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Camping with Ticks – Prevent Lyme and RMSF with Doxycycline
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Camping with Ticks – Prevent Lyme and RMSF with Doxycycline

Ticks might be scarier than bears.
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Gail Ingram is an Adult Health Nurse Practitioner, former Girl Scout, and self-proclaimed campfire chef.  Using personal experience, she explains how she handles the growing tick, Lyme, and Rocky Mountain Spotted Fever [RMSF] problem in her professional practice.


I just returned from a short trip to Stokes State Forest in New Jersey where I rented a rustic cabin for 3 nights and enjoyed 4 full days of outdoor activity in the woods. Unlike my previous visit to Stokes (when I encountered 6 bears), this time I encountered 7 TICKS. I discovered one crawling on my pants, one on my finger, one on my friend’s leg, another on my bed AFTER I got home, pieces of a tick in my post-camping bathwater, and another climbing up my NYC bathroom wall.

Adult female dog tick brought home from Stokes.

Dog ticks don’t spread Lyme, but they can carry other bacteria, specifically Rocky Mountain Spotted Fever [RMSF].  Note that dog ticks have a silver head.

 

Prior to this, I had only seen ticks when patients brought them into my office for bacterial analysis.  Testing ticks can help determine if a patient is at higher risk for being infected.  However, the test results are not definitive for making a diagnosis; there are a lot of variables.

My patient’s adult female deer tick.

Deer ticks can be infected with the bacteria that cause Lyme.  Note that deer ticks have black legs and a black head.

 

Because I have easy access to medication, I took a single 200mg dose of doxycycline hyclate, a broad-spectrum antibiotic that kills most bacteria spread by ticks. This medication regimen is known to prevent the onset of Lyme disease or RMSF if taken within 72 hours of a tick bite.  However, my use of the drug is controversial.

There are providers who won’t prescribe doxycycline for the prevention of tick-borne illnesses unless patients meet specific criteria: Patients must have pulled a tick from their skin and the tick must have been latched on for over 36 hours and/or the patient must present with a rash.  This is a simple and popular approach to managing tick bites that was outlined in the 2006 Infectious Disease Society of America’s guidelines.  However, I don’t believe that strict adherence to these guidelines is always the best action.  Let me explain further by using my own experience.

  • Was I bitten?  I’m not sure, maybe.  Most ticks release an anesthetic when biting, so their activity goes undetected by their victims. It is possible that I was bitten and didn’t feel it.  Half of all people infected with RMSF don’t recall having been bitten.
  • Were any of the ticks engorged to the degree that I would expect after 36 hours of continuous feeding? I’m uncertain because I couldn’t fully assess the size of the waterlogged tick I found in my bathwater.  But more importantly, recent research from 2015 states that infection transmission might be immediate in some cases.
  • Did I have a bullseye patch or a spotty rash that is typical of a tick-borne infection? No, not that I could see, but not all tick bites result in a rash.  Up to 30% of cases have no skin changes.

Let’s also consider the emotional issues surrounding tick bites. Physical symptoms usually appear within days or weeks of the bite but there have been cases of delayed reactions up to 30 days after exposure.  I don’t want the thought of contracting a tick-borne illness to distract me for the next month.  I will be concerned that any fatigue or joint pain I experience is the onset of Lyme.  And what about the ticks that I brought home with me?  They can survive for up to 18 months without feeding.  I can’t live in fear, wearing DEET like perfume, and performing tick checks for the next year and a half.  That will drive me crazy.

 

It’s unlikely that I was infected with Lyme, RMSF, or another tick-borne illness during my Stokes trip.  But given new evidence, multiple variables, and a dramatic increase in the number of ticks and incidence of illness, I’m not ready to dismiss the small chance that I did.  Because I tolerate antibiotics well and doxyclycline has few side effects (it’s often prescribed long-term to control acne), I didn’t hesitate to take it.  I know other providers (yes, medical doctors) who do the same thing for their family and friends.

Of course I will continue to be vigilant about preventing tick bites, but I feel better knowing there is a drug in my medicine cabinet that I can fall back on.  But what about campers who don’t have their own prescription pads?  My advice is to visit your provider and fully explain the situation.  If your provider doesn’t have time to listen or to fully explain their position on preventative antibiotics, maybe you have the wrong provider.  Some providers don’t understand that guidelines are just that–guidelines.  They are a tool to guide a provider’s decision-making, but they aren’t always appropriate for every situation.

It is up to each individual provider to decide, based on a patient’s unique history and experience, if they want to follow the guidelines or not.  Safety is the biggest consideration when practicing outside of established guidelines, and your provider should compare the worst possible outcome for each scenario.  For me, the risks associated with constant worry and possible infection outweigh the risks of taking a single dose of doxycycline.

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A note from NurseGail.com:  If you suspect a tick-related infection, see your primary care provider. Doxycycline is well tolerated by most healthy adults excluding pregnant women.  The CDC wants you to know, if antibiotics aren’t helping, you might not have Lyme or RMSF.

 

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10 Comments

  • James says:

    Growing up on Long Island I saw a lot of Lyme. Lately I was wondering why it seems to be coming up more frequently. I’m wondering if you agree with my theory that it’s got to do with climate change?

  • Angelica Porres says:

    Great post Gail! Quick question regarding Doxycycline. I’ve heard that antibiotics majorly screw with the gut biome. Is this true, and if so how do the risks compare?

  • Diane says:

    Very interesting! Your post caught my eye because my brother-in-law was hospitalized over the weekend with Lyme disease. The concept of preventative antibiotics was new to me.

  • Leo Herndon says:

    Thanks for the article!

  • Protect Patients says:

    You are actually really terrible for medicine. Throwing antibiotics or steroids at everything doesn’t make you a great provider except to naive people like Diane above. I WISH you could spend a day in medical school or medical residency and get the grilling we would get and understand the reason you can’t just throw antibiotics or steroids at everything.

    • Gail Ingram NP Gail Ingram NP says:

      You are making some sweeping generalizations without much information. If you are truly in medical school, I hope you do not use this approach when treating patients. Your comment does nothing to present medicine and doctors in a favorable light.

  • Owen says:

    What a fascinating if not terrifying article. And kudos for you in ignoring evidence based guidelines, how compassionate of you!

    Just one question. If the tick can be attached to me and I don’t know it, and the infected tick can live on my house for 18 months, how often should I take prophylactic doxycycline? I would assume but what you said, every 72 hrs for 18 months after any exposure to a lyme endemic area.

    Before physicians are granted prescribing privileges they take a Hippocratic oath that states they will do no harm. This includes both intentional harms, and unintentional harms such as side effects or antibiotic resistance from sloppy prescribing practices. I would be very careful with your laissez-faire antibiotic prescribing practices, especially when you are going against published guidelines. Side effects are fairly uncommon, however when you increase prescribing, you increase your incidence of side effects. That is why the prescribing of antibiotics unnecessarily is discouraged (well that and the fact that you are contributing to the ever worsening state of antibiotic resistance).

    Also, just a small point, but you misrepresent the guidelines. The guidelines say nothing about a rash for prophylactic dosing. Erythema migrans points to a Lyme infection (beyond prophylaxis at this point). The guidelines state that a prophylactic dose can be given (if doxycycline is not otherwise contraindicated) to a patient that has had an exposure to the known vector Ixodes scapularis (deer tick) with an attachment of around 72 hours (from history or degree of engorgement) and was in a tick endemic area (local infection rate of around 20%). The dose should be given within 72 hrs of tick removal.

    • Gail Ingram NP Gail Ingram NP says:

      I do not ignore guidelines and I do not have a laissez-faire attitude toward prescribing medication. You clearly know nothing about me, my practice, or the purpose of the blog post. The guidelines linked in the post were established over a decade ago and new research has emerged. The links to the new literature are also provided. The guidelines associated with Lyme prevention are due for review. Not only do I use guidelines, I supplement my practice with new peer-reviewed information, and collaborate with colleagues. This post serves to show that I empathize with my patients, that new data is emerging, and providers need to listen to their patients and treat each one on a case-by-case basis.

  • Dana says:

    What happens if I take 200 mg of Doxy 5 days after the tick bite, is that any good? I do not want to take for 21 days

  • Dana says:

    https://www.hopkinsarthritis.org/arthritis-info/lyme-disease/lyme-disease-treatment/

    Lyme Disease Treatment Research Overview
    In a study by Nadelman, et.al., they compared treatment with placebo versus a single 200-mg dose of doxycycline in 482 subjects who had removed attached I. scapularis ticks from their bodies within the previous 72 hours. Erythema migrans developed at the site of the tick bite in a significantly smaller proportion of the subjects in the doxycycline group than of those in the placebo group (1 of 235 subjects [0.4 percent] vs. 8 of 247 subjects [3.2 percent], P<0.04). The efficacy of treatment was 87 percent (95 percent confidence interval, 25 to 98 percent). Objective extracutaneous signs of Lyme disease did not develop in any subject, and there were no asymptomatic seroconversions. These data suggest that a single 200-mg dose of doxycycline given within 72 hours after an I. scapularis tick bite can prevent the development of Lyme diseas

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