Prescribing Doxycycline for Lyme to a Patient You Have Never Met

To the Editor: Two years ago, the authors established a university-affiliated center to address the clinical needs related to Lyme disease and other tick-borne illnesses. At this center, patients are seen in a dedicated clinic 2 days a week. Through our experience, we have found 2 clinical scenarios that would prompt the prescribing of doxycycline over the phone without a standard clinical encounter to a patient not in our practice. These are outlined in Table 1 below. However, apart from the implementation of expedited partner therapy in the setting of sexually transmitted infection treatment, we found no guidance in the literature for prescribing antibiotics without seeing a patient who is not in our practice.1TABLE 1: Guidelines for Prescribing Doxycycline for Lyme Without In-person Patient EncounterCenters for Disease Control and Prevention and the Infectious Diseases Society of America guidelines recommend timely treatment of Lyme in the appropriate clinical setting for symptoms such as a new rash in an individual with tick exposure in a Lyme endemic area. The concern about Lyme in the general public makes it difficult for patients to delay seeking treatment, although they are generally not severely ill enough to warrant a visit to an emergency department. We have had patients request a prescription for doxycycline who reported an appropriate exposure history and provided us with a picture of a rash indicative of early Lyme disease. Patients also needed to report practical reasons as to why they could not access an appointment with their primary care physician in the next three to five days. A course of treatment for doxycycline was initiated for 4 patients that called and met the criteria listed in Table 1. In addition, patients who live in a Lyme endemic area and have identified an embedded deer tick have called the Lyme center requesting 2 doses of doxycycline to decrease the risk of Lyme disease.2 Patients must have reliably identified it as a deer tick, not a dog tick, after consulting helpful websites such as the TickEncounter Resource Center3 or Centers for Disease Control and Prevention informational web pages.4 We have provided 6 prescriptions for a prophylactic dose of doxycycline to patients who have met the criteria listed in Table 1. Recently, a pharmacy-based program was initiated in Rhode Island where patients can receive 2 doses of doxycycline without seeing a physician (but using a physician's prescription) if they have identified an embedded deer tick and meet similar criteria to those shown in Table 1.5 Prompt and appropriate treatment of infectious diseases is always a challenge, particularly when primary care services are not readily accessible. It may be helpful to develop guidelines or suggestions for prescribing antibiotics for patients that cannot be evaluated in real time. Meghan McCarthyTimothy Flanigan, MDJennie Johnson, MDRebecca Reece, MD Division of Infectious Disease Alpert Medical School Brown University Providence, RI [email protected]