A patient shows you a tick that’s still attached. Do they need antibiotics to prevent Lyme disease, or is watchful waiting enough?
In this episode, TRC Healthcare Assistant Editor and Clinical Pharmacist Gina Corley, PharmD, discusses tick bites and Lyme disease prevention and treatment. She goes over how to assess a tick bite, when a single dose of doxycycline is recommended to prevent Lyme disease, and how treatment differs across the three stages of the disease.
This is an excerpt from our July 2026 Pharmacy Essential Updates continuing education webinar series.
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Transcript:
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00:00:00 Narrator
Your patient has a tick bite.
00:00:02 Narrator
How do you know if they need antibiotics?
00:00:05 Narrator
If a child has a tick bite, is doxycycline actually safe to use?
00:00:13 Narrator
Welcome to Clinical Capsules from TRC Healthcare, your trusted source for practical, evidence-based updates.
00:00:20 Narrator
On this episode, Assistant Editor and Clinical Pharmacist Gina Corley shares practical guidance on tick bites and Lyme disease prevention and treatment in an excerpt from our popular Pharmacy Essential Updates webinar series.
00:00:33 Narrator
This podcast offers continuing education credit for pharmacists and pharmacy technicians.
00:00:37 Narrator
Please log into your Pharmacistâs Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.
00:00:45 Narrator
None of the speakers have anything to disclose.
00:00:48 Narrator
Catch new episodes of Clinical Capsules every 2nd and 4th Tuesday, bringing concise, actionable insights from TRC experts straight to your ears.
00:00:57 Narrator
Let’s dive in.
00:01:04 Gina Corley
And as our article says, it’s that time of year to stay alert for tick bites and know when to recommend antibiotics for preventing Lyme disease.
00:01:15 Gina Corley
But first, let’s start with a little background about Lyme disease.
00:01:20 Gina Corley
There are many different tick species found in the United States.
00:01:24 Gina Corley
And some of those ticks carry pathogens that can cause disease in humans.
00:01:30 Gina Corley
The one we’re going to talk about today is Lyme disease, since it’s the most common tickborne disease in North America.
00:01:38 Gina Corley
Lyme disease is caused by the bacteria Borrelia burgdorferi and is spread by black-legged ticks, so either the deer tick or the western tick.
00:01:50 Gina Corley
And really the best defense against Lyme disease is preventing tick bites.
00:01:56 Gina Corley
So we can remind patients to take steps such as limiting exposure to grassy, brushy, wooded areas where ticks are more common, wearing protective clothing and treating clothing and gear with permethrin, using tick repellents, such as DEET, and checking their body and clothes for ticks after being outdoors.
00:02:18 Gina Corley
Ticks can attach to any part of the body, but tend to hide in hard-to-see spots, such as under the armpits, behind the knees, or in the hair.
00:02:29 Gina Corley
So tell patients not to overlook those areas.
00:02:33 Gina Corley
But even though prevention can greatly reduce the risk of a tick bite, these bites can still happen, such as with the patient in our case today.
00:02:45 Gina Corley
So this is Jon.
00:02:46 Gina Corley
He’s a 26-year-old patient at your pharmacy and he comes up to the counter looking a little anxious and panicky.
00:02:53 Gina Corley
He tells you he just got back from his annual family camping trip and he shows you the area behind his left knee where a tick is attached.
00:03:03 Gina Corley
So if you were in this situation, what would you do next?
00:03:07 Gina Corley
How would you advise Jon to remove the tick?
00:03:10 Gina Corley
And what kind of questions would you want to ask him to determine if he needs medication treatment?
00:03:16 Gina Corley
So if a patient comes into your pharmacy with a tick bite, the first thing we want to do is assess the bite and ask questions.
00:03:25 Gina Corley
For example, we would want to know where the patient was when the bite occurred or when they noticed the bite.
00:03:33 Gina Corley
We also want to know how long the tick has been attached for.
00:03:38 Gina Corley
Keep in mind that ticks that are attached for a longer period of time will be round or engorged, as opposed to a flat tick that hasn’t been fed yet.
00:03:49 Gina Corley
We also want to educate patients about how to monitor for early symptoms of Lyme disease, which usually occur within 30 days of the bite.
00:04:00 Gina Corley
For example, the most common symptom is a localized skin lesion, which is usually a ring-like rash around the bite with or without a bull’s-eye.
00:04:10 Gina Corley
And then if the tick is still attached, we can explain the best way to remove it.
00:04:16 Gina Corley
So of course, if patients find a tick attached to their skin, they should remove it as soon as possible to minimize infection risk.
00:04:26 Gina Corley
But there’s a right way and some wrong ways to try and do this.
00:04:30 Gina Corley
Advise patients to use fine-tipped tweezers to grab the tick close to the skin and pull it straight out slowly using steady, even pressure.
00:04:40 Gina Corley
Explain not to twist or jerk the tick as they’re pulling it out since this can cause the mouthparts to break off and remain in the skin.
00:04:49 Gina Corley
Once the tick is out, advise cleaning the bite with soap and water or rubbing alcohol and possibly saving the tick in a sealed container or taking a picture of it before disposal since knowing the species can help determine the course of action.
00:05:07 Gina Corley
Tell patients they can use websites such as TickEncounter or eTick to help identify the species if needed.
00:05:15 Gina Corley
So how do we know which patients actually need antibiotic prophylaxis for tick bites, and which ones are safe to “watch and wait”?
00:05:24 Gina Corley
A good rule of thumb is to save antibiotic prophylaxis for high-risk tick bites.
00:05:30 Gina Corley
But what medication should we recommend and how do we determine if a bite is high risk?
00:05:37 Gina Corley
Well, for the patients who need prophylaxis, we want to recommend a single dose of doxycycline to prevent Lyme disease if all of the following criteria are met.
00:05:50 Gina Corley
First, patients should be in a highly endemic area, such as the Northeast, Mid-Atlantic, Minnesota, Wisconsin, or places like that.
00:06:00 Gina Corley
And a blacklegged tick should be attached for 36 hours or more.
00:06:05 Gina Corley
And the doxycycline dose can be taken within 72 hours of tick removal.
00:06:12 Gina Corley
If all of these are true, we can recommend a single 200 milligram dose of doxycycline for adults or one dose of doxycycline based on the patient’s weight for kids.
00:06:24 Gina Corley
Now, if it’s after that 72-hour window, we should rely on “watchful waiting” instead since data are lacking about med benefit beyond that timeframe.
00:06:35 Gina Corley
So let’s go back to our patient, Jon.
00:06:39 Gina Corley
After we instruct him on how to remove the tick, we talk with him a little more and find out that his camping trip was in Wisconsin, which is a high-risk area for ticks.
00:06:50 Gina Corley
And it’s likely that the tick has been attached for over 36 hours as Jon made his way home.
00:06:56 Gina Corley
So he meets the criteria for getting doxycycline prophylaxis, which we can recommend to his prescriber.
00:07:02 Gina Corley
So now that we know about prophylaxis dosing, let’s talk about how we actually treat Lyme disease.
00:07:10 Gina Corley
There are three main categories of Lyme disease, early localized, early disseminated, and late disseminated Lyme.
00:07:18 Gina Corley
So let’s start with early localized Lyme disease.
00:07:23 Gina Corley
In this stage, Lyme disease has not yet spread throughout the body and symptoms are more localized, as the name suggests.
00:07:31 Gina Corley
Early symptoms can include a red skin rash, flu-like illness, fatigue and headache or stiff neck.
00:07:40 Gina Corley
At this stage, doxycycline is typically where we go first, and one reason why is because it can be taken as a more simple regimen.
00:07:50 Gina Corley
Adult patients can take 100 milligrams twice per day or 200 milligrams once per day, both for 10 days.
00:07:57 Gina Corley
Amoxicillin is another option, but patients would need to take 500 milligrams three times per day for 14 days.
00:08:06 Gina Corley
Similarly, patients could also take cefuroxime 500 milligrams twice per day, but it’s taken for 14 days as well.
00:08:15 Gina Corley
So we can think about amoxicillin or cefuroxime as other options when doxycycline can’t be used, such as in pregnancy.
00:08:24 Gina Corley
Keep in mind that doxycycline is appropriate even in kids under age eight for prophylaxis or early Lyme treatment.
00:08:33 Gina Corley
However, you might get a drug-age computer alert due to concern about the risk of tooth discoloration.
00:08:41 Gina Corley
So if parents are concerned with this, we can suggest one of the other two options.
00:08:47 Gina Corley
However, limited data suggest that short courses of doxycycline don’t cause tooth staining in young kids.
00:08:55 Gina Corley
Next, let’s talk about treatment for early disseminated Lyme disease.
00:09:00 Gina Corley
This stage occurs several weeks to months after the tick bite as the bacteria begins to spread throughout the body.
00:09:07 Gina Corley
Patients often get flu-like symptoms such as chills, fever, headaches, and fatigue, but this stage can also come with pain or weakness in the arms or legs, vision changes, heart problems known as “Lyme carditis,” and even facial paralysis.
00:09:24 Gina Corley
In patients that are hospitalized with Lyme carditis, or if there’s brain or spinal cord involvement, we want to suggest ceftriaxone 2 grams IV once per day for 14 to 21 days in adults, or 50 to 75 mg/kg/day doses in kids.
00:09:42 Gina Corley
Patients can eventually switch to oral antibiotics such as doxycycline once there’s clinical improvement.
00:09:50 Gina Corley
Similarly, patients who aren’t hospitalized with these symptoms can also take doxycycline 100 mg twice per day or 200 mg daily for 10 days or 4.4 mg/kg/day doses for kids.
00:10:04 Gina Corley
All right, so if Lyme disease isn’t promptly or effectively treated in the first two early stages, it can develop into “late” Lyme disease, which occurs weeks, months, or even years after the infected tick bite.
00:10:20 Gina Corley
In this stage, the bacterial infection has spread throughout the body and nervous system.
00:10:25 Gina Corley
And one of the main things we see in this stage is many patients develop chronic Lyme arthritis as well as more intense neurological and cardiac symptoms such as severe migraines or heart rhythm disturbances.
00:10:40 Gina Corley
In the case of chronic Lyme arthritis, we can use the same meds and dosages as we did in early localized Lyme disease, but this time we want to use them for 28 days.
00:10:51 Gina Corley
And then for neurologic symptoms, or if patients become hospitalized, we can treat with IV antibiotics such as ceftriaxone 2 grams once per day, like I mentioned earlier.
00:11:02 Gina Corley
So lastly, let’s go over some practice pearls when it comes to Lyme disease.
00:11:07 Gina Corley
First, if patients come into the pharmacy that are worried about Lyme disease and are having symptoms, we ultimately want to refer them to their prescriber for further evaluation, but we can also help reassure them that their risk of developing Lyme disease is low, usually around 1-3%.
00:11:27 Gina Corley
Next, for patients who do need medication, we want to tailor the chosen antibiotic to their situation, meaning that we want to consider things like age, allergies, or pregnancy status.
00:11:39 Gina Corley
Then we want to counsel patients on the antibiotics that they get.
00:11:43 Gina Corley
So for instance, we want to remind patients to take amoxicillin or cefuroxime with food and a full glass of water to help minimize stomach upset.
00:11:53 Gina Corley
We also want to remind patients that long-term antibiotics aren’t likely to help with chronic symptoms such as fatigue, pain, or cognitive impairment, and can lead to things like resistance, C. diff infection, and other problems.
00:12:08 Gina Corley
So that was a lot of information that we went over today.
00:12:11 Gina Corley
But if you’d like to know more, we have this nice chart on our website called Treatment of Lyme Disease that breaks down a stepwise approach from tick bite to treatment, and also goes over the three stages of Lyme disease in more detail.
00:12:28 Narrator
Thanks for listening.
00:12:29 Narrator
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00:12:33 Narrator
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00:12:37 Narrator
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00:12:45 Narrator
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00:12:50 Narrator
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00:12:57 Narrator
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00:13:14 Narrator
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00:13:17 Narrator
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00:13:29 Narrator
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