Posted in Flagyl on March 23, 2015

Posted by Mark Crislip on March 20, 2015 ( Comments)

The Lyme tick

The west. occidental black-legged tick, carrier of the Borrelia burgdorferi bacteria what one. causes Lyme disease.

The practice of polluting disease (ID) is both easy and unyielding. If you read my ID blog on Medscape you are aware of my trials and tribulations in diagnosing and treating infections.

ID is unconstrained since, at least in theory, diseases desire patterns and an infecting organism has a predictable epidemiology and life cycle. So if you can recognize the design and relate it to the life cycle and exposure history, you can frequently make a diagnosis before the cultures approach back.

My favorite story is the time I was asked to behold a young girl with endocarditis. The annals was she had a week of fevers, cephalalgy and myalgia that went away conducive to five days, returned for a week, went gone for five days and returned over and above again.

So I asked her “How was your holidays at Black Butte?”

The direct the eye of astonishment on her face in the same proportion that she asked how I knew she had been to Black Butte was in such a manner satisfying.

But the pattern was relapsing agitation and Black Butte is where the whole of the relapsing fever in Oregon is located. And unfailing enough, her smear had Borrelia. A run of antibiotics and the spirochete was dead and gone.

However, my son says the whole of I ever do is say “Get cultures and rouse vancomycin.” How hard is that?

ID is obdurate because in practice patients do not read the textbooks and do not through all ages. present with the correct signs and symptoms. If you bear an uncommon infection with an noteworthy presentation it can be difficult to diagnose. I achieve a fair number of these in council and syphilis has been the tricky single in kind the last few years. While in that place is the classic progression from first to secondary to latent to tertiary, patients ~times have peculiar manifestations that bypass the model production findings and are sometimes hesitant to mention risk factors.

Once you make the diagnosis of syphilis, you bestow a course of antibiotics and the spirochete is dead and gone.

Relapsing flush and syphilis are two spirochetal illnesses that be possible to be both straightforward and difficult. Both gain well-understood pathophysiology but that doesn’t average that they are easy to diagnose.

Lyme is furthermore a simple and complex diseases. Caused through the spirochete Borrelia burgdorferi (as least in the US; there are other Borrelia in Europe that action Lyme and worldwide there at in the smallest degree 36 Borrelia species) its epidemiology, pathophysiology, and management are well understood. Like all infections, it can be tricky and present atypically, unless the science is clear: there is nay chronic Lyme disease that is within the reach to long term antibiotics.

Let me cursory reference here, not that it will perform any difference, that I do not withhold the symptoms and suffering of patients with the “diagnosis” of chronic Lyme. They are ~times quite ill with something that is not, though, from Lyme.

Unfortunately, in public sermon science and reality do not necessarily triumph over pseudo-science. Last year, New York passed a advertisement to allow:

rogue doctors [to] exist able to shill their non-ground of belief-based treatments without worrying about agency.

the bill:

prohibits the state Office of Professional Medical Conduct from investigating a licensed physician based solely upon the recommendation or preparation of a treatment that is not uniformly accepted by the medical profession.

Those protections embrace, but are not limited to, treatments with respect to Lyme disease and other tick-borne illnesses.

A like bill is now before the Oregon Legislature, House Bill 916. A open hearing on the bill will subsist held on Monday, March 30th. I desire no doubt that similar bills order be appearing in legislatures throughout the US. They may have ~ing there now, unbeknownst to you. I solitary discovered the Oregon bill by serendipity.

The brush-cutter, sponsored by the Oregon Lyme Disease Network, says:

SECTION 1. (1) The Oregon Medical Board and the Oregon State Board of Nursing shall each adopt rules regarding the diagnosis and treatment of Lyme disease.

(2) The rules adopted subject to this section must:

(a) Permit professionals regulated ~ the agency of the boards to diagnose and use, in manners consistent with the standards of care guidelines developed ~ the agency of the International Lyme and Associated Diseases Society, Lyme disease and associated viral, bacterial and meanly submissive diseases;


(b) Establish disciplinary procedures that ponder as a mitigating factor whether, in diagnosing or treating Lyme disease or associated diseases, a professional who is facing punish followed evidence-based diagnosis and method of treating guidelines not recognized by the the stage.

There are two sets of Lyme Treatment Guidelines. One is from the Infectious Disease Society of America and is hind part before to undergo an update from the 2006 guidelines. The guidelines advise (note the not):

Selected antimicrobials, remedy regimens, or other modalities not recommended by reason of the treatment of Lyme disease.

Doses of antimicrobials in a great degree in excess of those provided in tables 2 and 3

Multiple, repeated courses of antimicrobials for the same episode of Lyme disease or a time of antimicrobial therapy prolonged far in immoderation of that shown in table 3

Combination antimicrobial therapy

Pulsed-dosing (i.e., antibiotic therapy steady some days but not on other days)

First-family cephalosporins, benzathine penicillin G, fluoroquinolones, carbapenems, vancomycin, metronidazole, tinidazole, trimethoprim-sulfamethoxazole, amantadine, ketolides, isoniazid, or fluconazole

Empirical antibabesiosis therapy in the preoccupation of documentation of active babesiosis

Anti-Bartonella therapies

Hyperbaric oxygen therapy

Fever therapy (through or without malaria induction)

Intravenous immunoglobulin



Intravenous hydrogen peroxide

Vitamins or nutritional managements

Magnesium or bismuth injections

I think, given the creativity of those who deal by chronic Lyme, that this list wish grow in the next version of the guidelines. These are the kinds of pseudo-therapies, and in that place are many more, that the the many the crowd with the pseudo-diagnosis of chronic Lyme undergo. All useless, all sumptuous, and, occasionally, fatal. Key in the IDSA guidelines is the avoidance of tedious term and repeat courses of intravenous antibiotics.

Long expression antibiotics are not benign. Besides allergic and other side effects, secondary infections of the intravenous catheters be possible to and has killed people.

A 30-year-antique woman died as a result of a immense Candida parapsilosis septic thrombus located ~ward the tip of a Groshong catheter. The catheter had been in area for 28 months for administration of a 27 month line of conduct of intravenous cefotaxime for an unsubstantiated diagnosis of of long duration Lyme disease.

I keep thinking the 27 months is a typo, on the contrary it is neither a typo nor atypical in the inveterate Lyme world. Twenty five years of defilement control has only served to emphasize that superfluous intravenous catheters can only cause damage and one of the keystones of non-flag chronic Lyme therapy is prolonged intravenous antibiotics.

The other Lyme treatment guideline is from ILADS, The International Lyme and Associated Disease Society. They be at variance from the IDSA, as noted ~ the agency of ILADS:

The ILADS panel recommendations differ from those of the IDSA. Different guideline panels reviewing the like evidence can develop disparate recommendations that cogitate the underlying values of the array members, which may result in conflicting guidelines. The IOM explains that conflicting guidelines ut~ often result ‘when evidence is unsound; developers differ in their approach to evidence reviews (systematic vs non-systematic), proof synthesis or interpretation and/or developers possess varying assumptions about intervention benefits and harms. Conflicting guidelines remain for over 25 conditions and there is no current system for reconciling conflicting guidelines.

It may have existence more than a simple difference of view. But I would note that each recommendation in the ILADS guidelines is based without ceasing:

very low-quality evidence.

There are multiple differences in the brace approaches to Lyme. First is the reliance (belief is what you have whenever you lack data), unsupported by the preponderance of the scientific medical literature, that Lyme persists notwithstanding adequate treatment.

The other major issues relate to treatment. ILADS supports prolonged intravenous therapy in quest of Lyme, re-treatment for patients through persisting symptoms after treatment and the application of adjunctive therapies including treatments of co-infections. All are not supported ~ dint of. Lyme literature.

ILADS suggests repeat menstrual discharge of intravenous antibiotics for patients who remain symptomatic; IDSA does not and the most wise studies to date supports the IDSA be at hand:

There is considerable impairment of soundness-related quality of life among patients through persistent symptoms despite previous antibiotic management for acute Lyme disease. However, in these brace trials, treatment with intravenous and oral antibiotics for 90 days did not improve symptoms greater quantity than placebo.

This is because antibiotics are potent in killing off Lyme:

There continues to exist no evidence that viable B. burgdorferi persevere in humans after conventional treatment by antimicrobials.

Most studies looking for livelihood B.burgdorferi after treatment have failed and those that behave have severe flaws. Antibiotics eradicate the organism and in animal models, where they can culture the entire mouse, 5 days of antibiotics is plenty to kill off all the Lyme:

Our tools and materials further document the effectiveness of antibiotic therapy in eradicating cultivable cells of B. burgdorferi, irrespective of tissue or organ site.

The organism does not hide finished, protected in some organs, as more believe. As the 2014 NEJM critique succinctly puts it:

Several carefully conducted, placebo-controlled, randomized trials of prolonged antimicrobial management in patients with persistent subjective symptoms from treatment for Lyme disease have shown a minimal behoof or none and a substantial put in peril of adverse effects. Consequently, prolonged antimicrobial handling for subjective symptoms is not recommended in patients whose belonging to signs of Lyme disease have resolved in rejoinder to conventional therapy. Consideration of other causes of persistent symptoms is warranted. In most of these patients, nonspecific symptoms resolve from one side of to the other time without additional antimicrobial treatment.

When it comes to adjunctive therapies, ILADS is ~ amount proscriptive than the IDSA:

ILADS agrees that before anything else-generation cephalosporins, intravenous hydrogen peroxide and bismuth injections are not recommended. However, ILADS has concluded that it is untimely to exclude other potentially beneficial therapies based in successi~ the evidence to date. Therefore, ILADS contends that the exercise of such agents should not have existence precluded until studies have demonstrated their ineffectiveness in the method of treating of Lyme disease.

A real contest in approach to treatment. Given the possible dangers in all medical interventions, therapies should exist precluded until studies have demonstrated their effectiveness in the management of Lyme disease.

Lyme diagnosis is in like manner mentioned in the Oregon bill, notwithstanding the ILADS guidelines do not art issues related to the diagnosis of Lyme. Lyme is classically diagnosed through a two-step procedure: a screening ELISA followed by a confirmatory Western Blot, although the ELISA because of antibodies against the C6 peptide may have existence helpful.

There are laboratories, in my actual observation evidently beloved by naturopaths, that conversion to an act unvalidated and unreliable non-standard tests, of that there are many. This is for the reason that:

in the mid–1970s, the FDA began exempting indubitable diagnostic tests from its approval projection. Many of these tests — developed, manufactured, and offered ~ dint of. a single lab, such as in a hospital — were variations ~ward common tests, low-risk, or devised towards rare diseases and could not have ~ing adequately validated.

And Lyme testing has proliferated through all the subsequent false positives in patients and resultant un-needed therapies. Patients ~times do not realize that when a lab is CLIA certified it means little as to the validity of the testing offered, rightful as a restaurant being certified being of the kind which sanitary says nothing about the gentry of the cooking.

The FDA recognizes this is a point to be solved with many kinds of tests:

The US Food and Drug Administration, responding to enlarging concerns that a host of diagnostic tests for illnesses from cancer to Lyme ailment may be inaccurately identifying conditions, announced Thursday that it intends to order many of the tests.

and in that place are new guidelines for these tests that may rise in less unreliable testing.

I heard a fabrication at a meeting that a visitors developed a Lyme test and everyone tested positive. Rather than recognize a flawed proof, they concluded everyone had Lyme. Probably dubious, but the mindset of the Lyme universe is often:

No Lyme test has ~t one false negatives, but it is influential to understand that there is ~t one such thing as a false indubitable.

Also popular in the nonstandard Lyme earth is treating co-infections. I formerly had a patient tell me she moreover had a Babesia infection as well for example Lyme, diagnosed at one of the creative Lyme labs ~ dint of. a naturopath. The accompanying photomicrograph had ~y arrow pointing to…a platelet cluster misidentified as Babesia. While there is casually more than one infection spread by a tick bite, it is not for the use of all:

Often, the controversial diagnosis of of long duration Lyme disease is given to patients through prolonged, medically unexplained physical symptoms. Many so patients also are treated for inveterate coinfections with Babesia, Anaplasma, or Bartonella in the non-attendance of typical presentations, objective clinical findings, or laboratory confirmation of active infection…The medicinal literature does not support the diagnosis of inveterate, atypical tick-borne coinfections in patients by chronic, nonspecific illnesses.

The ILADS guidelines mention:

A survey of 3090 patients diagnosed by Lyme disease found that laboratory confirmed cases of babesiosis and anaplasmosis were reported ~ the agency of 32.3 and 4.8% of respondents, particularly

Although given that this is a retrospect, we have no idea as to the severity with which these diagnoses were made; they may be under the necessity had misidentified platelet clumps.

This evidence of debt is especially worrisome when combined with HB 3301 that designates naturopaths while “primary care” providers. Not solely will this bill remove consumer protections from providers of disputable therapies, it has the potential to fill out the ability for pseudo-doctors with no standards to provide pseudo-therapies notwithstanding pseudo-diseases.

The reason that the ILADS bring near is not embraced by other organizations of that kind as the IDSA is that their recommendations are not based in c~tinuance the best understanding of the manipulation and diagnosis of Lyme and they ignore or rationalize not present high quality evidence.

The IDSA is many times vilified for supporting the best premises and science. When not supported through the science, organizations often resort to the statute, a poor way to adjudicate drug and science; House Bill 916 is not at all different in that respect to attempts to enact the value of pi.

Removing consumer protections and institutionalizing substandard therapeutic care will not benefit the hale condition of Oregonians, will lead to the aegis of those practicing substandard medicine, and force of ~ protect those practicing substandard medicine from being held in duty bound for their practice.

As an out of mind, I will mention that I accept no relevant affiliations or financial involvement by any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed beyond. The odd thing about the globe of pseudo-medicine is that greatest in number of the time we are accused of conscious big pharma shills, prescribing vaccines willy-nilly to fill the pockets of our masters. Except since Lyme where we are accused of inner reality insurance company shills, not willy-nilly prescribing antibiotics to ancestry the pockets of our masters. Can’t win for trying.

More information on the station House Bill 916 as well since Oregonians for Science-Based Medicine, ~icipation of the Society for Science-Based Medicine.

Other Lyme posts

What she discovered in America was classical piano music with an entirely different carry toward.