ALGORITHM FOR PROPHYLAXIS OF LYME DISEASE IN PEDIATRIC PATIENTS

a. Lyme disease is known to be

The prevalence in Ottawa of Borrelia burgdorferi (bacteria causing transmitted by Ixodes scapularis
Lyme Disease) in local Ixodes scapularis (blacklegged tick) is now high ticks (blacklegged tick/deer tick)
enough that Ottawa Public Health is recommending post-exposure
prophylaxis in certain cases.
Known tick bite that carry the Lyme bacteria
(Borrelia burgdorferi).
Other areas currently deemed High Risk areas include the
Transmission is during the
following:
1) Eastern Ontario Health Unit (includes counties of Stormont, Dundas, nymphal or adult stages. Dog and
Glengarry, Prescott, Russell, and the city of Cornwall), 2) Kingston, Frontenac, Is the tick identified as groundhog ticks do NOT carry and
Lennox and Addington (includes Kingston, Napanee, Cloyne, and Sharbot Lake), transmit Lyme disease.
3) Lanark, Leeds and Grenville Health Unit (includes Gananoque, Perth, Smiths an Ixodes scapularis? a
Falls, Carleton Place, and Brockville), 4) Hastings-Prince Edward Health Unit
(includes the County of Prince Edward, Hastings County, Quinte West and Ticks can be submitted through
Belleville) Ottawa Public Health for tick
See Ref 4& 8. YES/POSSIBLE NO speciation. Call 311 or (613) 580-
6744 ext 26301 or email
healthsante@ottawa.ca to make
an appointment to have the
Tick was engorged Tick was not No prophylaxis. patient submit the tick.
Testing ticks for B. burgdorferi is only for
(attached > 24 hours) engorged (attached Monitor x 30 days d surveillance purposes and not for clinical
management (due to long turn-around time
(See Figure 1 & 2) < 24 hours) and possible false negative results).

(See Figure 1 & 2)

d. Signs of Early Lyme disease:
Generally presents within 7-14 days of bite, up to 30 days. 70-80% of
Time from tick removal? No Prophylaxis patients present with a classic Erythema Migrans (EM) rash which consists
d
Monitor x 30 days of a single erythematous, expanding, > 5 cm rash +/- central clearing at the
site of the tick bite. This may be associated with symptoms such as
arthralgia, headaches, fatigue and fever. If a person develops evidence of
early Lyme disease, they should consult a physician and receive appropriate
< 72 hours > 72 hours or No need for serology antimicrobial treatment (not prophylaxis).

unknown in the context of

prophylaxis
Prophylaxis Prophylaxis not
Recommended recommended
d
Monitor x 30 days

Prophylaxis for Lyme Disease:

> 8 years: Doxycycline 200 mg PO once
(<50 kg, 4 mg/kg to a maximum of 200 mg once)
< 8 yo: Not usually recommended. Monitor for
Figure 1. Female blacklegged tick in various
early Lyme disease. May contact ID for guidance. Figure 2. Fully engorged, partially fed and unfed
stages of feeding, noting change in size and color
nymphs of blacklegged tick.
Last revised June 2017 CHEO, Division of Infectious Diseases
 APPROACH TO THE PEDIATRIC PATIENT WITH SUSPECTED EARLY LYME DISEASE
b. Areas currently deemed Suspected
High Risk: e. Possible Early Disseminated Lyme
City of Ottawa, Renfrew Early Lyme Disease Disease
District Health Unit (includes
the County of Renfrew, the
Known or suspected tick bite Skin: Multiple EM lesions
Neuro: facial palsy, meningitis,
City of Pembroke, the meningoradiculoneuritis
Township of South Algonquin Cardiac: AV block, myopericarditis
and most of Algonquin Joints: arthritis
Provincial Park), Eastern Time from tick detachment Possible Late Lyme Disease
Ontario Health Unit (includes (Tick attached for > 24 hours) Joint: Chronic, intermittent arthritis
counties of Stormont, Dundas, Neuro: peripheral neuropathy,
Glengarry, Prescott, Russell, encephalomyelitis
and the city of Cornwall), Can occur months/years after known or
Kingston, Frontenac, Lennox potential exposure
and Addington (includes
Kingston, Napanee, Cloyne, < 3 days > 3 30 days
and Sharbot Lake), Lanark,
Leeds and Grenville Health
Unit (includes Gananoque, f. Lyme serology is done by
Perth, Smiths Falls, Carleton two- tier testing as
Place, and Brockville), Rash < 5 cm at site No rash Flu-like symptoms, recommended by the
Classic EM rash: Single erythematous
Hastings-Prince Edward Health of tick bite expanding rash +/- central clearing > 5 cm at headache, fatigue Canadian Public Health
Unit ( includes the County of Laboratory Netwok: 1st
Systemically well and site of tick bite, +/- flu-like symptoms. If
Prince Edward, Hastings step: ELISA to detect total
improving multiple lesions or other symptoms of Lyme antibodies against B.
County, Quinte West, and e
Belleville) Disease - ID consult is recommended. burgdorferi. If
reactive/indeterminate,
Western Blot is performed
to further test for IgM and
IgG specific antibodies and
Most likely tick saliva Start empiric Consider confirm result.
hypersensitivity therapy empiric therapy ** If tick bite acquired in
reaction Europe please specify on
NO TREATMENT REQUIRED requisition to test for
European Lyme.

Serologic testing is often

No serology Send serology now negative in the first 2-4
weeks after infection,
Age
Antibiotic Dosage Max dose Duration
required and in 6 weeksf therefore not useful in the
(years) diagnosis of Early Lyme
Disease.
4 mg/kg/day PO div BID
Doxycycline 100 mg po BID 14 days
>8 (max 200 mg) False positive results may
Amoxicillin 50 mg/kg/day PO div TID 500 mg PO TID 14 days occur with autoimmune
disorders, inflammatory
<8 Amoxicillin 50 mg/kg/day PO div TID 500 mg PO TID 14 days conditions, or infections

< 8 and
Cefuroxime
Notify Public Health (syphilis, CMV, EBV, HBV,
HCV and Parvovirus). (Ref
pen- 30 mg/kg/day div BID 500 mg PO BID 14 days
allergic axetil* 613-580-6744 ext 24224 10).

*If contraindicated consult ID

Last revised: June 2017, CHEO, Division of Infectious Diseases
See Reference 8
 Quick Clinical Pearls

Single Erythema Migrans lesion Bulls eye at the site
of a tick bite. (see Ref 9 for more pictures).
The vector and bacteria of Lyme Disease is present in Ottawa. Over the years, the
prevalence of B. burgdorferi in blacklegged ticks has increased and currently at a level that
warrants post-exposure prophylaxis.
Black-legged ticks are present in Ottawa and transmission of Lyme disease from infected
ticks is known to occur here.
The overall risk of acquiring Lyme disease following an I scapularis tick bite in a high-risk
area is approximately 2.2 %.
If prophylaxis is given, the overall risk of progression to Lyme Disease is 0.2 % (data based
on systematic review and meta-analysis of antibiotic prophylaxis) (Ref 2)
Transmission < 24 hours of tick attachment is highly unlikely. Based on animal models,
there is almost invariably a delay of at least 36 hours between the time of tick attachment
and transmission of B. burgdorferi.
Prevention is key: Avoid ticks, wear appropriate protective clothing, use insect/tick
repellent (DEET), check body daily for ticks, remove attached tick promptly (within 24
hours).
Treatment of early Lyme disease with appropriate antimicrobials is easy and effective (>
95%).
Lyme disease is not transmitted by dog (Dermacentor variabilis) or groundhog ticks
(Ixodes cookei).

References and Resources:

1. Wormser GP et al. The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of
America. Clin Inf Dis. 2006; 43:1089-134.
2. Warschafsky S et al. Efficacy of antibiotic prophylaxis for the prevention of Lyme Disease: an updated systematic review and meta-analysis. J Antimicrob Chemother. 2010; 65: 1137-1144.
3. Onyett, H et al. Lyme disease in Canada: Focus on Children; Paediatr Child Health 2014;19(7):379-83.
4. Lyme disease and other tick-borne diseases: Surveillance of Lyme Disease: http://www.phac-aspc.gc.ca/id-mi/tickinfo-eng.php (Accessed June 1st 2017)
5. Lyme disease Ottawa Public Health: http://ottawa.ca/en/residents/public-health/disease-and-medical-conditions/lyme-disease (Accessed June 1st 2017)
6. Guidelines for removal and submission of ticks for identification and possible screening for disease-causing agents: http://www.phac-aspc.gc.ca/id-mi/guide-dir-ti-eng.ph
7. Technical report: Update on Lyme disease prevention and control: June 2016. Prepared by Public Health Ontario:
http://www.publichealthontario.ca/en/eRepository/Technical_report_update_on_Lyme_disease_prevention_and_control.pdf (Accessed June 1st 2017)
8. Public Health Ontario Lyme Disease Risk Area Map: http://www.publichealthontario.ca/en/eRepository/Lyme_disease_risk_areas_map.pdf (Accessed June 1st 2017)
9. Information for health professionals on Lyme disease: http://healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/lyme/professionals-professionnels/index-eng.php (Accessed
March 23rd 2017).
10. Lyme Disease Serology: http://www.publichealthontario.ca/en/ServicesAndTools/LaboratoryServices/Pages/Lyme_Disease_Serology.aspx (Accessed June 1st 2017)

Last revised: June 2017, CHEO, Division of Infectious Diseases