There is a place for antibiotic use in chronic Lyme disease, and certainly there are people who get well with use of synthetic antibiotics alone, but if most people, or even a large portion of people with chronic Lyme got well using antibiotics, there wouldn’t be hordes of people searching for other solutions. Many people either don’t tolerate antibiotic therapy or don’t get well with antibiotics.
The best use of antibiotics in Lyme occurs when something truly heroic is indicated — early-stage Lyme disease, chronic Lyme disease with severe involvement of heart or brain, when there is suspicion of a highly virulent microbe such as Rickettsia, or when nothing else works. The usefulness of antibiotics is limited by their inherent toxicity. Often, antibiotics must be discontinued because toxicity builds up, sometimes even within a few weeks.
Whenever you decide to use synthetic antibiotics, you enter a race — can you kill off all the pathogens before the toxic effects of the antibiotics catch up with you? You’re much more likely to win the race against a highly virulent pathogen, which typically responds well to synthetic antibiotics, than you are with stealth pathogens, which typically respond very slowly to synthetic antibiotics.
Selective killing is the reason why synthetic antibiotics have any use for treating any bacterial infection. Antibiotics kill pathogens and, with short-term use, are less destructive to the trillions of normal flora in your body. With continued or chronic use, however, the harm inflicted on normal flora also adds up.
One of the keys to selective killing is bacterial growth rate. The microbes that make up your normal flora reproduce very slowly and maintain stable concentrations in the body. Synthetic antibiotics rely on the rapid growth rate of pathogens for killing. Aggressive pathogens, such as those that cause pneumonia, divide very rapidly and concentrate at specific sites in the body (in the case of pneumonia, congestion of lobes of lungs). This type of infection is very susceptible to synthetic antibiotic therapy.
The survival strategy used by stealth microbes makes them very resistant to antibiotic therapy. Like normal flora, stealth microbes such as Borrelia grow very slowly. Streptococcus pneumoniae, a common pneumonia-causing pathogen turns over a generation every 20 minutes. In contrast, it takes Borrelia 12 hours to turn over a generation — they win by persistence, not aggression. This factor alone makes a stealth microbe such as Borrelia much less susceptible to antibiotic therapy.
Stealth microbes do not concentrate at specific sites. They disperse throughout tissues in the body and occur at very low concentrations. They have an uncanny ability to penetrate the most isolated recesses of the body where they are protected from immune functions and antibiotics. Stealth microbes can live inside cells where they are protected from many types of antibiotics. They also have the ability to exist inside biofilms, though this is likely only a minor survival strategy for stealth microbes (See Chapter 22, Understanding Biofilm).
Borrelia (and others) have the ability to wrap themselves into protective cysts when a hostile environment is encountered. When antibiotics are administered, Borrelia microbes rapidly encyst and become dormant (note that a healthy immune system is well equipped to mop up cysts). The harder you hit them with antibiotics, the more they encyst until all Borrelia microbes in the body are present in antibiotic-resistant cyst forms. When the antibiotics are discontinued, they return to normal form and go about life.
In general, the less virulent a microbe is, the worse its response to synthetic antibiotics. In other words, Rickettsia will respond to doxycycline much better than Borrelia. Of all the stealth microbes, Mycoplasma is probably the most resistant to synthetic antibiotics.
To kill off stealth microbes with synthetic antibiotics, antibiotics must be used in high concentrations (sometimes several antibiotics at a time) for very long periods of time (months). This makes winning the race problematic on multiple levels.
Normal flora microbes are less susceptible to antibiotics, but prolonged use of high concentrations of antibiotics does have an adverse effect. Disruption of normal flora allows for emergence of pathogens. There are always potential pathogens present in the mix of microbes in the body, but they are suppressed by normal flora. When normal flora microbes are inhibited by antibiotics, pathogens are able to flourish. Overgrowth of pathogens, such as Clostridium difficile (C. diff) in the gut, has become commonplace with overuse of antibiotics.
It’s only a matter of time before a pathogen develops antibiotic resistance. When an antibiotic is used against a pathogen, most of the bacteria are killed, but a few of the microbes develop resistance to the antibiotic and survive. With each new generation, antibiotic-resistant survivors accumulate until all of them are resistant to the antibiotic.[29] If healthy immune function is not present to mop up the resistant survivors as they develop, the antibiotic becomes useless.
Chronic immune dysfunction allows antibiotic-resistant survivors to flourish and displace normal flora. This disrupts immune function even further. With time, a vicious cycle develops that is hard to overcome.
Excessive use of antibiotics in both human and animal populations (antibiotics are heavily used in the livestock industry) creates resistance and enhances virulence in nonpathogenic bacteria. Antibiotic-resistant strains of bacteria that were once every day normal flora have now become quite aggressive. Methicillin-resistant Staphylococcus aureus (MRSA) on the skin, and pathogenic strains of E. coli and other microbes in the gut, have become a worldwide health hazard. These new pathogens are much more destructive than stealth microbes.
Long-term antibiotic use breaks down beneficial biofilms in the large bowel. Friendly microbes create biofilm in the mucous lining of the distal small intestine and the large colon. This type of biofilm is protective and essential for a healthy colon. Long-term use of antibiotics can disrupt this very important protective barrier. Studies show that loss of bifidobacteria in this layer with replacement with pathogenic bacteria is associated with gut illnesses such as ulcerative colitis and colon cancer (Macfarlane 2005, 2007, 2011).
If all that wasn’t enough, synthetic antibiotics have been found to destroy mitochondria in normal cells (Morgun 2015, Kalghatgis 2013). There is evidence that mitochondria, the powerhouses within every cell in the body, were once primitive bacteria. A billion years ago, when higher life was evolving, primitive bacteria with high-energy capacity were hijacked by cells of higher living creatures to produce energy. Eventually, they became part of cells of all higher life forms, but they still retain bacteria-like characteristics.
Having bacteria-like characteristics makes mitochondria susceptible to damage by many types of antibiotics. This may be why many people experience fatigue with antibiotic use. Antibiotics are especially damaging to cells lining the intestines.
In summary, usefulness of prolonged antibiotics for chronic stealth microbe infections is limited because:
People suffering from chronic Lyme disease do report getting well with long-term antibiotic therapy, but it may be the exception rather than the rule.
Current Recommendations for Antibiotics in Lyme Disease
There is a place for use of antibiotics for treatment of Lyme disease, but when and how to administer antibiotics, however, remains controversial.
Current recommendations for the treatment of Lyme disease, per the Centers for Disease Control and Prevention (CDC) are defined in a scientific article published in the journal, Clinical Infectious Diseases, in 2006. The article has not been updated in the intervening years and is criticized by many experts who treat Lyme disease.
The current recommendations for treatment of “adult patients with early localized or early disseminated Lyme disease associated with erythema migrans or positive serologic testing, in the absence of specific neurologic manifestations or advanced atrioventricular heart block” is “doxycycline (100 mg twice per day), amoxicillin (500 mg 3 times per day), or cefuroxime axetil (500 mg twice per day) for 14 days (range, 10–21 days for doxycycline and 14–21 days for amoxicillin or cefuroxime axetil)”. However, many doctors prescribe 30 days of treatment.
Routine use of antimicrobial prophylaxis or serologic testing is not recommended by the CDC for prevention of Lyme disease after a recognized tick bite. “A single dose of doxycycline may be offered to adult patients (200-mg dose) when the tick can be identified as an adult or nymphal I. scapularis tick that is estimated to have been attached for >36 hours.” Antibiotics must be administered within 72 hours of attachment.
The article goes on to recommend ceftriaxone, 2 g once per day intravenously for 14 days (range, 10–28 days) for acute neurological symptoms and similar treatment for acute cardiac manifestations of Lyme disease. This brief treatment is considered curative by the CDC.
For symptomatic late-stage Lyme disease, the article recommends 14 days of oral or intravenous antibiotics (depending on the type of symptoms) and suggests that this is also curative.
The article does not recognize “chronic Lyme disease”, but does recognize “Post Treatment Lyme Disease Syndrome (PTLDS)”. The authors strongly suggest, however, that the symptoms are not related to persistent Borrelia bacteria in the body: “The notion that symptomatic, chronic B. burgdorferi infection can exist despite recommended treatment courses of antibiotics in the absence of objective clinical signs of disease, is highly implausible as evidenced by the lack of antibiotic resistance in this genus.” They go on to imply an emotional link: “Delayed convalescence can be related to the emotional state of the patient before onset of the illness.”
Studies cited in the article strongly supported use of antibiotics in early-stage Lyme disease, but not use of prolonged antibiotic therapy in late-stage or post-treatment Lyme disease.
Many doctors in the Lyme community disagree very strongly with this seemingly outdated and narrow-minded summation of Lyme disease treatment. For persistent Lyme disease symptoms, many doctors prescribe 6-9 months of either oral or intravenous antibiotics. To date, however, there are no studies supporting this practice either (Berende 2016).
In fact, one recently published study challenges everything accepted about Lyme disease by both the conventional medical community and the Lyme community (Rudenko 2015).
In the study, published in March 2016, researchers tested people from around the country who had atypical symptoms of Lyme disease (typical presentations are not the norm), had a negative Western blot for Lyme disease, and were treated for 6-9 months with antibiotics, but continued having symptoms.
In several of these people, using special techniques to culture and isolate the microbe (not practical for routine use), they were able to isolate two species of Borrelia from blood samples: Borrelia burgdorferi and Borrelia bissettii.
Negative Western blot, atypical Lyme symptoms, aggressive prolonged antibiotic therapy, persistent Lyme symptoms despite therapy, followed by positive culture for two species of Borrelia are direct evidence that Borrelia is very hard to diagnose and responds poorly to any level of antibiotic therapy, especially with chronic illness. (The study also provides hope and verification to all the patients who have had a negative Western blot, but still feel they have Lyme disease.)
In summary, scientific evidence does support use of antibiotic therapy in early-stage Lyme disease. This makes sense because bacteria are migrating through the bloodstream and have not disseminated deeply into tissues. It is unlikely that antibiotics alone eliminate all Borrelia microbes, but it may give the immune system the upper hand enough to gain control. It does not, however, completely eliminate the possibility of chronic infection.
In contrast, treating chronic Lyme disease for months on end continually with synthetic antibiotics is highly controversial. There is no good science to back it up, and the potential for toxicity is quite high.
Some physicians have started pulsing antibiotics for several weeks to a month on and several weeks to a month off to reduce potential toxicity, but there are no studies supporting this practice. It may be worth considering, however, especially in conjunction with herbal therapy in a person who is not making progress with herbal therapy alone. Short courses of antibiotics during relapses or setbacks may enhance recovery without accumulating the toxic effects of long-term antibiotic use.
Antibiotics for Other Tick-Borne Infections
Use of antibiotics for treatment of low-virulence stealth microbes, including Mycoplasma, Bartonella, and Chlamydia should be mostly reserved for acute infections. When infection by these microbes occurs by tick bite, however, the initial acute infection is often not recognized.
Synthetic antibiotics are most useful for acute infections with more virulent bacteria that grow rapidly. For tick-borne microbes, this mostly includes acute infections with Rickettsia, Ehrlichia, Anaplasma, and Babesia species.
The potential for acute severe illness with these microbes is high, especially with Rickettsia. For this reason, anyone presenting with a history of tick bite, high fever, and severe flu-like illness should receive 30 days of antibiotic therapy. Antibiotics should be started empirically without waiting for test results.
Rickettsia, Ehrlichia, and Anaplasma respond well to tetracyclines, such as doxycycline. The standard treatment protocol is doxycycline, 100 mg twice daily for 30 days or 3 days after symptoms subside completely. The course of antibiotics can be repeated if symptoms are persistent. Alternative antibiotics for acute infection are posted on the CDC website (www.cdc.gov).
Equally concerning is an acute infection with Babesia. Babesia is a protozoan, which does not respond to doxycycline. The current CDC Guidelines for Babesia recommend treatment for 7-10 days with two antibiotics: atovaquone 750 mg twice daily and azithromycin 500-1000 mg initially followed by 250-1000 mg daily or clindamycin 600 mg 3 times daily or 600 mg IV 4 times daily and quinine 650 mg 3 times daily.
Aggressive therapy for Babesia is especially indicated in someone who has had a splenectomy. Individuals who have had the spleen removed are especially at risk of severe life-threatening infection with Babesia.
Atovaquone is associated with high incidence of side effects; some people are very sensitive to it. The clindamycin/quinine combination is an older regimen also associated with a high incidence of side effects. Clindamycin should never be used orally because it can stimulate overgrowth of Clostridium difficile in the gut. Clostridium difficile (C. diff) is a notorious pathogen associated with severe bloody diarrhea.
As a less toxic alternative, some physicians are prescribing metronidazole 500 mg twice daily for 14 days (metronidazole should never be used for more than 2 weeks because of toxicity) or tinidazole 500 mg twice daily for 14 days (less toxic, but more expensive). This is not a standard protocol, however.
Chronic Babesia infection is characterized by relapsing high fever or positive test for Babesia. A relapse of Babesia should be treated just like an acute infection.
It should be noted that Babesia is actually harder to kill than malaria because it grows slowly and occurs in low concentrations in the body (a characteristic in common with lower virulence stealth microbes; Babesia is on the fence between low virulence and high virulence). Limiting duration of therapy to 7-10 days is associated with a high relapse rate of 40-50%. Longer therapy of 6-8 weeks, especially in immunocompromised individuals, is recommended by most experts who regularly treat Babesia. Longer treatments with any of the antimicrobials used for Babesia, however, are associated with high rates of side effects and toxicity. Natural therapies discussed later in the book provide a potentially safer long-term solution.
Symptoms associated with Babesia infection are related to clumping of blood cells and blockage of small blood vessels. This process impedes recovery. There is evidence that heparin, a commonly used anticoagulant administered by subcutaneous or IV injection, has value for treating severe Babesia. Heparin inhibits blood coagulation, reduces cerebral impacts (brain blood clots), and suppresses replication of organisms.
General Guidelines for Antibiotic Use in Lyme Disease