Table 3 Therapy for persistent Lyme arthritis refractory to the first antibiotic treatment

Antibiotic-refractory persistent arthritis

Significant inflammation (effusion, limited range of motion, oligoarthritis)

Repeat

• Intravenous cefotaxime 50 mg/kg/day in one dose (maximum dose 2,000 mg/day)

• Intravenous cefotaxime 200 mg/kg/day in three divided doses (maximum dose 6,000 mg/day)

• Intravenous penicillin G 0.5 million U/kg/day in four to six divided doses (maximum 20 million U/day)

for 14 days up to 28 days

Limited inflammation (for example, monoarthritis)

• Doxycycline 4 mg/kg/day in two divided doses (maximum 200 mg/day; after 8 years of age)

for 28 days

Additional anti-inflammatory therapy: nonsteroidal anti-inflammatory drugs

No remission reached

In synovial fluid or synovia:

Prolong antibiotic oral treatment for another month

   B. burgdorferi DNA present

Consider

• Intra-articular steroid injection

• Disease-modifying antirheumatic drug therapy

• Arthroscopic synovectomy

   B. burgdorferi DNA not present

Consider

• Intra-articular steroid injection

• Disease-modifying antirheumatic drug therapy

• Arthroscopic synovectomy