In March of 2015, some of the researchers from the above study expanded upon the results from the 2014 drug screen. 2014;12(9):11031135. Inside of cells, Lyme exists without a cell covering known as an L-form. The results confirm that a Lyme disease infection can trigger PTLD despite early treatment with 21 days of the antibiotic doxycycline. Therefore, in people who have failed years of antibiotics, without an active co-infection, I recommend a trial of disulfiram alone. Identification of FDA-approved drugs with activity against stationary phase Bartonella henselae. For more information about this, review the sitewide Terms & Conditions. Identification of new drug candidates against Borrelia burgdorferi using high-throughput screening. For the rifamycins, no laboratory experiments show these agents work against cysts. Two of the top three hit cephalosporins are administered intravenously, but the oral-form Cefdinir was also effective. People can feel better while on antibiotics because the bacteria shift to the inactive persister phase, but symptoms often return when the antibiotics are stopped. For more information, please see theChronic Lyme Diseasesection. 2018;7(4):89. doi:10.3390/antibiotics7040089, Gao J, Gong Z, Montesano D, Glazer E, Liegner K. Repurposing disulfiram in the treatment of Lyme disease and Babesiosis: Retrospective review of first 3 years experience in one medical practice. Antibiotics that work on germs inside and outside of cells include the tetracyclines, macrolides, rifamycins, and azoles. I recommend disulfiram-only regimens to people who have taken extensive numbers of antibiotics for a year or more of treatment and remain ill. Grapefruit seed extract is better tolerated than both tinidazole and metronidazole and supports killing of Lyme cysts. The state of the science relating to persistent symptoms associated with Lyme disease is limited, emerging, and unsettled. Skip to content. Combine antibiotics to treat all forms of the germ. The use of antibiotics is critical for treating Lyme disease. A small percentage of patients can get into remission with this treatment. Augmentin is a combination medication that includes both amoxicillin and the enzyme inhibitor clavulanate that allows the amoxicillin to be more effective against other penicillin-resistant microbes; a downside of this combination is that it might cause significantly more gastrointestinal disturbance than plain amoxicillin. Most recently, a clinical trial out of the Netherlands concluded that in patients with persistent symptoms attributed to Lyme disease, longer term treatment with antibiotics did not provide additional benefits compared with traditional treatment regimens. PTLD is characterized by a constellation of symptoms that includes severe fatigue, musculoskeletal pain, sleep disturbance, depression, and cognitive problems such as difficulty with short-term memory, speed of thinking, or multi-tasking. A research study published by our Center in 2022 found that even when Lyme disease patients were early diagnosed and promptly treated (a best case scenario condition), 14% of the patients developed Post Treatment Lyme Disease (PTLD). When symptoms persist, it is very important to take a fresh look at the patient and determine whether other problems have emerged (possibly unrelated to Lyme disease) that may be causing the symptoms. They also determined that the combination of azlocillin and cefotaxime was more effective at killing Borrelia persisters than azlocillin alone. Cefazolin. In a statistical model, the ceftriaxone group showed a slightly greater improvement at 12 weeks, but at 24 weeks both the ceftriaxone and the placebo groups had improved similarly from baseline. The limitation of most of these studies is that they were performed in vitro (outside of a living organism), but they establish a starting point for future in vivo studies. The roles of immune dysfunction, autoimmunity, chronic inflammation, persistent bacterial infection, persistent bacterial antigenic debris, neural network alteration, and other potential causative biologic mechanisms of PTLD are being investigated at our Center. treats all growth phases of Lyme at the same time. Neurologic Lyme disease Lyme carditis Lyme arthritis Some patients report persistent symptoms of pain, fatigue, or difficulty thinking even after treatment for Lyme disease. A major goal of these studies was to optimize the Rhesus monkey model of Lyme disease as well as to determine the pathogenesis of the disease with a focus on its neurological manifestations. Antibiotic-associated diarrhea is likely to begin about a week after you start taking an antibiotic. However, multiple research studies have demonstrated that the bacteria that causes Lyme disease can persist following treatment with antibiotics. Some medications are more effective as the dose is increased. It is usually taken once a day. Some patients report persistent symptoms of pain, fatigue, or difficulty thinking even after treatment for Lyme disease. Daptomycin alone could not eradicate microcolonies, but when combined with other drugs, daptomycin was effective against round body forms and microcolonies. The results were published in April 2016 in the paper Identification of new drug candidates against Borrelia burgdorferi using high-throughput screening. Follow the steps in Cant Get Better? As an alternative, ceftriaxone could be given daily as 2 gm IV 1 time a day. Physicians and other health care professionals are encouraged to consult other sources and confirm the information contained within this site. These can happen alone or at the same time. But the risk of serious side effects is higher. Borrelia can exist in humans in other forms to protect it from the immune system and antimicrobial agents. Antibiotics (Basel). Future in vivo research identifying effective treatments for stationary phase Borrelia will have a significant impact against chronic Lyme. Patients were treated with 30 days of an intravenous antibiotic followed by 60 days of treatment with an oral antibiotic. Consumers should never disregard medical advice or delay in seeking it because of something they may have read on this website. Thus, the majority of people with chronic Lyme do not require IV antibiotics. Persistent symptoms of Lyme disease are similar to and overlap with other conditions involving fatigue, pain, and cognitive symptoms. In this article, by antibiotics I mean prescription and herbal medicines that have antimicrobial effects against the Lyme germ. Removing disulfiram from the three-drug combinations, cefuroxime + clarithromycin + furazolidone, cefuroxime + nitroxoline + furazolidone, and cefuroxime + nitazoxanide + clarithromycin was significantly more effective than the disulfiram combinations. The study, titled Identification of novel activity against borrelia burgdorferi persisters using an FDA approved drug library, screened over 1500 medications and identified 165 that had better activity against stationary Borrelia than doxycycline and amoxicillin. Dr. Ross is licensed to practice medicine in Washington State (License: MD00033296) where he has treated thousands of Lyme disease patients inhis Seattle practice. Based on his reports and based on my experience, this repurposed drug is effective at putting about 36 percent of people with Lyme into remission and may help a larger group to have symptom improvements. These options are ones I am using with various degrees of success in my Seattle practice. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. These cookies may also be used for advertising purposes by these third parties. These approaches are considered for those patients who have persistent symptoms that have not abated or resolved after antibiotic therapy. dose: 600 mg/24 hr Levofloxacin may also be used to treat people who have been exposed to anthrax or certain types of plague. In my practice, I offer two persister-oriented regimens for those that have failed years of regular antibiotics. This medicine may cause severe side effects like irritated or torn tendons; nerve problems in the arms, hands, legs, or feet; and nervous system problems. Interestingly, the alcohol abuse medication disulfiram was effective against Borrelia. Research studies have shown that Borrelia bacteria can exist in all three phases simultaneously. The authors concluded that because of the limited duration of the cognitive improvement and the risks involved, 10 weeks of intravenous ceftriaxone was not an effective strategy for cognitive improvement in these patients, and more durable and safer treatment strategies are still needed. Nonanaphylactic penicillin-allergic: cefdinir (Omnicef), cefpodoxime (Vantin), or cefuroxime (Ceftin) Severe penicillin allergy: azithromycin (Zithromax) or clarithromycin (Biaxin) Unable to . They debuted about 30 years ago, around the time I was in medical school. One or more of these underlying causes may be occurring simultaneously. J Clin Exp Dermatol Res. Be aware methylene blue costs nearly $350 a month. This article reviews research studies that identified antibiotics that are effective against the persistent forms of the bacteria that cause chronic Lyme disease. A reappraisal of several of these studies concluded that IV antibiotics may provide benefit to PTLDS fatigue, but in light of significant adverse events they were not recommended and improved methods of treatment were needed. 500 mg of amoxicillin is a very high dose, which is four times stronger than physicians prescribe for other infections, such as ear infections. This should be transient and last no more than a day or two after the initiation of antibiotics. In more complicated cases, Lyme disease can usually be successfully treated with three to four weeks of antibiotic therapy. Note 4: Patients on blood thinners (anti-coagulants) should be aware that doxycycline can lead to an enhancement of the anti-coagulant effect, possibly increasing the risk of bleeding. However, the bacteria did not grow in cell cultures. We refer the reader to other sources that describe why patients might have persistent symptoms and other treatment options (e.g., in portions of our book Conquering Lyme Disease: Science Bridges the Great Divide). Published July 2010. 2020;7:6. doi:10.3389/fmed.2020.00006(, Feng J, Weitner M, Shi W, Zhang S, Sullivan D, Zhang Y. For some with chronic Lyme disease, a cure does not occur. Your clinician will need to order a glucose 6 phosphate dehydrogenase (G6PD) blood test. When macrolides are used with paroxetine (Paxil) an anti-depressant drug, there may be an unexpected increase in the blood level of the parosetine due to the macrolide-inducted inhibition of the liver enzyme metabolism; this could lead to mania or serotonin syndrome. Levofloxacin injection is indicated for inhalational anthrax (post-exposure) to reduce the incidence or progression of disease following exposure to aerosolized Bacillus anthracis. When memory is a problem, consider that this could be due to a primary problem with attention or with mood. Drug combinations were most effective at eradicating stationary phase Borrelia burgdorferi. Arthritis Center News Ceftriaxone is a third generation cephalosporin and, like other cephalosporins, is bacteriocidal. In the evaluation of the patient prior to insertion of a PICC line or a Mid-Line, the clinician orders blood tests to determine if the patient is at higher risk of forming blood clots or inquires about ones family history of blood clotting. If you have learned that chronic Lyme disease is the underlying cause of your symptoms, the next hurdle is finding effective treatments. An effective treatment approach must address both forms. How to Successfully Treat Lyme: Key Info before You Treat or Treat Again, Kills Anaplasma and Ehrlichia: A Brief Guide, Target Viruses, Mycoplasma, & Chlamydia in Lyme? It works by killing bacteria or preventing their growth. Some doctors prescribe Actigall to dissolve biliary stone formation, especially if the patient is starting to complain of epigastric pain or nausea. In addition, six of the study participants had serious adverse events associated with intravenous antibiotic use, and four patients required hospitalization. The mechanisms of these Lyme disease conditions are different and effective treatments need to be tailored accordingly. These regimens are consistent with guidanceexternal icon published by the by the Infectious Disease Society of America, American Academy of Neurology, and American College of Rheumatology. None of these medications were as effective as the top hits from the previous drug screens. Tetracyclines can be used in children under eight, but there is a risk of tooth staining. Lyme can live outside of cells and inside of cells. The SNRIs are particularly useful for patients with persistent Lyme-related symptoms as they are quite effective for reducing pain as well as for improving mood and decreasing anxiety. I use this one most commonly because it is the easiest to administer and one of the lowest cost IV regimens. These pilot clinical trials are made possible thanks to the generous support of the Steven and Alexandra Cohen Foundation. Neuropathic, muscular, and arthritic pain can often be helped with agents such as amitriptyline, cyclobenzaprine, or SNRIs (e.g., duloxetine (Cymbalta), milnacipran (Savella), venlafaxine (Effexor)). It is time to stop a full treatment when someone is either symptom-free for two months or the improvements have plateaued for four months after adjusting the regimen. I want to stay up to date on Lyme disease and associated conditions. Unfortunately, nitroxoline and furazolidone are not available in the United States, but the combination of cefuroxime + nitazoxanide + clarithromycin is readily available. By distinguishing research subsets of Lyme disease, such as PTLD, our patient-centered clinical research program is illuminating the complex pathophysiology of the illness to improve diagnostics, treatments, and quality of life for patients. Cefdinir (Omnicef) $$$ Fourth generation: Cefepime: . We also review other treatment approaches for pain, fatigue, insomnia, and memory and mood issues. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. But, it's a known culprit in CDI. 2019;8(2):72. doi:10.3390/antibiotics8020072(, Ma X, Leone J, Schweig S, Zhang Y. Botanical medicines with activity against stationary phase Bartonella henselae. Continue treatment with antibiotics until you are well. Any antibiotic can cause skin rashes, and if an itchy red rash develops while on antibiotics, a patient should see their physician. Beware however that long-term use of NSAIDS increases the risk of gastric ulcers and kidney damage. The Lyme disease patient population is heterogeneous and the drivers of persistent illness can be varied and multifactorial. Arthritic pain that persists after antibiotic therapy may be reduced by nonsteroidal anti-inflammatory drugs (NSAIDS) that reduce inflammation. They help us to know which pages are the most and least popular and see how visitors move around the site. Poor sleep can lead to daytime fatigue, impaired cognition, and musculoskeletal pain. Levofloxacin is also used to treat and prevent plague (including pneumonic and septicemic plague). All information contained within the Johns Hopkins Lyme Disease Research Center website is intended for educational purposes only. However, they each bind to a different part of the ribosome, thereby improving the blockade of protein production. This herbal medicine is traditionally used to treat Babesia and malaria. Another team of NIAID-supported investigators found that intactB. burgdorferipersist in nonhuman primates after antibiotic treatment. It belongs to the class of medicines known as cephalosporin antibiotics. 2020;9(9):633. doi:10.3390/antibiotics9090633(, Sapi E, Kaur N, Anyanwu S, et al. In those studies, physicians examined long-term antibiotic therapy in patients with a well-documented history of previous Lyme disease, but who reported persistent pain, fatigue, impaired cognitive function, or unexplained numbness. Marty Ross, MD is a graduate of Indiana University School of Medicine and Georgetown University Family Medicine Residency. Therefore, treatments must be individualized by addressing specific findings, symptoms, and circumstances for each individual. Therefore, it is unwise to stop an anti-depressant after only three or four weeks, as staying on it another two to three weeks may lead to a good response. After completing antibiotic treatment, tissues from the mice were analyzed using a variety of scientific methods. This is typically given 2-3x week. Amoxicillin can be taken with or without food. In two different studies in 2021, however, Dr. Zhang and colleagues have shown Cryptolepsis is effective at treating growing and persister forms of Bartonella and Lyme. Cefdinir is used to treat bacterial infections in many different parts of the body. In 2014, researchers from Johns Hopkins published the first study to assess the full spectrum of antibiotic susceptibility against persister phase Borrelia. In one randomized controlled trial, fatigue and mental functioning were significantly improved in the experimental group compared to the wait-list controls. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. Drug Des Devel Ther. Neurofeedback may be helpful in improving sleep, as well as in improving attention and reducing pain. The active hits that affect bacterial cell membranes, energy productions, and produce reactive oxygen species had more significant activity against the bacteria that causes Lyme disease than commonly used antibiotics that inhibit cell wall, protein, RNA, and DNA synthesis. 2020;9(9):542. doi:10.3390/antibiotics9090542(. It should be noted however that to obtain the pain relief from a medication such as venlafaxine, in most patients the dose needs to be increased to 225-300 mg/day in order to obtain the benefits for pain and mood. Since the drugs used in the screening studies were from research drug libraries, some of the effective medications are not available commercially. Doxycycline, amoxicillin, azithromycin, clarithromycin, and penicillin G (Bicillin) had poor activity against Borrelia persisters. Note: I work with the following anti-cyst agents based on the mechanism by which these antibiotics work and some scientific experiments. Doxycycline, a bacteriostatic antibiotic, has the advantage of twice daily dosing and effectiveness not only for Lyme disease but also for some other tick-borne diseases such as borrelia miyamotoi disease, ehrlichiosis, anaplasmosis, tularemia, and rocky-mountain spotted fever. 2020;9(12):868. doi:10.3390/antibiotics9120868(, Goc A, Rath M. The anti-Borreliae efficacy of phytochemicals and micronutrients: An update. For example, erythromycin or clarithromycin can lead to dangerously increased blood levels of the anticonvulsant drug carbamazepine (Tegretol) as well as increases in the anti-anxiety drug alprazolam (Xanax). Despite these differences, the study results reinforced the conclusions of the earlier trials. Identification of essential oils with strong activity against stationary phase Borrelia burgdorferi. In 2020, the paper Evaluation of Disulfiram Drug Combinations and Identification of Other More Effective Combinations against Stationary Phase Borrelia burgdorferi was published. Doxycycline side effects include moderate to severe gastric symptoms (nausea, vomiting, diarrhea), vaginal yeast infections, decreased effectiveness of birth control pills, and rarely liver damage or esophagitis. Antibiotics, like all medications, have the potential for side effects. They published their results in a research paper titled Drug Combinations against Borrelia burgdorferi persisters in vitro: eradication achieved by using daptomycin, cefoperazone, and doxycycline. These persistershibernating phase germsignore regular standard antibiotics we traditionally used to treat Lyme. You will be subject to the destination website's privacy policy when you follow the link. With low G6PD there is a risk that your red blood cells will break apart. Furthermore, Dr. Rajadas and Dr. Zhang both showed that disulfiram can treat growing Lyme, although it is only moderately effective. The lower the MIC, the more effective the medication kills the bacteria. Without antibiotic treatment, the Lyme disease causing bacteria can evade the host immune system, disseminate through the blood stream, and persist in the body. They all have either laboratory experiments or published human experiments supporting their use. The only time I pulse is for two months on and two months off when using regimens to address persister Lyme. The latter medications or vitamins should be taken 6 hours before or 2 hours after the doxcycline. Disulfiram does not have any benefit for Bartonella and is a very weak anti-Babesia agent. In Europe, doxycycline is considered to have comparable efficacy for neurologic Lyme disease as intravenous ceftriaxone; this has not yet been examined in the United States however and may not apply to U.S. neurologic Lyme disease as the genospecies causing neurologic Lyme in the US is B.burgdorferi while in Europe it is most commonly caused by B.garinii. The following treatment regimens reflect CDCs interpretation of the most current data for four important manifestations of Lyme disease. In that study, people receiving antibiotics reported a greater improvement in fatigue than those on placebo. doi:10.1177/2049936116655502(, Horowitz R, Freeman, PR. It is not recommended for people who are on medications that inhibit the liver enzyme CYP3A such as clarithromycin ("Biaxin") or ketoconazole ("Nizoral") or fluconazole ("Diflucan") or erythromycin. Studies of the effects of antibiotic therapy in animals infected withB. burgdorferihave been conducted most often with mice but also with rats,hamsters, gerbils, dogs, and non-human primates. Doxycycline should not be combined with the acne drug isotretinoin as that will increase the risk of elevated intracranial pressure (and the potential for vision loss). Rule 1. Dapsone for Lyme Persisters. Richard Horowitz, MD has promoted the use of dapsone-based regimens to treat both Lyme and Bartonella persisters. There are study design problems with the research studies of azithromycin and clarithromycin; therefore, it is hard to know whether they are truly less efficacious than the first-line agents for early Lyme disease. Macrolides (like clarithromycin) and tetracyclines (like doxycycline), work in the intracellular and extracellular spaces. Rule 3: Combine antibiotics that work in different ways to attack the germ from different angles. When the bacteria are exposed to harsh environments including antibiotics the bacteria morph into round bodies and microcolonies (also known as biofilms). Qigong is a mind-body-spirit practice that integrates posture, movement, breathing technique, self-massage, sound, and focused attention. J Neuroinflammation. Antibiotics (Basel). Cefdinir* 300 mg PO Q12H for 5 days OR TMP/SMX 1 DS tab PO Q12H for 3 days OR IV option: Cefazolin 1 g IV Q8H for 3 days *Use Cefazolin susceptibility as a surrogate to predict susceptibilities for Cefadroxil, Cephalexin, Cefuroxime, Cefdinir for E. coli, K. pneumoniae, and P. mirabilis. Some anti-depressants work fine at low doses; some medications however are effective only at higher doses. In 2016, researchers from Stanford University used high-throughput screening to identify compounds that were effective against Lyme disease. The other option I offer is a disulfiram-only regimen or a disulfiram-combination regimen. Because the suggestions listed below have not yet been studied in clinical trials of Lyme disease , these suggestions are based on evidence obtained from other disorders with similar clinical features. Post Treatment Lyme Disease (PTLD) represents a research subset of patients who remain significantly ill 6 months or more following standard antibiotic therapy for Lyme disease. This is why most of the antibiotics prescribed to people who have had Lyme disease for months or years are ineffective. The key to consider is that these antibiotics impact the liver enzymes that help to metabolize other medications; specifically they can affect the cytochrome P450 1A2 and 3A4 isoenyzmes. The rates of Post Treatment Lyme Disease after neurologic involvement may be as high as 20% or even higher. (Lyme, Babesia, & Bartonella Timelines), Herxheimer Die-off Reaction: Inflammation Run Amok, Best Tests and Laboratory for Tick-Borne Illnesses. Examples of defined Lyme disease subsets include Post Treatment Lyme Disease (PTLD), and Antibiotic Refractory Late Lyme Arthritis. Evaluation of natural and botanical medicines for activity against growing and non-growing forms of B. burgdorferi. Macrolides however should be used with caution given the risk of interaction with other medications. These drugs had to kill at least 65% of stationary phase Borrelia and could be used in humans. Note 3: Rarely ceftriaxone can trigger hemolytic anemia and pancreatitis. This has been studied for migraines, fibromyalgia, and ADHD. Neuropathic pain (numbness, tingling, burning, shooting) and central "brain" pain syndromes can often be helped with agents such as gabapentin ("Neurontin") or pregabalin ("Lyrica"). The most effective drug combination against microcolonies was daptomycin + doxycycline + cefoperazone. PTLD patients have persistent functionally impairing symptoms 6 months or more following the end of treatment, including severe fatigue, body pain, and cognitive challenges. Highly sensitive laboratory tests were able to detect the presence ofB. burgdorferiin these mice. If you are interested in information on chronic Lyme diseaseexternal icon, see NIHs website. Further, whenIxodes scapularisticks fed on some of the antibiotic-treated mice, the ticks were able to transmit the bacteria to mice with weakened immune systems who were not previously infected withB. burgdorferi. Buhner SH. These antibiotics have been around a while. For example, fatigue may be due to anemia or thyroid deficiencies. Ken Liegner, MD published a case report of more than 70 people he treated with disulfiram as a solo agent. Centers for Disease Control and Prevention. However, disulfiram is a very difficult drug to use. Stanford researchers that identified azlocillin as an effective antibiotic against stationary phase Borrelia in culture in 2016 performed another study in 2020, but this time with mice. The B31 strain of Borrelia was grown on a culture medium until the bacteria reached the stationary/persister phase between 6-7 days. And How to Prevent Relapse for a discussion of this. The three first-line oral antibiotics for Lyme disease include doxycycline (Monodox, Doryx, Vibramycin, Oracea), amoxicillin (Amoxil), and cefuroxime (Ceftin, Zinacef). The implications of these findings in terms of persistent infection and the nature of PTLDS in humans are yet to be fully understood. 2011;4:97113. It is important to note that these studies were performed on cultures in a laboratory, and benefits may not directly translate in animal studies or humans. Though a number of drugs have been tested and approved against various spirochetes, the currently available drug therapies, such as amoxicillin and doxycycline, were unable to killB. burgdorferipersisters in vitro.. In this situation, symptom-based therapies can be quite helpful. 2015;4(3):397-410. doi:10.3390/antibiotics4030397, Feng J, Zhang S, Shi W, Zubcevik N, Miklossy J, Zhang Y. fever, chills, body aches, flu symptoms; pale skin, easy bruising, unusual bleeding; seizure (convulsions); fever, weakness, confusion; dark colored urine, jaundice (yellowing of the skin or eyes . Most anti-depressant agents also help in reducing anxiety. Testing already-approved medications with established safety profiles allow quick identification of effective treatments without developing new medications, attaining approval, and establishing safety in humans. Here, what I'm referring to is Lyme disease patients, and others, being treated with a class of antibiotics called fluoroquinolones. The first-line standard of care treatment for adults with Lyme disease is doxycycline, a tetracycline antibiotic. CDC twenty four seven. Most studies have found plain amoxicillin to be highly effective against Borrelia burgdorferi and thus the combination (Augmentin) is not needed. Note: In most individuals Bicillin is self-administered, often in the muscle of the buttocks. Evidence assessments and guidelines recommendations in Lyme disease: The clinical management of known tick bites, erythema migrans rashes and persistent disease. Methylene blue is approved to treat a problem called methemoglobinemia where methylene blue causes hemoglobin to release oxygen. Subscribe to receive our FREE pdf download book: How to Successfully Treat Lyme: Key Info before You Treat or Treat Again & The Ross Lyme Support Protocol; health tips; updates; special offers; and more. With approximately 500,000 new U.S. cases of Lyme disease per year, the number of people experiencing chronic symptoms is a growing public health concern. One regimen I offer is a Horowitz dapsone-persister regimen. They started with over 4,000 compounds from various drug libraries and published their findings in the paper Identification of new drug candidates against Borrelia burgdorferi using high-throughput screening. Note 1: Doxycycline raises the risk of sunburns due to increased skin sensitivity to sunlight. Infect Drug Resist. Antibiotics (Basel). (The term generation when applied to cephalosporins simply refers to when the drug was developed and generally means that the later generation versions have a longer half-life (so they dont need to be taken as frequently) and have better efficacy and safety.)
levofloxacin lyme disease omnicef