Lyme Disease: An Evidence Based Discussion



Lyme Disease: An Evidence Based Discussion

Jamie Kruger

Ferris State University

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

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 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).

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 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 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 evidence-based 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).

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” (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, 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.

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

Centers for Disease Control and Prevention. (2011). Reported Lyme disease cases by state, 2000-2010 [Statistical table]. Retrieved from

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 with antiinflammatory activity. The Journal of Experimental Medicine, 205(9), 2019-2031. doi: 10.1084/jem.20072689

Elsevier. (2009). Nursing diagnosis: Fear/anxiety. Retrieved from

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 (an evidence-based review): Report of the quality standards subcommittee of the American academy of neurology. Neurology, 69, 91-102. doi: 10.1212/01.wnl.0000265517.66976.28

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

Hoen, A. G., Margos, G., Bent, S. J., Diuk-Wasser, M. A., & Barbour, A. (2009). Phylogeography of Borrelia burgdorferi in the eastern United States reflects multiple independent Lyme disease emergence events. Proceedings of the National Academy of Sciences, 106(35), 15013-15018. doi: 10.1073/pnas.0903810106

Johnson, L., Aylward, A., & Stricker, R. B. (2011). Healthcare access and burden of care for patients with Lyme disease: A large United States survey. Health Policy, 102, 64-71. doi: 10.1016/j.healthpol.2011.05.007

Karjalainen, E., Sarjala, T., & Raitio, H. (2010). Promoting human health through forests: Overview and major challenges. Environmental Health and Preventative Medicine, 15(1), 1-8. doi: 10.1007/s12199-008-0069-2

Keesing, F., Brunner, J., Duerr, S., Killilea, M., LoGiudice, K., Schmidt, K.,...Ostfeld, R. S. (2009). Hosts as ecological traps for the vector of Lyme disease. Proceedings of the Royal Society, 276, 3911-3919. doi: 10.1098/rspb.2009.1159

Killilea, M. E., Swei, A., Lane, R. S., Briggs, C. J., & Ostfeld, R. S. (2008). Spatial dynamics of Lyme disease: A review. EcoHealth, 5, 167-195. doi: 10.1007/s10393-008-0171-3

Lubelczyk, C. B., Elias, S. P., Rand, P. W., Holman, M. S., Lacombe, E. H., & Smith, R. P. (2004). Habitat associations of Ixodes scapularis (Acari: Ixodiae) in Maine. Environmental Entomology, 33(4), 900-906. Retrieved from

Manderson, L. (1998). Applying medical anthropology in the control of infectious disease. Tropical Medicine and International Health, 3(12), 1020-1027. doi: 10.1046/j.1365-3156.1998.00334.x

Nau, R., Christen, H., & Eiffert, H. (2009). Lyme disease- Current state of knowledge. Deutsches Ärzteblatt International, 106(5), 72-82. doi: 10.3238/arztebl.2009.0072

Rathinavelu, S., Broadwater, A., & de Silva, A. M. (2003). Does host complement kill Borrelia burgdorferi within ticks? Infection and Immunity, 71(2), 822-829. doi: 10.1128/IAI.71.2.822-829.2003

Savely, V. (2008). Update on Lyme disease: The hidden epidemic. Journal of Infusion Nursing, 31(4), 236-240. doi: 10.1097/01.NAN.0000326832.59655.d7

Wormser, G. P., Dattwyler, R. J., Shapiro, E. D., Halperin, J. J., Steere, A. C., Klempner, M. S.,...Nadelman, R. B. (2006). The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: Clinical practice guidelines by theinfectious diseases society of America. Clinical Infectious Diseases, 43(9), 1089-1134. doi: 10.1086/508667

|Evidence-based Paper |Below Expectations |Needs Improvement |Meets Expectations |Exceptional |Points |

|Abstract, Introduction |(3 points) Abstract |(5 points) Abstract poorly |(7 points) Abstract poorly|(10 points) Abstract, |10 |

|and Conclusion |poorly written, |written, introduction lacks |written, introduction lacks|introduction and conclusion| |

| |introduction lacks focus or|focus or poor conclusion. (2|focus or poor conclusion. |well-written. (All) | |

| |poor conclusion. (3 of |of these) |(1 of these) | | |

| |these) | | | | |

|Evidence related to an |(12 points) |(15 points) |(17 points) |(20 points) |20 |

|emerging infectious | ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download