A new patient yesterday.
A 50 year old female developed a flu like syndrome last May. She had fever, chills and malaise. She went to her family doctor and was told she had a virus. No therapy was prescribed. Two months later she complained of persistent symptoms. She now had severe fatigue, migratory joint pains, numbness and tingling and a brain fog associated with some memory impairments and difficulty concentrating. Her doctor didn't know what she had. she requested a test for Lyme disease. The two step ELISA/WB was positive for Lyme. She was prescribed Doxycyline for 28 days. Within a week she experienced dramatic improvement and was nearly back to normal. Her physician proudly pronounced her cured. Over the ensuing 3 months all of the original symptoms returned. A second round of Doxycycline was prescribed. When I saw her yesterday she was two weeks into the course and feeling a little better. The physician would not extend the therapy beyond this second course.
Lyme is treated for 14 days, perhaps 21 or even 28 days. That's what the text books say. After all, it is new disease, very mysterious, so confusing. Doctors feel obligated to follow the textbooks- to stay in their safe zone.
I once heard that doctors treat things for 10 days because we have 10 fingers on our hands. They treat for seven days because there are seven days in the week. Is this true???
Suppose a patient came into the same doctors office with sinusitis. Recommendations for the length of therapy vary, in part based on which antibiotic is chosen. Doctors are taught that antibiotics penetrate poorly into the sinus cavities. For the sake of this discussion let us say that the physician prescribed an antibiotic for 10 days. Perhaps the same patient returned after 10 days feeling somewhat better, but complained of persistent sinus pain and bloody green mucous. The physician then prescribed another course of antibiotics, this time for 14 days. Subsequently, the patient was still unimproved. The physician then ordered a CT scan which showed infection of the frontal and ethmoid sinuses. The concerned doctor quickly started IV antibiotics; after all, this sort of infection can spread into the brain and be deadly.
The point here is a clear. A physician will not stop treatment because textbook guidelines say that drug X should be used for Y days, for a particular infection: Y days exactly, not Y+1 or Y-2. No. The treatment stops when the patient is better.
Unless of course you have Lyme disease. Lyme has different rules.
Sinusitis is a common, generally self limited disease. Even without treatment it generally resolves. Lyme is a much more serious disease. Extension into the brain, past the blood brain barrier is the rule, not the exception.
What are these doctors thinking? Even the IDSA says its guidelines or just that, "guidelines." Treatment decisions should be individualized with each patient.
Perhaps they are not (thinking).