), so that effective concentrations of ceftriaxone can be expected for the entire duration of treatment.

We think that the differentiation proposed by Haufs—of the variable European disease spectrum caused by different subspecies of B burgdorferi sensu lato versus the more uniform disease picture of the North American Lyme borreliosis (caused by B burgdorferi sensu stricto)—makes sense and is desirable. However, we are not in a position, nor do we wish to, decide here whether the term "non-Lyme" borreliosis is suitable for this or whether the disease should be termed "Eurasian" borreliosis.
DOI: 10.3238/arztebl.2009.0525


Prof. Dr. med. Roland Nau
Prof. Dr. med. Hans-Jürgen Christen
Prof. Dr. med. Dr. rer. nat. Helmut Eiffert
Geriatrisches Zentrum
Evangelisches Krankenhaus Göttingen-Weende
Abteilung Neurologie und Medizinische Mirkobiologie
Universität Göttingen
Kinderkrankenhaus auf der Bult, Hannover
An der Lutter 24
37075 Göttingen, Germany
rnau@gwdg.de

Conflict of interest statement
The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.
1.
Hunfeld KP, Ruzic-Sabljic E, Norris DE, Kraiczy P, Strle F: In vitro susceptibility testing of Borrelia burgdorferi sensu lato isolates cultured from patients with erythema migrans before and after antimicrobial chemotherapy. Antimicrob Agents Chemother 2005; 49: 1294–301.
2.
Dever LL, Jorgensen JH, Barbour AG: In vitro antimicrobial susceptibility testing of Borrelia burgdorferi: a microdilution MIC method and time-kill studies. J Clin Microbiol 1992; 30: 2692–7.
3.
Mursic VP, Wilske B, Schierz G, Holmburger M, Süß E: In vitro and in vivo susceptibility of Borrelia burgdorferi. Eur J Clin Microbiol 1987; 6: 424–6.
4.
Nau R, Prange HW, Muth P et al.: Passage of cefotaxime and ceftriaxone into cerebrospinal fluid of patients with uninflamed meninges. Antimicrob Agents Chemother 1993; 37: 1518–24.
5.
Nau R, Christen H, Eiffert H: Lyme disease—current state of knowledge [Lyme-Borreliose – aktueller Kenntnisstand]. Dtsch Arztebl Int 2009; 106: 72–81.
1. Hunfeld KP, Ruzic-Sabljic E, Norris DE, Kraiczy P, Strle F: In vitro susceptibility testing of Borrelia burgdorferi sensu lato isolates cultured from patients with erythema migrans before and after antimicrobial chemotherapy. Antimicrob Agents Chemother 2005; 49: 1294–301.
2. Dever LL, Jorgensen JH, Barbour AG: In vitro antimicrobial susceptibility testing of Borrelia burgdorferi: a microdilution MIC method and time-kill studies. J Clin Microbiol 1992; 30: 2692–7.
3. Mursic VP, Wilske B, Schierz G, Holmburger M, Süß E: In vitro and in vivo susceptibility of Borrelia burgdorferi. Eur J Clin Microbiol 1987; 6: 424–6.
4. Nau R, Prange HW, Muth P et al.: Passage of cefotaxime and ceftriaxone into cerebrospinal fluid of patients with uninflamed meninges. Antimicrob Agents Chemother 1993; 37: 1518–24.
5. Nau R, Christen H, Eiffert H: Lyme disease—current state of knowledge [Lyme-Borreliose – aktueller Kenntnisstand]. Dtsch Arztebl Int 2009; 106: 72–81.