I wish to thank Stricker and colleagues for defining the ideology of the International Lyme and Associated Disease Society (ILADS). This ideology is testimonial-based, not evidence-based. Let me address some of their points.
- Stricker and colleagues imply (Table 1 of the Stricker article) that “community” physicians follow the recommendations of ILADS versus “academic” physicians do not. This is incorrect. Very few physicians follow the ILADS teachings. The ILADS recommends >4 weeks of therapy for erythema migrans (EM). In a study of 267 randomly selected Connecticut primary care physicians,1 1 of the 267 (0.3%) physicians routinely treated EM for >4 weeks. The ILADS network appears to be a very small group of physicians, and most “community” physicians do not follow their recommendations.
- Stricker and colleagues state that Borrelia burgdorferi, the bacterial agent of Lyme disease, can be transmitted within hours of a tick bite, but they present no data showing that this is the case. In an animal study, Piesman2 demonstrated that B. burgdorferi is not passed from tick to skin until >24 hours after attachment. In human cases of Lyme disease, it has been shown that the tick must be engorged (which takes >24 hours of feeding) to cause Lyme disease.3,4 Thus a tick check with removal of ticks within 24 hours of attachment is a reasonable strategy to prevent Lyme disease.5
- Stricker and colleagues state that the incidence of EM is overstated and that EM is absent in the majority of Lyme disease patients. They present no convincing data that EM is unusual. In a prospective Lyme disease vaccine trial,6 10,936 subjects were followed prospectively for almost 2 years. During this study, 147 of the 10,936 subjects developed Lyme disease and 132 of 147 (90%) of these subjects had EM. In a prospective study of Lyme disease in 5 pediatric practices,7 201 children developed Lyme disease and 179 of 201 (89%) subjects had EM. Thus EM is the presenting sign of Lyme disease in the great majority of patients.
- Stricker and colleagues state that the risk of acquiring Lyme disease from a tick bite may be quite high, but they give no data. Four prospective studies of prophylaxing deer tick bites8–11 reported the development of Lyme disease in 1.1–3.4% of patients receiving placebo. The largest of these studies was done by Nadelman et al.11 They compared a single dose of doxycycline (200 mg) to placebo for patients with a tick bite (1 of 235 subjects given doxycycline versus 8 of 247 subjects given placebo developed Lyme disease). They concluded that doxycycline prevented Lyme disease (P < 0.04).11 Stricker and colleagues stated that the Nadelman study “was flawed and inconclusive” but provide no reasons.
- Stricker and colleagues state that the standard treatment of EM for 14–21 days results in a 50% treatment failure rate. In actuality, a prospective pediatric study reported that the treatment of EM for a median of 21 days in 189 children resulted in no treatment failures.7 A prospective study12 of 115 adults with EM reported resolution of EM and fever in all patients after a median of 25 days of antibiotics. Three of the 115 (3%) subjects had persistent fatigue, headache or arthralgias for >60 days after treatment. The cause of the persistent symptoms in these 3 patients was unknown. In an elegant follow-up study of Lyme disease patients and control patients without Lyme disease, Seltzer et al13 reported persistent symptoms like fatigue, headache, arthalgias occurred equally among patients and age-matched controls.
- Stricker and colleagues state that chronic congenital B. burgdorferi infection can occur. However, a careful search for chronic congenital Lyme disease cases failed to document a single case.14
Stricker and colleagues challenge the Lyme disease recommendations of the Centers for Disease Control and Prevention, the American Academy of Pediatrics, the American College of Rheumatology, the American College of Physicians and the Infectious Disease Society of America. We termed information from these organizations as “accurate” in our paper.15 Stricker and colleagues referred to this information as “deceitful and invalid,” but they provide no evidence-based data in their attack. Instead Stricker and ILADS rely on testimonial-based experiences.16 Following the recommendations of Stricker and the ILADS of using prolonged antibiotic therapy for presumed Lyme disease has been shown to be harmful17 and even fatal.18
I stand by the conclusion of our paper15; that is, some internet sites provide accurate information and others provide inaccurate information about Lyme disease.
Henry M. Feder Jr., MD
Departments of Pediatrics and of Family MedicineUniversity of Connecticut Health CenterFarmington, CT
1. Murray T, Feder HM Jr. Management of tick bites and early Lyme disease: a survey of Connecticut physician. Pediatrrics
2. Piesman J. Dynamics of Borrelia burgdorferi
transmission by Ixodes dammini
ticks. J Infect Dis
3. Sood SK, Salzman MB, Johnson BJ, et al. Duration of tick attachment as a predictor of risk of Lyme disease in an area in which Lyme disease is endemic. J Infect Dis
4. Nadelamn RB, Nowakowski J, Fish D, et al. Prophylaxis with single dose doxycycline for the prevention of Lyme disease after an Ixodes scapularis
tick bite. N Engl J Med
5. Hayes EB, Piesman J. How can we prevent Lyme disease? N Engl J Med
6. Steere AC, Sikand VK, Meurice F, et al. Vaccination against Lyme disease with recombinant Borrelia burgdorferi
outer-surface lipoprotein A with adjuvant. N Engl J Med
7. Gerber MA, Shapiro ED, Burke GS, Parcells VJ, Bell GL, Lyme Disease Study Group. Lyme disease in children in southern Connecticut. N Engl J Med
8. Costello CM, Steere AC, Pinkerton RE, Feder HM Jr. A prospective study of tick bites in an endemic are for Lyme disease. J Infect Dis
9. Shapiro ED, Gerber MA, Holabird NB, et al. A controlled trial of antimicrobial prophylaxis for Lyme disease after deer tick bites. N Engl J Med
10. Agre F, Schwartz R. The value of early treatment of deer tick bites for the prevention of Lyme disease. Am J Dis Child
11. Nadelman RB, Nowakowski J, Forseter G, et al. The clinical spectrum of early Lyme borreliosis in patients with cultures-confirmed erythema migrans. Am J Med
12. Smith RP, Schoem RT, Rahn DW, et al. Clinical characteristics and treatment outcome of early Lyme disease of patients with microbiological confirmed erythema migrans. Ann Intern Med
13. Seltzer EG, Gerber MA, Cartter ML, Freudigman K, Shapiro ED. Long term outcomes of persons with Lyme disease. JAMA
14. Gerber MA, Zalneraitis EL. Childhood neurologic disorders and Lyme disease during pregnancy. Pediatr Neurol
15. Cooper JD, Feder HM Jr. Inaccurate information about Lyme disease on the Internet. Pediatr Infe Dis J
16. Feder HM Jr. Differences are vocal by two Lyme camps at a Connecticut public hearing on insurance coverage of Lyme disease. Pediatrics
17. Klempner MS, Hu LT, Evans J, et al. Two controlled trials of antibiotic treatment in patients with persistent symptoms and a history of Lyme disease. N Engl J Med
18. Patel R, Grogg KL, Edwards WD, Wright AJ, Schwenk NM. Death from inappropriate therapy for Lyme disease. Clin Infect Dis