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Running head: LYME DISEASE: AN EVIDENCE BASED DISCUSSION
Lyme Disease: An Evidence Based Discussion
Jamie Kruger
Ferris State University
1
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
Abstract
A summary of the best evidence pertaining to Lyme disease in terms of transmission, isolation,
clinical presentation, diagnosis, and treatment were scrutinized. Factors that promote Lyme
disease were identified and examined. Recommendations were considered on how evidence
based practices relating to Lyme disease are applicable to nursing practice.
Keywords: lyme disease, infectious disease, tick
2
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
3
Lyme Disease: An Evidence Based Discussion
One of the biggest public health threats facing the United States is Lyme disease. The
Centers for Disease Control and Prevention declares that Lyme disease is the most commonly
reported vector borne illness in the United States, with 22,572 cases being reported in 2010
(Centers for Disease Control and Prevention, 2011). The public health threat from this disease is
considerable, with increasing incidence of disease, and signs and symptoms difficult to diagnose.
Lyme disease is described as a flu-like illness that can lead to serious organ system
involvement if not treated. The disease is caused almost exclusively in the United States by
Borrelia burgdorferi (Brissette et al., 2010, p. 274). Borrelia burgdorferi, a spirochete, is a
species of gram negative bacteria that lives within many different vectors, primarily ticks
(Rathinavelu, Broadwater, & de Silva, 2003).
Transmission
Transmission of Borrelia burgdorferi to a human host occurs through a vector, or an
instrument of transmission for a disease. The vector most likely to transmit the bacteria are
several species of ticks, with the blacklegged tick (Ixodes scapularis) being the largest offender
in the United States and the castor bean tick (Ixodes ricinus) responsible for transmission in
Europe (Hoen, Margos, Bent, Diuk-Wasser, & Barbour, 2009). Ticks do not particularly seek a
human host, but are opportunistic in that if a human host is available, it will feed on one. Once a
human is infected, they are not able to pass the disease on, and require no isolation.
Within the tick, the spirochete Borrelia burgdorferi is located in the lumen of the gut
(Rathinavelu et al., 2003). When the tick finds its way to a human with the intent of finding a
meal, the transmission occurs. During the feeding (which can take several days), the tick injects
his proboscis into the skin of the host with the intent of siphoning out blood. The saliva of the
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
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tick is rich in Borrelia burgdorferi, and it is during this feeding that the bacteria makes its way
into the host, making the transmission complete (Deruaz et al., 2008).
Isolation
The first recorded case of Lyme disease occurred in 1970 in Wisconsin, prior to being
recognized as a syndrome. No other cases were recorded until 1976 when a group of children in
Lyme, Connecticut developed a cluster of symptoms similar to the case described in 1970. This
cluster of cases, and diagnosis of a new disease, soon coined the term Lyme disease. Over the
next several decades, the disease has been recorded in every state in the Union, with additional
cases reported in Europe, Asia, and Russia (Hoen et al., 2009).
Clinical Presentation
Lyme disease is said to present in three distinct phases. Not everyone will experience
every symptom associated with each phase, with most symptoms being attributed to other
diseases. The best scenario for identifying if the patient is in any of these three phases is
watching for likely symptoms after recognizing the tick bite. For many the actual tick bite goes
unnoticed, with the tick falling off without the person knowing it was ever there (Albert &
Skolnik, 2008).
The first phase, or the early localized stage, presentation is with the trademark bull’s eye
rash, erythema migrans. This expanding rash, however, is not always in the form of the typical
bull’s eye; it can have irregular edges, be entirely erythemic, or have pustules present throughout
(Aucott et al., 2009). This rash often accompanies nondescript flu like symptoms such as fevers,
muscle aches, headaches, and general malaise. This phase usually occurs within one month of
the tick bite (Albert & Skolnik, 2008).
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
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The second phase, or early disseminated phase, can occur up to a year after the tick bite.
This phase presents with the most serious of symptoms. Symptoms include cardiac disorders
and various neurological disorders (Albert & Skolnik, 2008). Cardiac involvement often occurs
in the form of carditis that later involves a conduction delay at the atrioventricular node.
Presenters initially complain of “palpitations, light headedness, syncope, chest pain, and
dyspnea” with later stages progressing into second degree heart block (Harburger & Halperin,
2011, p. 181). Neurological sequela present as meningitis, encephalopathies, and peripheral
neuropathies (Halperin et al., 2007).
The last stage, or late disease stage, takes place in the form of chronic arthritis and
chronic neurological disorders. This phase can occur up to several years after the tick bite. The
patients experiencing arthritic involvement at this stage are said to have persistent and chronic
arthritis, with one or more joints presenting with an exceptional amount of effusion (Nau,
Christen, & Eiffert, 2009). Chronic neurological symptoms include “paresis of extremities,
cranial nerve deficits, bladder disturbances, altered personality, sexual dysfunction, and ataxia”
(Nau et al., 2009, p. 75).
A fourth stage that has recently developed is known as post treatment Lyme disease
syndrome. This stage occurs some time after the initial four-week course of antibiotics have
finished. This stage includes residual chronic symptoms such as “musculoskeletal pain without
evidence of arthritis, fatigue, cognitive difficulties, sleep disturbances, irritability, depression,
and headache” (Halperin et al., 2007, p. 92).
Diagnosis
In order to standardize diagnostic testing, the Centers for Disease Control and Prevention
(CDC) established a surveillance guideline for Lyme disease, that updates periodically. This
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
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diagnostic standard is widely accepted throughout the infectious disease community, including
the Infectious Disease Society of America (IDSA) (Aucott, et al., 2009). The diagnostic process
for Lyme disease includes clinical judgment and serological findings (Albert & Skolnik, 2008).
The CDC guidelines for diagnosis rely heavily on the presence of erythema migrans
(EM). A case that is said to be confirmed presents in three ways: “presents with EM and has a
known exposure, presents with EM and has laboratory evidence of infection without known
exposure, and presents with at least one late manifestation that shows laboratory evidence of
infection” (Aucott et al., 2009, p. 80). The CDC also publishes guidelines for probable and
suspected cases. Probable cases are any physician-diagnosed case with evidence of laboratory
infection, while suspected cases are those that present with EM but have no exposure or
laboratory signs of infection (Aucott et al., 2009).
Therapy
Treatment therapies vary by stage of disease. Treatments have been traditionally
accepted throughout the infectious disease community, with recommendations published by the
IDSA. However, there is a community of practitioners that have questioned these practices, and
are in the process of researching new treatment modalities (Johnson, Aylward, & Stricker, 2011).
The antibiotics of choice sanctioned by the IDSA for treatment during the first phase of
Lyme disease include oral doxycycline, amoxicillin, and cefuroxime for fourteen to twenty one
days. For patients experiencing meningitis during the disseminated phase, intravenous
ceftriaxone for fourteen days is recommended. Those presenting with Lyme carditis in the
disseminated phase are recommended for two weeks of oral antibiotic treatment and
symptomatic monitoring of their conduction delays. Those carditis patients with severe
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
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conduction delays are recommended with a two week course of intravenous ceftriaxone and
cardiology management (Wormser, et al., 2006).
Patients presenting with neurological symptoms in the disseminated phase are
recommended for two to four weeks of intravenous ceftriaxone. For patients with recurring
arthritis symptoms after an initial course of oral antibiotics are recommended for another two to
four weeks on oral antibiotics. Those patients presenting with neurological problems in the third
phase of the disease are recommended for intravenous ceftriaxone for a two to four week period
(Wormser, et al., 2006).
For post treatment Lyme disease syndrome, the IDSA has no recommendations for
treatment. The IDSA stance on this phase is that the distinction is too new with no evidencebased practice guidelines yet available. They recommend further testing, with reportable results
to be evaluated by multiple researchers (Wormser et al., 2006).
Factors for Disease Promotion
Reforestation
The emergence of Lyme disease has increased as reforestation has taken place.
“Ecosystem alterations affect the emergence of the diseases by changing the ecological
system as well as the habitats of hosts or vectors” (Karjalainen, Sarjala, & Raitio, 2010, p. 4).
Studies have shown that tick abundance is prominent “in forests with a shrub layer and
deciduous litter with loamy soil” (Lubelczyk et al., 2004, p. 901). Previously, land in the
northeastern United States was used for agriculture and manufacturing. During this time period,
the deer population was not as abundant, as they had no cover or food supply. It was not until
reforestation took place in the mid 20th century that the deer population has expanded (Hoen et
al., 2009).
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
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Forest Fragmentation
Urban sprawl has contributed to forest fragmentation over the years, which in turn
promotes the incidence of Lyme disease. Forest fragmentation occurs when complete forests are
divided up into suburban communities, creating small pockets of forests within. These small
pockets of forests are able to support increased concentrations of deer, as they “benefit from the
presence of edge habitat, which provides preferred forage in abundant vegetation” (Brownstein,
Skelly, Holdfor, & Fish, 2005, p. 469). The deer population, in an ideal habitat and having a
preferred source of food, now make the perfect host for the tick.
Host Demographic
As reforestation and forest fragmentation has occurred over the last half century, the deer
population has increased. Suburban areas have promoted and protected the deer population, as
suburban homes provide vegetation in the form of landscaping that provide winter food. Most of
these communities also forbid hunting. There are also a reduced amount of predators in these
areas, so the deer population is less threatened (Brownstein et al., 2005).
Mice are the preferred host for young ticks and are found in abundance in most areas. A
twelve-year study in one county in New York discovered, as the chipmunk population decreased
there was an inverse population increase in mice. This population boom in mice brought with it
an increase in the tick population, thereby creating an environment that increased tick exposure
to humans (Keesing et al., 2009).
Human Contact
Humans are spending more time in areas where ticks are most dense. “Several studies, at
multiple scales, have found that the presence and amount of forest on, or in close proximity to,
individual properties is a good predictor of Lyme disease among members of a household”
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
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(Killilea, Swei, Lane, Briggs, & Ostfeld, 2008, p. 169). Humans are spending more time outside
for leisure and physical activity, living in communities that are encroaching further into forest
lands, and many of these people are not educated on prevention (Keesing et al., 2009).
Nursing Application
Prevention
One of the stated roles of public health nurses is to “translate knowledge from health and
social sciences to individuals and population groups while providing health education and care
management to vulnerable populations” (Capps, Pinger, Russell, & Wood, 1999, p. 2). Nurses
are in a position to educate the public on preventative measures regarding Lyme disease. Public
health nurses can participate in teaching large amounts of people the best way to prevent tick
bites, such as wearing protective clothing, tucking pants into socks, etc (Albert & Skolnik, 2008).
Nurses can also teach people to examine themselves closely after leaving areas of known tick
habitat.
Recognition
As previously mentioned, early recognition of Lyme disease is key (Capps et al., 1999).
Clinical assessment by nurse practitioners, bedside nurses, and public health nurses is crucial
when interacting with any patient, but essential in terms of recognizing Lyme disease.
Recognition of erythema migrans, neurological or cardiac symptoms, in reference to the patient’s
recent activity in a tick dense area are important in assisting diagnosis (Capps et al., 1999).
Many instances of Lyme disease are thought to be underreported due to lack of recognition of the
symptoms of the disease (Aucott et al., 2009).
Nursing Diagnosis
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
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Lyme disease, while causing a host of physical ailments, is also responsible for anxiety
related to the disease. Because of difficulty in diagnosis, some patients have seen multiple
practitioners before getting the correct diagnosis. Patient’s can be irritable or depressed,
therefore requiring reassurance and tolerance (Savely, 2008). A nursing diagnosis of
fear/anxiety related to lack of understanding of disease is applicable for these patients (Saunders,
2009).
Treatment Compliance
Because of the extended antibiotic regimen in the treatment of Lyme disease, patients
may be tempted to stop treatment early. “Compliance appears particularly problematic where
regimes are drawn out” (Manderson, 1998, p. 1024). Nurses are able to assess patients for their
susceptibility to complete treatment. Nurses are able to intervene with those patients that may be
considering stopping treatment, encouraging compliance.
Conclusion
Lyme disease is increasing in numbers and can be debilitating if not caught early.
Prevention is key in helping to stop the incidence of this disease. Educating the public on how
Lyme disease is transmitted and conditions that are favorable for tick bites will assist in
decreasing occurrence of infection. Nurses are instrumental in providing this education and they
have influence to help recognize signs and symptoms so treatment can begin. Once treatment
begins, nurses are able to assist with patient compliance and ease the fears and anxiety of the
patients suffering with this illness. Together, through education and compliance, Lyme disease
might have met its match.
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
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References
Albert, R. H., & Skolnik, N. S. (2008). Lyme disease prevention, diagnosis, and treatment.
Current Clinical Practice, 4, 235-239. doi: 10.1007/978-1-60327-034-2_15
Aucott, J., Morrison, C., Munoz, B., Rowe, P. C., Schwarzwalder, A., & West, S. K. (2009).
Diagnostic challenges of early Lyme disease: Lessons from a community case series.
BMC Infectious Diseases, 9, 79-86. doi: 10.1186/1471-2334-9-79
Brissette, C. A., Rossmann, E., Bowman, A., Cooley, A. E., Riley, S. P., Hunfeld,
K.,...Stevenson, B. (2010). The borrelial fibronectin-binding protein RevA is an early
antigen of human Lyme disease. Clinical and Vaccine Immunology, 17(2), 274-280. doi:
10.1128/CVI.00437-09
Brownstein, J. S., Skelly, D. K., Holdfor, T. R., & Fish, D. (2005). Forest fragmentation predicts
local scale heterogeneity of Lyme disease risk. Oecologia, 146(3), 469-475. doi:
10.1007/s00442-005-0251-9
Capps, P. A., Pinger, R. R., Russell, K. M., & Wood, M. L. (1999). Community health nurses’
knowledge of Lyme disease: Implications for surveillance and community education.
Journal of Community Health Nursing, 16(1), 1-15. Retrieved from http://0www.jstor.org.libcat.ferris.edu/stable/3427627?seq=1
Centers for Disease Control and Prevention. (2011). Reported Lyme disease cases by state, 20002010 [Statistical table]. Retrieved from
http://www.cdc.gov/lyme/stats/chartstables/reportedcases_statelocality.html
Deruaz, M., Frauenschuh, A., Allesandri, A. L., Dias, J. M., Coelho, F. M., Russo, R.
C.,...Proudfoot, A. E. (2008). Ticks produce highly selective chemokine binding proteins
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with antiinflammatory activity. The Journal of Experimental Medicine, 205(9), 20192031. doi: 10.1084/jem.20072689
Elsevier. (2009). Nursing diagnosis: Fear/anxiety. Retrieved from
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Halperin, J. J., Shapiro, E. D., Logigian, E., Belman, A. L., Dotevall, L., Wormser, G.
P.,...Bever, C. T. (2007). Practice parameter: Treatment of nervous system Lyme disease
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American academy of neurology. Neurology, 69, 91-102. doi:
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Harburger, J. M., & Halperin, J. L. (2011). Cardiac involvement. In J. J. Halperin (Ed.), Lyme
disease: An evidence-based approach (pp. 179-189). Retrieved from
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Savely, V. (2008). Update on Lyme disease: The hidden epidemic. Journal of Infusion Nursing,
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S.,...Nadelman, R. B. (2006). The clinical assessment, treatment, and prevention of Lyme
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LYME DISEASE: AN EVIDENCE BASED DISCUSSION
Evidence-based
Paper
Abstract,
Introduction
and Conclusion
Below
Expectations
(3 points)
Abstract poorly
written,
introduction lacks
focus or poor
conclusion. (3 of
these)
Needs
Improvement
(5 points) Abstract
poorly written,
introduction lacks
focus or poor
conclusion. (2 of
these)
Meets
Expectations
(7 points)
Abstract poorly
written,
introduction lacks
focus or poor
conclusion. (1 of
these)
15
Exceptional
Points
(10 points)
Abstract,
introduction and
conclusion wellwritten. (All)
10
(12 points)
<2 not clear:
transmission,
isolation, clinical
Evidence related presentation,
to an emerging diagnosis, and
infectious
therapy. Not
disease
supported by
literature.
(15 points)
2 - 4 not clear:
transmission,
isolation, clinical
presentation,
diagnosis, and
therapy.
Minimally
supported by
literature.
(17 points)
One not clear:
transmission,
isolation, clinical
presentation,
diagnosis, and
therapy. Not fully
supported by
literature.
(20 points)
Evidence includes
transmission,
isolation, clinical
presentation,
diagnosis, and
therapy.
Supported by
literature.
20
Factors /
situations that
promote
emerging
disease
(12 points)
<2 biological,
environmental,
societal,
behavioral,
situational factors.
Not supported by
literature.
(15 points)
2+ biological,
environmental,
societal,
behavioral,
situational factors.
Minimally
supported by
literature.
(17 points)
3+ biological,
environmental,
societal,
behavioral,
situational factors.
Not fully
supported by
literature.
(20 points)
4+ biological,
environmental,
societal,
behavioral,
situational factors.
Supported by
literature.
20
Application to
nursing
(12 points)
<2 applications to
nursing practice.
Not supported by
literature.
(15 points)
2+ applications to
nursing practice.
Minimally
supported by
literature.
(17 points)
3+ applications to
nursing practice.
Not fully
supported by
literature.
(20 points)
4+ applications to
nursing practice.
Supported by
literature.
(5 points)
5+ current
resources. 4 - 6
errors in citation:
in-text and
references.
(7 points)
6+ current
resources. 3
errors in citation:
in-text and
references.
(10 points)
8+ current
resources. <3
errors in citation:
in-text and
references.
17
96%
Subtotal
Resources
(3 points)
<5 current
resources. 7+
errors in citation:
in-text and
references.
7
LYME DISEASE: AN EVIDENCE BASED DISCUSSION
Points
Subtracted
APA Format;
Spelling &
Grammar;
Clarity of ideas
Total
Plagiarism
Late work
(5 points)
Ideas not clearly
presented. >15
errors in citation
formatting,
running head,
title, headings,
margins, spacing,
indentations,
pagination, left
justified, font,
grammar, spelling,
paragraphing,
sentence
structure,
punctuation,
capitalization,
quotations,
numbers,
abbreviations,
pronouns, etc.
(10 points)
Most Ideas clearly
presented. 11-15
errors in citation
formatting,
running head, title,
headings, margins,
spacing,
indentations,
pagination, left
justified, font,
grammar, spelling,
paragraphing,
sentence
structure,
punctuation,
capitalization,
quotations,
numbers,
abbreviations,
pronouns, etc.
16
Excessive use of
quotations
Length not 6-8
pages.
(15 points)
Ideas clearly
presented. 5-10
errors in citation
formatting,
running head,
title, headings,
margins, spacing,
indentations,
pagination, left
justified, font,
grammar, spelling,
paragraphing,
sentence
structure,
punctuation,
capitalization,
quotations,
numbers,
abbreviations,
pronouns, etc.
(20 points)
Ideas clearly
presented. <5
errors in citation
formatting,
running head,
title, headings,
margins, spacing,
indentations,
pagination, left
justified, font,
grammar, spelling,
paragraphing,
sentence
structure,
punctuation,
capitalization,
quotations,
numbers,
abbreviations,
pronouns, etc.
20
94%