I HAVE A TICK ATTACHED!  WHAT DO I DO NOW??

DON’T PANIC!
Prompt, careful tick removal is very important in not causing accidental transmission of bacteria from the tick to the host. Tick removal instructions can be found here.

DO I NEED TO HAVE ANTIBIOTIC THERAPY FOR LYME DISEASE?

Anyone removing an engorged deer tick should call their doctor as soon as possible per Maine CDC!

Some considerations for determining whether or not to treat for a tick bite include the following:

Is this a Deer tick (Ixodes Scapularis or black-legged tick)?
There are a variety of other ticks that carry other diseases, but at this time it is not thought that other ticks transmit Lyme disease to humans.

Was the tick attached for longer than 24 hours?
Not all ticks carry infection. We know that the longer the tick is attached the higher the risk of disease transmission from an infected tick, though some other tick borne diseases may be transmitted earlier than Lyme disease. Obvious engorgement of the tick indicates a sufficiently long attachment for infection to happen, but some engorgement can occur before it is visible to the naked eye. Less than 24 hours attachment can be a low risk attachment time, but it is not always known how long the tick has been attached.

Was the tick removed easily with all identifiable parts intact?
Squeezing or damaging the tick body, or annoying the tick with applied substances increases the risk of bacterial transmission, and may increase the need for treatment. Leaving mouth parts in the wound does not increase bacterial transmission, but may cause a local infection. Ideally, you would like to have a live, active tick after removal.

Is there a rash?
When there is a single, small, eraser sized red area at the site of the tick bite in the first 24 hours, this usually indicates a local reaction to the tick bite and is not considered an Erythema Migrans, or bulls-eye rash. If there is any other kind of rash, draw an ink line around the rash and check in the following days to see if the rash increases beyond the borders of the line. The hallmark rash of Lyme disease is a red, expanding rash.
If there is such a rash present, this IS Lyme disease and must be treated with a full course of antibiotic therapy. (There are at least two views on how long to treat early Lyme disease, varying between 2 weeks to 6 weeks. See guideline recommendations www.mainelyme.org/what-is-lyme/treatment-guidelines/ According to the 2013 Lyme Legislative Report by the Maine CDC, an EM rash was present in only 51% of CDC positive cases reported for surveillance in Maine. Therefore, we cannot rely on seeing the rash as necessary for the diagnosis of Lyme disease.

Should I get tested for Lyme disease?
Test results for Lyme disease are unlikely to be positive until about 4 weeks AFTER the known tick bite. It takes our bodies that long to mount a measurable antibody response. There are problems with our current 2 tier testing methods, but the Western Blot (WB) tends to be more reliable than the ELISA. The WB was developed for surveillance purposes, but is now used for diagnosis in many instances. If you are symptomatic, but
not testing CDC positive, and unable to get any relief, you should continue to explore the issues surrounding tests and disease. Approximately 20% of individuals with well-characterized Lyme disease may have a negative test.

Should I test the tick?
Testing a tick by PCR is more reliable that other methods. If the tick tests positive it does not necessarily mean you have acquired the disease, but it may heighten your vigilance if you are taking the wait and watch approach. If you or your doctor want to send the tick for free testing in Maine, to the Maine Lyme Research Lab in Portland, the type of tick and the state of engorgement will be identified. It will not be tested for disease. Therefore, at this time we recommend sending to MMCRI for counting purposes only, those ticks which are not attached to a person, or in which the demonstration of infection will not influence the choice of treatment. There are labs around the country that will test the tick for a fee and IGenex www.igenex.com in California is one, but there are several others you can find by doing a Google search.

Can I watch and wait?
Watch and wait to evaluate for symptoms has been a realistic option in the past, but as If you and your doctor do choose to watch and wait, you must be attentive not only to the development of a rash, but also to the subtle and variable symptoms that can occur and be ready to treat aggressively if they do.

Is one (or 2 or 3) doses of Doxycycline the answer?
Choosing to treat patients with one dose of Doxycyline on tick bite as recommended by the IDSA Clinical Practice Guidelines for certain tick bites is becoming very common, may be being applied to situations for which it was not recommended, and may be very dangerous. The recommendation for this treatment came from a single study with insufficient follow up on patients who received this treatment. An ILADS physician has written a challenge to this protocol http://www.ilads.org/lyme_disease/written_testimony/5%20Maloney-Prophylaxis.pdf which may be helpful to the provider who is recommending this very short treatment. In short, the one dose of Doxycycline may prevent an antibody response, and may prevent the rash from appearing, but may not prevent disease dissemination. Opting for watch and wait may be the better choice.

Other treatment considerations
Some very small studies in the past failed to demonstrate a statistically significant benefit to treatment with 10 days of an antibiotic for tick bite. Some physicians treat tick bite as if it were early Lyme disease with 3-6weeks of antibiotic. Interesting note: A mouse study demonstrated that using a single dose of long-acting doxycycline was able to prevent Lyme disease in 100% of experimentally tick infected mice. That antibiotic was active in mice for 19 days. There has not been a similar human study.

FOR MORE DETAILED INFORMATION SEE
www.mainelyme.org

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