Topical azithromycin for the prevention of Lyme borreliosis: a randomised, placebo-controlled, phase 3 efficacy trial

The major epidemiologic, microbiologic, immunologic, and clinical aspects of Lyme disease that form the basis for a newly developed vaccine that may become available soon for human use

Working together, two major pharmaceutical companies have developed a Lyme disease vaccine consisting of recombinant-derived outer surface protein A (OspA) of the etiologic agent Borrelia burgdorferi. Multiple clinical trials have shown the vaccine to have good safety and efficacy results, and it is hoped that it would become available for human use at least by the year 2025 after receiving approval from the U.S. Food and Drug Administration. There are still challenges left to ensure that the vaccine has, at most, minimal side effects. Also, because the previously developed Lyme disease vaccine was discontinued in 2002 after four years of distribution, due in part, for frivolous reasons having little or no scientific basis, that even led to legal entanglements involving the vaccine manufacturer and some of the medical personnel overseeing the clinical trials, there will be concerns that this newly developed one could be subject again to some of the same unnecessary scrutiny rendering its implementation suboptimal. Initially this review will focus on the key epidemiological, microbiologic, immunologic and clinical aspects of Lyme disease that provide the foundation for developing this type of vaccine that could have a serious impact on the prevalence of this and even certain other tick-transmitted infections.

Antibiotic prophylaxis for prevention against Lyme disease following tick bite: an updated systematic review and meta-analysis

Background

In areas where Lyme disease is endemic, bites from ticks are common, but no vaccine is currently available against Lyme disease for humans. Therefore, the feasibility of using antibiotic prophylaxis to prevent Lyme disease after a tick bite is worth further exploration. Previous meta-analyses lack sufficient power to demonstrate the efficacy of about antibiotic prophylaxis for the prevention of Lyme disease following a tick bite. In this study, we explored more precise evidence and attempted to identify and update optimum treatment strategies.

Methods

We searched PubMed, Embase, and the Cochrane Library for studies until March 23, 2021. We included studies if the enrolled patients were randomly allocated to a treatment or control group within 72 h following a tick bite and had no clinical evidence of Lyme disease at enrolment. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed for data abstraction. Two authors (GZZ and XX) independently reviewed the abstracts and identified articles for detailed assessment. We used a random-effects model to calculate the pooled results and reported the 95% confidence interval (CI). Study quality was assessed using a modified Jadad scale, and publication bias was assessed using Egger’s test. We calculated the risk ratio (RR) for the rates of unfavorable events in patients who received intervention versus the control group. This study is registered with PROSPERO, number CRD42021245002.

Results

Six studies (3,766 individuals) were included. The pooled rate of unfavorable events in persons receiving treatment and the control group were 0.4% (95%CI: 0.1–1.1%) and 2.2% (95%CI: 1.6–3.0%), respectively. The pooled RR was 0.38 (95%CI: 0.22–0.66). Subgroup analysis revealed that the pooled RR was 0.29 (95%CI: 0.14–0.60) in the single-use 200-mg doxycycline group; 0.28 (95%CI: 0.05–1.67) in a 10-day course group (Amoxicillin, Penicillin or tetracycline); and 0.73 (95%CI: 0.25–2.08) in a topical antibiotic treatment group (Azithromycin).

Conclusions

The available evidence supports the use of antibiotics for the prevention of Lyme disease, and reveals advantages of using single-dose; however, further confirmation is needed.

Effect of Adjunctive Topical Liposomal Azithromycin on Systemic Azithromycin on Old World Cutaneous Leishmaniasis: A Pilot Clinical Study

The treatment of Cutaneous Leishmaniasis (CL) is complex, and the search for safer, more efficient, and cost-effective treatments is ongoing. This study aimed to evaluate the efficacy of the combination of liposomal and oral azithromycin as the first clinical study against CL. This assessor-blind, randomized clinical trial was conducted in out-patients Leishmaniasis clinic of Skin Diseases and Leishmaniasis. The cutaneous lesions of eligible participants were randomized to receive either oral azithromycin or the combined oral and topical liposomal azithromycin. All participants received 250 mg of azithromycin twice daily or 8 mg/per kg for 4 weeks. In the combination group, a topical liposomal formulation of 0.04 mmol/mL of azithromycin was administered as 0.2-0.5 cc twice daily according to the lesion size in order to make a thin layer of the drug on the surface of the lesion. The size and induration changes from baseline to the end of the study were analyzed. Twenty-one lesions of 13 patients in the combination group and 20 lesions of 14 patients in the oral group were recruited. The mean ± SD of improvement was significantly different between two groups after 12 weeks (3.89 ± 0.46 vs. 3.15 ± 1.23 P = 0.02 combination group vs. oral group respectively). The patients did not experience any systemic adverse effects related to azithromycin and the only adverse effects related to topical treatment were mild pruritus in 2 cases. In conclusion, the combination of oral and topical liposomal formulation of azithromycin is safe and effective to treat CL.

Infections with Tickborne Pathogens after Tick Bite, Austria, 2015-2018

Knowledge about outcomes of tick bites is crucial because infections with emerging pathogens might be underestimated.

The aim of this prospective study was to assess the risk for tickborne infections after a tick bite. A total of 489 persons bitten by 1,295 ticks were assessed for occurrence of infections with Borrelia burgdorferi sensu lato, Anaplasma phagocytophilum, Rickettsia spp., Babesia spp., Candidatus Neoehrlichia mikurensis, and relapsing fever borreliae. B. burgdorferi s.l. infection was found in 25 (5.1%) participants, of whom 15 had erythema migrans. Eleven (2.3%) participants were positive by PCR for Candidatus N. mikurensis. One asymptomatic participant infected with B. miyamotoi was identified. Full engorgement of the tick (odds ratio 9.52) and confirmation of B. burgdorferi s.l. in the tick by PCR (odds ratio 4.39) increased the risk for infection. Rickettsia helvetica was highly abundant in ticks but not pathogenic to humans. Knowledge about the outcome of tick bites is crucial because infections with emerging pathogens might be underestimated because of limited laboratory facilities.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease

This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.

Lyme disease: "End of the debate?"

Lyme borreliosis is a tick-borne disease that is widespread throughout the northern hemisphere. Ixodes ricinus is present throughout metropolitan France, except for the Mediterranean region. The debate revolves around whether or not a chronic form of Lyme disease exists. This controversy is not limited to France but has been reported worldwide. In France, in 2019, 24 scientific societies representing the medical disciplines most involved in Lyme disease, including the Société Française de Rhumatologie (French Rheumatology Society [SFR]) and the Société de Pathologie Infectieuse de la Langue Française (French Infectious Disease Society-SPILF), published recommendations on the management of Lyme borreliosis following a submission to the Director General of Health. These recommendations conflict with those of the Haute Autorité de Santé (HAS), a multi-specialties independent group of physician, on a key point: whether to add a new nosological entity labeled as "persistent polymorphous signs and symptoms (or syndrome) possibly due to tick bite." The creation of this new syndrome risks should increase anchoring bias, leading to the attribution of all symptoms to a possible tick bite, without considering differential diagnoses. Lyme disease has been extensively studied. Erythema migrans is the primary clinical manifestation. In the presence of nonmetabolic, nonseptic monoarthritis involving the knee or radiculitis of a lower limb during the summer, Lyme disease should be suspected. Serologic testing for Lyme disease is reliable in the case of late forms such as chronic arthritis, while the detection of Borrelia DNA in synovial fluid by PCR is inconsistent. Sometimes, the serology can be misleading in early forms such as radiculitis. Treatment is based on doxycycline for 14 days in early forms (radiculitis), or 28 days in late forms (arthritis). Arthritis can persist or recur after antibiotic therapy. The prevalence of a diffuse polyalgia syndrome (fibromyalgia) following Lyme disease does not seem to differ much from that in the general population. It is not improved by prolonged antibiotic therapy, which is therefore not recommended.

Lyme borreliosis: diagnosis and management

Lyme borreliosis is the most common vectorborne disease in the northern hemisphere. It usually begins with erythema migrans; early disseminated infection particularly causes multiple erythema migrans or neurologic disease, and late manifestations predominantly include arthritis in North America, and acrodermatitis chronica atrophicans (ACA) in Europe. Diagnosis of Lyme borreliosis is based on characteristic clinical signs and symptoms, complemented by serological confirmation of infection once an antibody response has been mounted. Manifestations usually respond to appropriate antibiotic regimens, but the disease can be followed by sequelae, such as immune arthritis or residual damage to affected tissues. A subset of individuals reports persistent symptoms, including fatigue, pain, arthralgia, and neurocognitive symptoms, which in some people are severe enough to fulfil the criteria for post-treatment Lyme disease syndrome. The reported prevalence of such persistent symptoms following antimicrobial treatment varies considerably, and its pathophysiology is unclear. Persistent active infection in humans has not been identified as a cause of this syndrome, and randomized treatment trials have invariably failed to show any benefit of prolonged antibiotic treatment. For prevention of Lyme borreliosis, post-exposure prophylaxis may be indicated in specific cases, and novel vaccine strategies are under development.

Guidelines for diagnosis and treatment in neurology - Lyme neuroborreliosis

Lyme borreliosis is the most common tick-borne infectious disease in Europe. A neurological manifestation occurs in 3–15% of infections and can manifest as polyradiculitis, meningitis and (rarely) encephalomyelitis.

This S3 guideline is directed at physicians in private practices and clinics who treat Lyme neuroborreliosis in children and adults.

Twenty AWMF member societies, the Robert Koch Institute, the German Borreliosis Society and three patient organisations participated in its development. A systematic review and assessment of the literature was conducted by the German Cochrane Centre, Freiburg (Cochrane Germany).

The main objectives of this guideline are to define the disease and to give recommendations for the confirmation of a clinically suspected diagnosis by laboratory testing, antibiotic therapy, differential diagnostic testing and prevention.

Novel targets and strategies to combat borreliosis

Lyme borreliosis is a bacterial infection that can be spread to humans by infected ticks and may severely affect many organs and tissues. Nearly four decades have elapsed since the discovery of the disease agent called Borrelia burgdorferi. Although there is a plethora of knowledge on the infectious agent and thousands of scientific publications, an effective way on how to combat and prevent Lyme borreliosis has not been found yet. There is no vaccine for humans available, and only one active vaccine program in clinical development is currently running. A spirited search for possible disease interventions is of high public interest as surveillance data indicates that the number of cases of Lyme borreliosis is steadily increasing in Europe and North America. This review provides a condensed digest of the history of vaccine development up to new promising vaccine candidates and strategies that are targeted against Lyme borreliosis, including elements of the tick vector, the reservoir hosts, and the Borrelia pathogen itself.

Lyme Neuroborreliosis - The Mystifying Pitfall: "Neuropathology and Current Therapeutics"

Lyme's Disease (LD) is a severe, rapidly growing, broad spectrum chronic infection caused by the bacterium 'Borrelia (B.) burgdorferi', which can be easily transmitted through the bite of certain species of ticks. The prevalence of LD is swiftly mounting in the present scenario in many countries from species to species. Although Lyme's infection is now detectable via serologic examination of early and late Lyme neuroborreliosis (LNB), the management of persistent symptoms is still fraught with quora of doubt and debate. LD is a multisystem spirochete which results after the dissemination of B. burgdorferi from a dermal inoculation site after a tick bite. Lyme's infection can easily get transmitted to the central nervous system and develop various neurological symptoms due to inflammation and an autoimmune response from body may lead to life-threatening "Lyme Borreliosis". The neurological symptoms are well mixed in presentation, late and confusing to get differentiated easily from other diseases. The use of antibiotics in post Lyme infection with neurological complications is still a topic of debate. Babesiosisstates, and human ehrlichiosis' the two other diseases, are associated with the same ticks that spread the LD. However, the prevalence of diagnosed human cases is usually much lower than that of actual cases of LD due to misdiagnosis, late diagnosis or undiagnosis at y such lateral neuroinfection stage after the tick bite. The current review focuses on the molecular neuropathology and current advancements in LD. There are very few patents or discoveries made on borrelia infection, drawing attention towards more focused and targeted research for the cure.

Adverse events in people taking macrolide antibiotics versus placebo for any indication

BACKGROUND

Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment-specific, rather than disease-specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases.

OBJECTIVES

To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides.

SELECTION CRITERIA

We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide-resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta-analysis when three or more included studies reported a specific adverse event.

MAIN RESULTS

We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin.Most studies (89%) reported some adverse events or at least stated that no adverse events were observed.Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low-quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low-quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate-quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate-quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate-quality evidence) were also reported more often in participants taking macrolides compared to placebo.The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000.The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting.There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration.Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low-quality evidence).Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low-quality evidence).We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low-quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low-quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low-quality evidence) compared to placebo.We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo.Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate-quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate-quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate-quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non-significant.There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low-quality evidence).Only 24 studies (13%) provided useful data on macrolide-resistant bacteria. Macrolide-resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent.Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials.

AUTHORS' CONCLUSIONS

The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as "none were observed". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance.

Lyme borreliosis-from tick bite to diagnosis and treatment

Lyme borreliosis is caused by certain genospecies of the Borrelia burgdorferi sensu lato complex, which are transmitted by hard ticks of the genus Ixodes. The most common clinical manifestation is erythema migrans, an expanding skin redness that usually develops at the site of a tick bite and eventually resolves even without antibiotic treatment. The infecting pathogens can spread to other tissues and organs, resulting in manifestations that can involve the nervous system, joints, heart and skin. Fatal outcome is extremely rare and is due to severe heart involvement; fetal involvement is not reliably ascertained. Laboratory support-mainly by serology-is essential for diagnosis, except in the case of typical erythema migrans. Treatment is usually with antibiotics for 2 to 4 weeks; most patients recover uneventfully. There is no convincing evidence for antibiotic treatment longer than 4 weeks and there is no reliable evidence for survival of borreliae in adequately treated patients. European Lyme borreliosis is a frequent disease with increasing incidence. However, numerous scientifically questionable ideas on its clinical presentation, diagnosis and treatment may confuse physicians and lay people. Since diagnosis of Lyme borreliosis should be based on appropriate clinical signs, solid knowledge of clinical manifestations is essential.

[What's new in dermatological treatment?]

On a therapeutic point of view, 2017 in dermatology could be summarized in one disease, one pathway and in one number : atopic dermatitis, JAK inhibitors and 23. 2017 will be the year of the first registration of a biologic treatment in atopic dermatitis, dupilumab, with numerous other drugs currently in development. JAK inhibitors show promising results in several difficult-to-treat conditions, such as alopecia areata, vitiligo or atopic dermatitis, but still warrant confirmation in upcoming controlled trials. Monoclonal antibodies targeting IL-23 have confirmed in phase III studies their great efficacy in controlling psoriasis and will be soon available in practice, illustrating well the optimal link between bench side and bed in this emblematic inflammatory dermatological condition.