Antibiotic Therapy
The following is an excerpt from "An Overview of Lyme Disease and Hyperbaric Oxygen (HBO) Therapy" by
Mitchell L. Hoggard and L. James Johnson. The article can be found in it's entirety at http://www.hbotoday.com/treatment/lymedisease.shtml
Lyme disease is a bacterial infection and like other bacterial infections it is treated with antibiotics. Antibiotics are administered orally, with intramuscular (IM) injections, or intravenously (IV) through the veins. Physicians often prescribe combinations of antibiotics to take advantage of the diverse ways that individual antibiotics affect the Bb organism.
Physicians not only prescribe more than one oral antibiotic at a time, but they combine oral antibiotics with IM or IV antibiotics. This shotgun (or multiple) approach to antibiotic therapy is used in hopes of affecting the Bb organism in as many ways as possible.
Just as no two Lyme patients appear to be affected by Lyme bacteria in the same way, a patient's response to antibiotic therapy is highly individual, too. The individual nature of an antibiotic's effect on a patient is believed to be due in part to the theory that different strains of the bacteria react differently to each antibiotic.
Other factors may include the duration of infection, the amount of time between the onset of symptoms and treatment, and the location of the Bb organism in the body. Also, co-infections or the transmittal of more than one infectious disease, can occur from a single tick bite. This can make diagnosis and treatment more difficult still.
Co-infections
Co-infections may include more than one strain of the Bb organism and may include the tick-borne disorders of babesiosis and/or ehrlichiosis. Babesiosis and ehrlichiosis are also bacterial infections that present Lyme-like symptoms. However, treatment is often handled in a different manner from Lyme disease. Babesiosis requires a treatment program that is altogether different from antibiotic therapy for Lyme disease. Not all antibiotics that are used to treat Lyme disease are effective in treating ehrlichiosis.
Information on Lyme disease and co-infections is relatively new. It is highly recommended that those suffering from long-term, chronic symptoms be tested for babesiosis and ehrlichiosis if they have not already done so. Obviously, patients who have recently been diagnosed with Lyme disease should make sure that they are tested for co-infections, too.
It is our experience that many Lyme patients have not been tested for babesiosis and ehrlichiosis. This is a situation in which many patients, and health care professionals alike, have not yet adopted the most current medical practices.
Testing is a Problem
The diagnosis of Lyme disease remains clinically basedthat is, a diagnosis based primarily on symptoms alone because, unfortunately, there is no test available that is 100 percent accurate to rule out or confirm the infection. False positive results and false negative results are common. Accordingly, the patient's entire clinical picture is taken into account when diagnosing and treating Lyme disease.
We can better understand the lack of proper testing for Lyme disease by identifying the fact that there is not a common test that allows health care professionals to accurately determine if Lyme bacteria are present in the body.
Amazingly, the lack of a common test also means that medical science cannot precisely determine whether someone is cured. This leads to contradictory treatment protocols and results in treatment guidelines that are more guesswork than many patients prefer, and less exact than many physicians and health insurance companies are comfortable with.
Science in general, and medical science in particular, prefers absolute and unmistakable testing, data and conclusions on which to base treatment protocols (or guidelines). Lyme disease was not recognized in the United States until 1977. Scientific research is lagging and there is much we don't know. Based on current scientific knowledge, the diagnosis and treatment of Lyme disease cannot be absolute and unequivocal. Instead, and no matter how unsettling this may be, until research catches up, the treatment of Lyme disease cannot be anything but subjective, open to question, individualized, and often complex.
Current Testing
The most common and current tests that are available today are limited to determining if antibodies to the Bb organism exist. The body creates antibodies after being exposed to the Bb organism. Lyme antibodies can remain in a person's body long after the Lyme organism has been eliminated. This means that a positive Lyme antibody test does not accurately indicate if active Lyme bacteria continue to be present in the body.
The ELISA and Western Blot tests are the most common tests currently used to confirm the presence of Bb antibodies. Current testing protocols were proposed in 1994 at the Second National Conference on Serological Diagnosis of Lyme Disease. A two-step process was established. The first step calls for a test such as the ELISA to be conducted. If positive, a Western-blot test is done in hopes of confirming that Lyme antibodies exist. However, even if Lyme antibodies exist, it does not mean that the patient has Lyme disease.
Further complicating matters is the fact that antibody tests can confuse Lyme antibodies with antibodies created by other complications in the body, including antibodies created in reaction to bacteria other than the Bb organism. This means that most of the current tests are not completely accurate. It also means that it is not uncommon to receive false positive and false negative results when using the ELISA or Western Blot tests.
In other words, a negative test result cannot guarantee that Lyme antibodies do not exist. Conversely, a positive test result cannot guarantee that you actually have Lyme antibodies in your system. In both cases, accurate positive antibody test results do not mean that you even have active Lyme bacteria in your system. As we stated earlier, a positive antibody test result does not mean that you have Lyme disease.
The PCR Test
Three final notes on testing. First, some physicians use a Polymerase Chain Reaction (PCR) test to confirm that Lyme bacteria are present in the body. The PCR test is relatively new. It is designed to confirm that Lyme bacteria DNA are present. A positive PCR test almost always guarantees that you have Lyme disease, depending upon the accuracy of the lab that performed the work. However, because it can be difficult to isolate the Bb organism's DNA, a negative PCR test does not eliminate a Lyme disease diagnosis. The PCR test is usually more expensive than the ELISA or Western Blot antibody tests.
The second note on testing has to do with the fact that test results often vary depending upon which lab performs the test. Some Lyme patients assume that testing for Lyme diseaseand the test results are uniform, standard and guaranteed. They are not. When we combine this fact with what we have already learned about testing for Lyme disease, it becomes obvious that the diagnosis of Lyme disease is not an exact science.
Jarisch-Herxheimer Reaction
A proper understanding of the Jarisch-Herxheimer reaction has helped Lyme specialists better manage the diagnosis and treatment of Lyme disease. This is especially true in light of inadequate testing. A Herxheimer reaction occurs in Lyme patients after they begin antibiotic therapy.
It is important to note that a Herxheimer reaction is not a common reaction that is associated with most other diseases or with other viral, bacterial or fungal infections. A Jarisch-Herxheimer reaction is limited to a few specific bacterial infections such as syphilis and Lyme disease. It is interesting that syphilis and Lyme disease stem from spirochetal or spiral-shaped bacteria.
A Herxheimer reaction occurs when symptoms recur, flare up or become exaggerated. Some call it a healing crisis, while others describe it as getting worse before you get better. Lyme patients refer to this reaction as a herx, or say that they are herxing.
A Herxheimer reaction usually occurs within days to weeks of starting antibiotic therapy. When antibiotics directly kill Lyme bacteria or work with the body's immune system to kill the organism, toxins are released that cause either "direct reactions or indirect actions through stimulation of the immune system."5
In simpler terms, a Herxheimer reaction occurs when Lyme bacteria are killed off more quickly than the body's organs (kidneys and liver) are able to process them. This increases the number of toxins in the blood stream. The higher the toxin count, the more severe the symptoms the patient experiences.
Without accurate testing, the Herxheimer reaction is often used as a clinical diagnostic tool to help determine the presence of the Bb organism. It can also be used to confirm the effectiveness of specific antibiotics or combinations of antibiotics.
Specifically, some health care professionals believe that a Herxheimer reaction can confirm that the Bb organism is present in the body by the fact that a bacteria die-off is causing the herx. Thus, for the frontline physician, the Herxheimer reaction can assist in the clinical diagnosis by unofficially confirming the presence of the Bb organism.
The Politics of Lyme Disease
This leads us to a pivotal and controversial issue that divides the medical community concerning the diagnosis and treatment of Lyme disease.
Some health care professionals are more tradition-bound and conservative in their approach to Lyme disease. They have adopted protocols for treating Lyme that don't go much beyond relatively short-term antibiotic therapy. This group believes that in almost all cases, one or two courses of oral antibiotics are all that are required to eradicate the bacteria. They believe that persistent, chronic Lyme symptoms are not the result of an ongoing infectionof active Lyme bacteria in the bodybut rather, are probably the result of a dysfunctional auto-immune system response or some other process occurring in the body.
Others, especially those physicians who remain on the frontline of the long-term treatment of Lyme patients, believe that Lyme bacteria are not always eliminated by short-term courses of antibiotics. They believe that this is especially true if the disease went undiagnosed and untreated for months or years following infection.
Further, this latter group believes that the Bb organism can persist through months and even years of antibiotic therapy, depending upon a wide range of individual factors relating to the patient and to the strain(s) of bacteria. The survival characteristics of the bacteria themselves also play a crucial role in Lyme bacteria's persistent longevity.
Survival Tactics?
Research has shown that the Bb organism can use the body's own protein to encapsulate itself. 6 This is also described as the Lyme bacterium shifting to a dormant or sleeping state. The reason that the organism undergoes this change is not fully understood. Some believe that this is a survival tactic because it may not be possible for our immune system to destroy the bacterium when it is in this state. Also, antibiotics may have little or no effect on the Bb organism when it is encapsulated and dormant.
Research also shows that the Lyme bacterium appears to be able to enter certain types of human cells. This ability may also be considered a survival tactic because it results in the bacterium evading some or all antibiotics as well as the body's immune system.
Alternative Health Care
Antibiotics are the main tools that medical science uses to combat Lyme bacteria. However, it is our experience that many Lyme patients invest time, money and energy into exploring non-antibiotic, alternative health measures to treat Lyme symptoms. These can vary from taking supplements to visiting alternative health care practitioners.
This area is much too large and diverse to explore in this article. Suffice it to say that Lyme disease is a highly individual ailment. Not only are symptoms experienced individually (and differently) by each Lyme patient, but every form of treatment (including antibiotic therapy) works differently for each individual. We do not know why this is so.
Most chronic Lyme patients have learned through experience that ultimately, it is their responsibility to manage their own health care. Many Lyme patients have made a conscious decision to explore alternative health care practices along with exploring conventional medical practices with their physician(s). We encourage responsible curiosity in both areas.
Antibiotics
Because antibiotics are the main tools that are used to fight Lyme disease, we can gain a better understanding of Lyme disease if we better understand how antibiotics affect the Bb organism. For a better understanding of how antibiotics work it helps to understand the mechanism of action they employ. Generally speaking, antibiotics fall into two categories:
Bactericidal: An agent that directly destroys bacteria.
Bacteriostatic: An agent that arrests or hinders the growth of bacteria.
Antibiotics that are bactericidal (for example, think homicidal) can directly attack the cell wall of the bacteria. This causes a rupture and the death of the organism follows. Antibiotics from the penicillin family of antibiotics are usually bactericidal, unless concentrations fall too low.
Antibiotics that are bacteriostatic (for example, think manipulative) do not directly attack bacteria. Instead, they interfere with the ability of the organism to reproduce. Without the ability to reproduce the bacteria can eventually die out.
Bacteriostatic antibiotics include tetracyclines such as Doxycycline. It is important to remember that most antibiotics can be both bactericidal and bacteriostatic, depending upon the amount or concentration of the antibiotic in the body. More clearly still, most bacteriostatic antibiotics can become bactericidal if the concentrations are strong enough.
One of the main points to understand about bacteriostatic antibiotics is that they are usually effective in debilitating bacteria only when bacteria reproduce. This is significant for two reasons. First, it is believed that dormant Lyme bacteria don't reproduce, which diminishes bacteriostatic antibiotic's effectiveness in fighting Lyme disease.
Second, Lyme bacteria have a long reproductive cycle. A mature Lyme bacterium reproduces once every 7 hours or so. This reproductive cycle may vary from species to species. In comparison, some species of the strep throat bacterium reproduce once every 20 to 30 minutes. It is not known how many reproductive cycles are needed before all Lyme bacteria are debilitated by antibiotics.
However, according to Karen Vanderhoof-Forschner in her book, Everything You Need To Know About Lyme Disease, the strep bacterium is normally treated with antibiotics through 480 reproductive cycles7. She says that if we were to treat Lyme disease through the same number of cycles it would take somewhere between 5 to 30 months of antibiotic therapy. If this is true, it is significant that some physicians follow a protocol for treating Lyme disease that allows just two to six weeks of antibiotic therapy. Based on the above scenario this may be inadequate.
If either of the above examples are true, this may mean that physicians who are acting in good faith by using conservative treatment protocols may actually be prolonging and thus complicating Lyme infection in their patients. However, much of this theory is speculative. Obviously, more research is needed.
Devastating Survival Tactic?
We have discussed how it is believed that Lyme bacteria primarily use two methods of invading the body's immune system and evading certain antibiotics. If the theory behind this belief is true then the two methods of evasion used by the Bb organism include:
-- The Lyme bacterium encapsulates itself in the body's protein (the cell wall membrane) and lies dormant for undetermined periods of time.
--The Lyme bacterium hides by entering the body's cells.
In both cases the bacteria may be able to evade the body's specialized defensive mechanisms, along with evading the offensive mechanisms of antibiotics.
However, the final piece of this puzzle has to be considered a genetic marvel no matter how devastating it is to Lyme patients. When Lyme bacteria shift from a dormant to an active state they can resume reproduction and effectively re-seed the body. This reestablishes the Lyme infection.
If it is true that dormant bacteria can wake up and re-seed the body, this particularly devastating maneuver indicates that short-term courses of antibiotics may be ineffective in eradicating Lyme bacteria from the body.
Mechanism of Action
Antibiotics and other anti-infective agents (anything that counteracts infection) can kill different kinds of bacteria. However, an antibiotic's mechanisms of action, or how they kill bacteria, varies depending upon the type of antibiotic used.
Because the mechanism of action varies among antibiotics and anti-infective agents, a specific antibiotic, or specific combinations of antibiotics, may be a better choice than other combinations when attempting to eradicate the Bb organism.
For example, Zithromax (azithromycin) is known to have higher tissue concentration levels when compared to the blood concentration levels it usually attains. Zithromax is also known to have an ability to penetrate some cells in our body more effectively than other antibiotics. This may have an added benefit when treating the Bb organism because we believe that Lyme bacteria have the ability to enter certain types of our cells.
Later, we will discuss in more detail why specific combinations of antibiotics work better than other combinations when treating Lyme disease. At this point we simply want to identify how the treatment of Lyme disease becomes a complex task with a myriad of options and protocols that are dependent upon an ever-widening circle of circumstances.
As we stated earlier, until research catches up, the treatment of Lyme disease cannot be anything but subjective, open to question, individualized, and often complex.
Between a Rock and a Hard Place
While the medical community waits for research to help our understanding of how we can better detect the Lyme organism, frontline Lyme physicians are left with the question, "What is the best way to treat chronic Lyme symptoms?"
Many of these physicians emphatically state that their experience indicates that the effects of long-term antibiotic therapy are a lesser consequence compared to what life would be like for their patients if they were left untreated and the bacteria left unchecked in their system.
The Lyme controversy is fueled by the fact that current Lyme testing cannot definitively prove or disprove the presence of active Lyme bacteria in a person's body. Not having an accurate Lyme test forces physicians to rely on less than exact medical science.
The alternative is to rely on no treatment at all. Thus, the controversy shows no sign of abating as long as testing methods that conclusively determine the existence of active Lyme infection remain unavailable to the frontline physician.
A final comment on Lyme disease. The medical community will continue to be perplexed and divided about Lyme disease until proper testing options become available. This has serious consequences for Lyme patients who are often left to fend for themselves in a confusing and contradictory medical environment.
In an ideal world, people who are in various stages of illnessmany of whom have been incapacitated by their Lyme symptomsshould not be put in this situation by a medical system whose purpose is to help, not frustrate their recovery.
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