Guideline Comparison
United States — IDSA (2020)
Short-course, single-agentRegimen: Doxycycline 100 mg BID × 10–14 days for early Lyme; ceftriaxone 2 g IV daily × 14–28 days for neuroborreliosis.
Does not recognise chronic Lyme; retreatment discouraged.
PubMed reference (PMID 33417672)United States — ILADS (2014)
Long-course, combination, individualisedRegimen: Doxycycline 200 mg BID + cefuroxime/azithromycin, 4–6 weeks minimum; extended if symptoms persist.
Allows clinical diagnosis; supports retreatment for persistent symptoms.
PubMed reference (PMID 25077519)Germany — DBG / Deutsche Borreliose-Gesellschaft
Pulsed, combinationRegimen: Doxycycline + hydroxychloroquine; minocycline + tinidazole for cyst-form coverage; rotated 3–6 months.
Cyst-form/persister coverage central. Often combined with herbals.
PubMed reference (PMID 32354067)United Kingdom — NICE NG95 (2018)
Single-agent, defined coursesRegimen: Doxycycline 100 mg BID × 21 days first line; amoxicillin or azithromycin as alternatives. IV ceftriaxone for CNS disease.
Updated to recognise post-treatment Lyme symptoms but limits retreatment.
PubMed reference (PMID 29632062)Switzerland
Conservative, mainstreamRegimen: Doxycycline 200 mg/day × 14–21 days; ceftriaxone IV for late neuroborreliosis.
Aligned with EFNS guidelines.
PubMed reference (PMID 20132514)Poland & Eastern Europe
Aggressive, combination, longer-courseRegimen: Doxycycline + amoxicillin or ceftriaxone, often 6+ weeks; metronidazole pulses for persisters.
Influence from Burrascano and ILADS schools; Lyme-Borreliosis Society guidelines.
PubMed reference (PMID 23097222)Coinfection Regimens
| Pathogen | Standard course | Extended / chronic | PubMed |
|---|---|---|---|
| Babesia | Atovaquone 750 mg BID + azithromycin 500 mg daily × 7–10 days (mild); clindamycin + quinine for severe. | Atovaquone + azithromycin × 4–6 weeks; add proguanil or methylene blue in refractory cases. | PMID 32651583 |
| Bartonella | Doxycycline + rifampin; or azithromycin + rifampin; 4–6 weeks. | Triple therapy with methylene blue or clarithromycin; 3–6 months. | PMID 32760465 |
| Ehrlichia / Anaplasma | Doxycycline 100 mg BID × 10–14 days. First-line in pregnancy as well (CDC, 2016). | Rifampin if doxycycline-intolerant. | PMID 27172113 |
| Mycoplasma | Doxycycline or azithromycin × 3–6 weeks. | Combination with moxifloxacin or minocycline for chronic cases. | PMID 29438949 |
| Rickettsia (RMSF, typhus group) | Doxycycline 100 mg BID × 7 days minimum (or until afebrile + 3 days). | Chloramphenicol as alternative in true doxycycline allergy. | PMID 27172113 |
Do antibiotics actually work?
The honest answer from the literature is: often, but not always, and rarely on the first try in late disease. The four pivotal NIH-funded retreatment trials (Klempner 2001, Krupp 2003, Fallon 2008, Berende 2016) showed only modest, mixed benefits from a further 10–12 weeks of antibiotics. Yet later work — Sapi 2011 (PMID 21993564), Feng 2014 (PMID 25337473), and the daptomycin/doxycycline/cefuroxime combination by Feng & Zhang 2020 (PMID 32175334) — demonstrates that persister Borrelia survive standard monotherapy and require combination, pulsed regimens.