Lyme diseaseThe Lyme disease or Lyme disease is a multisystemic infectious disease caused by the bacteria Borrelia burgdorferi or related species in the spirochete group. The disease can affect any organ, especially the nervous system and joints. The disease occurs in humans. Found in all mammals as well as birds. Transmission occurs primarily through the wood tick (Ixodes ricinus), a tick species; very rarely also caused by mosquitoes or horseflies. 
Discovery and naming
The name Lyme disease is composed of the names of the towns of Lyme and Old Lyme in the U.S. state of Connecticut, where the disease was first described in 1975 after the frequent occurrence of joint inflammation in connection with tick bites, and of the name of the family of pathogens named after the French bacteriologist Amedee Borrel. The physician and bacteriologist Willy Burgdorfer succeeded for the first time in 1981 in detecting a pathogen from ticks and in 1982 in cultivating it. In his honor this germ was named Borrelia burgdorferi named.
The causative agent of Lyme borreliosis is distributed worldwide. In Germany there is a south-north gradient in the infestation of the wood tick. While the tick population in the northern states of Germany is said to be only about 6 to 10 percent infested with Borrelia, the rate of infection in southern and central Germany is significantly higher. Regionally, every second tick can also be a carrier of Borrelia bacteria. However, there is a lack of current and sufficiently comprehensive studies for Germany.
There is a lack of comprehensive epidemiological studies and data on the spread and risk of infection not only of the individual genospecies for humans. Likewise, the pathomechanisms, the course of the individual disease manifestations and their treatability are still insufficiently researched. In contrast to the related disease syphilis, which is transmitted by lice Borrelia recurrentis as well as TBE, which is also transmitted by ticks, Lyme disease was not included in the Infection Protection Act. In the new federal states and Berlin, however, there is an obligation to report the disease Lyme borreliosis, which is regulated at the level of the federal states. Here, the case definitions of the Robert Koch Institute are used as a basis, which, however, only provide for the reporting of erythema chronicum migrans, early neuroborreliosis and Lyme arthritis. However, erythema migrans occurs in only about 50% of new cases.
In the DNA sequencing of the 5300-year-old glacier mummy otzi traces of Borrelia burgdorferi found. This makes it the oldest documented case of Lyme disease in human history. The first ever detection in a non-living individual. 
Risk of infection and rates of infestation
Lyme borreliosis is the most common tick-borne disease in the northern hemisphere.  Borrelia infection by ticks is – in contrast to TBE, which is caused by viruses – possible throughout Germany and even in cities. As a study of the Robert Koch Institute in cooperation with the National Reference Center for Borrelia at the Max von Pettenkofer Institute for Hygiene and Microbiology in Munich showed, “direct contact with bushes in gardens, especially near forests, poses a hitherto underestimated risk of contracting Borrelia burgorferi via tick bites on [. ] Lyme disease to be contracted".  However, not every tick bite results in a Borrelia infection or even a Lyme disease. According to an estimate by the Robert Koch Institute, the probability of contracting Lyme disease after a tick attack suffered in Germany is 1 in 300.
The infestation rates of ticks with Borrelia vary depending on the region and range from ca. 5 to well over 40 percent. On average, the infestation rate in Germany is about 20 percent. Researchers ame that in high-risk areas, such as z. B. in parts of southern Germany, from 30 to 50 percent of ticks infected with borrelia. In the region of Constance at Lake Constance, the average infestation rate of ticks with Borrelia (B. burgdorferi species) at 35 percent.  In the English Garden and the Isar meadows in Munich, more than 30 % of the ticks found were infected with Borrelia bacteria. 
In Germany, most of the Borrelia treatment cases billed by health insurance physicians occurred in Brandenburg, Saxony and Bavaria along the border to Poland and the Czech Republic; other focal points were Franconia and parts of the Palatinate.  A legal obligation to report Lyme disease exists only in Berlin and the new federal states. There, more than 5000 new cases are reported to the Robert-Koch-Institute per year. About 70 percent of all reported cases occurred in June through September.  This corresponded to an incidence (number of new cases occurring in a population per year) of more than 30 cases per 100.000 inhabitants, with individual counties having incidences above 150 (for comparison, if the incidence for TBE in a county exceeds 1.0 per 100 in a 5-year average.000 inhabitants, it is defined by the RKI as a TBE risk area  ).
For Austria, incidences of between 135  and 300  per 100.000 inhabitants, for Switzerland between 25  and 30.4  species .
At the University of Heidelberg the risk of infection was determined in a study according to of a tick bite was determined: According to this, an average of 3.3 percent of all persons bitten by ticks became infected. However, if one considers only the ticks infected with Borrelia burgdorferi infested ticks, the risk of becoming infected is 25.6 per cent. The infestation rate of the ticks amounted to 11 percent.  With a higher infestation rate, a higher risk of infection after a tick bite can be amed.
In a consensus paper published in 1998 by leading Lyme disease researchers in Germany, the following information can be found on the probability of contracting the disease after a tick bite (data for the whole of Germany, regardless of whether the ticks were infected or not):
– Seroconversion, i.e. the response of the immune system to the pathogen after infection, is to be expected in 2.6-5.6% of those affected – but manifest disease in only 0.3-1.4%.
There are no reliable figures on this. If these figures are taken as a basis, it can be amed that 25 to 50 % of the persons infected with Borrelia also fall ill with Lyme disease in the further course of the disease. Research is currently ongoing to determine whether the different genospecies of Borrelia burgdorferi Causal factors for the various clinical pictures are. These may not always be correctly diagnosed as "Lyme disease" by physicians.
A prophylactic one-time administration of antibiotics – at least after a tick attack in a high-risk area – is recommended by some researchers. This recommendation comes from the USA, where there is only one genospecies, and is therefore very controversial in Europe. In order to better assess the risk of infection after a tick bite, the tick can be examined for Borrelia infestation by means of PCR examination, if necessary. However, an infestation with Borrelia is not to be equated with a transmission of the disease. This is because, unlike the TBE virus, a certain amount of time must pass before the Borrelia bacteria can be transmitted after a tick bite. The data vary between 6 and 48 hours.  However, it is certain: The longer a tick infected with Borrelia has sucked, the higher the risk of transmission. However, some infections are also caused by improper removal of the tick, when it is squashed.
ticks should be removed as soon as possible. For this purpose, special tweezers are suitable, which should preferably be made of stainless steel (see also in detail under tick bite).
Carriers of the bacterium are usually ticks, which transmit the pathogen to humans after a few hours (usually in a time window of 8 to 12 hours after the bite) when they suck on it. In Germany this is mainly the tick Ixodes ricinus, also called common wood tick. Ticks are carriers of more than 50 diseases worldwide (see tick bite).
Scientists also discuss mosquitoes as further vectors of Lyme disease, although in previous studies   only a very low infestation of mosquitoes was found. Parasitologists at the University of Bonn have recently investigated the question of whether running mites (Trombiculidae), including the autumn mite (Neotrombicula autumnalis), as vectors for the bacterium Borrelia burgdorferi are possible, but no concrete evidence has been found. However, it is unclear here whether these arachnids are actually capable of transmitting Borrelia to humans. However, transmission by horseflies is known. 
There is no known direct human-to-human transmission of Borrelia, d. h. infected persons are not contagious. On the other hand, if an infected woman is pregnant, there is a risk of stillbirth or damage to the unborn child. Transmission through blood products is possible in principle, but is considered unlikely so far. According to the Robert Koch Institute, Lyme disease is not sexually transmitted. However, there are no sufficiently conclusive studies on this.
The diagnosis of Lyme disease is primarily made clinically, i.e., not on the basis of laboratory parameters, but from the clinical picture that the patient shows. The tick bite itself is a clear reason to follow up on symptoms of the early stage. The German Lyme Disease Society recommends a period of four to six weeks for the appearance of a migratory redness (erythema migrans, s. u.), but also for fever without reddening of the skin. 
Among the clinical symptoms, only migratory redness is considered to be evidence of disease (however, no migratory redness is observed in up to 50% of early Lyme disease cases  ) and in III. Stage the chronic skin inflammation ACA. In a study at the University Hospital Freiburg from 1990 to 2000, which included 86 cases of acute neuroborreliosis, even only 23% of the patients reported wandering redness.  Claims that migratory redness occurs in 90% of cases  are unsubstantiated. The many other symptoms, which affect numerous organ systems, can therefore only confirm the suspicion of an infection through exclusion diagnoses and laboratory tests.
As discussed below, there are extensive laboratory tests, but they are all characterized by a lack of sensitivity. This means that a negative test does not rule out the disease. 
A major problem in the detection of Lyme disease is the laboratory-chemical (serological) differentiation between a healed Lyme disease (seronary) and a still active Lyme disease requiring therapy. Therefore, there are still false negative. False positive serological findings.
In serology, antibody tests are used in routine diagnostics. These are usually the ELISA and the Westernblot, also called immunoblot. Some laboratories also perform an immunofluorescence test (IFT). Such tests can only measure antibodies, d. h. determine whether contact with the pathogen has taken place or not. However, it is not possible to control the course of a Lyme disease by these methods. Therefore, it is also not possible to determine on the basis of the serological results after a treatment with antibiotics whether these were effective and the Lyme disease is now cured. In addition, the individual test procedures are not standardized and have different specificities and sensitivities. With very sensitive tests there is often the problem of so-called cross-reactions. This means that the test shows a positive Borrelia result, but the person does not have Lyme disease (alpha error, false positive). The result is influenced by other pathogens, e.g. by other spirochetes like Treponema pallidum or Treponema denticola, Leptospires, but also caused by Epstein-Barr virus or cytomegalovirus. In the same way, false negative results occur (beta error). Serology is not more reliable than 50 % especially in the early stages. Newer tests are now said to have a somewhat higher reliability, with a sensitivity of approx. 70 to 80 % is indicated. However, this is information provided by the respective laboratories, which has not been verified.
As a rule, a so-called two-step testing is performed. Only one ELISA test is used, which, however, can cause cross-reactions or. polyclonal antibody stimulation by other pathogens and can therefore be false-positive. The result is confirmed by an immuno or. Westernblot verified and confirmed. If the ELISA is negative and clinical suspicion of Lyme disease persists, it is recommended to perform a Western blot.
Especially in the early phase many Lyme disease cases are overlooked, because within the first weeks no measurable antibody levels against Borrelia antigens are formed (so-called diagnostic gap = time from infection to first antibody production). Therefore, in early stages, the result of a blood test should not be waited for, but antibiotic therapy should be given immediately if there is a corresponding clinical suspicion, since the chances of recovery are greatest with early treatment. A wandering redness (erythema migrans) has to be treated immediately. Even in the case of florid Lyme disease requiring treatment, inflammation parameters such as BKS, CRP and other acute phase proteins can remain inconspicuous, so that normal values of these acute phase proteins (inflammation parameters) are not suitable to exclude active Lyme disease.
In later stages, the sensitivity of serological test methods (ELISA) is usually higher. It should be around 70 to 90 % in the second stage. If neuroborreliosis is suspected, which is sometimes clinically not very specific, a cerebrospinal fluid (CSF) examination is usually indicated, in which inflammatory CSF changes and the detection of a borrelia-specific intrathecal antibody synthesis can be confirmed if necessary.  However, it is possible that ca. 30 % to false negative results. In the early stages of neuroborreliosis, there is often no detectable infection with Borrelia. In these cases, the recently discovered chemokine CXCL13 (a B-lymphocyte-attracting protein) may play an important role, as it is already significantly elevated in the CSF of patients with neuroborreliosis in early stages of the disease. According to studies to date, the specificity of this marker is comparable to intrathecal antibody synthesis. In addition, the concentration of CXCL13 in the CSF decreases rapidly during treatment. Helps to distinguish an active infection from a serous scar. So far, however, this marker is not yet established in clinical diagnostics, but is only used in the context of studies (e.g., in the context of a clinical trial). B. examined at the University Hospital of the LMU Munich). Even if only peripheral nerve involvement is present, CSF diagnostics may be negative. The reliability of CSF diagnostics also depends on the experience of the laboratory, the criteria used for the evaluation, the reliability of the preparation, and the diagnostic procedures used. In Germany, numerous Borrelia serologies with different antigen compositions are on the market, which show a wide range in terms of sensitivity and specificity. Therefore, it is possible that one test is negative and another is positive. There is neither a licensing requirement for Borrelia serology, nor is participation in round robin tests obligatory.
In some specialized laboratories and institutes, a lymphocyte transformation test (LTT) is performed in case of positive serology and questionable pathogen activity. Since 2005, this test belongs to the laboratory methods accredited in Germany for the detection of cellular T-cell reactivities. A positive result indicates Borrelia-specific T-cells in the blood. Supports the clinical suspicion of active Lyme disease. However, a close correlation between a positive LTT and disease activity has not yet been investigated in larger clinical studies. The German Borreliosis Society recommends the LTT in its guidelines with restrictions , the German Society for Neurology describes it as unsuitable in its recommendations.  The LTT is no longer covered by the statutory health insurance since April 2006. PCR detection is another diagnostic method that can be used to detect active Lyme disease. Here DNA is processed from the examination material. By means of the PCR reaction a borrelia-specific fragment is amplified. This test is highly specific, but at the same time places high demands on laboratory personnel and equipment. Sensitivity is highly dependent on the body material tested (cerebrospinal fluid in neuroborreliosis about 20 to 30 %, synovial fluid in Lyme arthritis and skin in dermato-borreliosis about 70 %). A negative result does not exclude active Lyme disease. If contaminations as well as dead pathogens could be excluded, a positive result is an indication of active Lyme disease. The direct detection of Borrelia DNA from ticks by means of PCR is offered by different companies or by the German Borrelia Association. offered to laboratories. The cost of the service, which is not covered by health insurance, ranges from 10 to 100 euros, depending on the provider. Positive detection in the tick does not indicate that infection has also occurred in humans. This test is not recommended by any professional association as the sole proof of a Borrelia infection. Therapies based solely on this finding without symptoms and serology are not indicated.
Depending on the stage of the disease, the differential diagnosis is wide-ranging. It is recommended to exclude other tick-borne diseases and other infections (babesiosis, rickettsiosis, leptospirosis, bartonellosis and others).
Lyme disease, similar to lues, can "mimic" a variety of diseases. In case of neurological involvement, other causes should be considered, especially infection with neurotropic viruses and bacteria. In the case of neurological symptoms, it is important to reliably differentiate the diagnosis from multiple sclerosis in order to avoid serious mistreatment with steroids instead of antibiotics. In the case of joint inflammation, activated arthrosis, rheumatoid arthritis and other joint inflammations come into question. Differentiation of Lyme encephalopathy from chronic fatigue syndrome is often difficult.
Other important differential diagnoses – especially in the case of unsuccessful therapy – are tumors and other systemic diseases.
Erythema migrans as a result of a tick bite with Lyme disease infection on the lower leg of a male adult
After an infection, antibodies against Borrelia can be formed without any symptoms of disease at the same time. The serology can still be positive years after a cured Lyme disease. A definite diagnosis can often be made based on the symptoms of the disease, the course of the disease, the medical history and serological findings. In case of ambiguity, sometimes a treatment attempt with antibiotics can bring clarity. However, response to antibiotics does not indicate active Lyme disease and, conversely, failure to respond does not indicate that the disease has been cured. Which is the optimal therapy against Lyme disease is controversial.
As a rule, Lyme disease manifests itself through severe symptoms that worsen over the years. However, symptom-free latency periods are possible. Therefore, disappearance of symptoms does not mean that the pathogens have been eliminated. In the early phase, the symptoms of Lyme disease are similar to a flu-like infection (without cough and cold). At this stage, myalgias (muscle pain) and arthralgias (joint pain) often occur, which can be confused with fibromyalgia (chronic pain disorder). The same symptoms are often described after antibiotic treatment. However, if symptoms remain the same, as in fibromyalgia or chronic fatigue, and there is no worsening without antibiotic administration, one must rather ame that the symptoms are not caused by Borrelia burgdorferi especially if there is no history of leading symptoms typical of Lyme disease. This also applies to other non-specific symptoms such as chills, fever, joint and muscle pain, fatigue, and depression.
There is no immunity after a borreliosis has been contracted.
There are a number of symptoms that are typical for the individual stages. In addition, Lyme disease can also manifest itself through a variety of non-specific symptoms such as fatigue, headache, fever, neck stiffness, vision problems, dizziness, nausea and vomiting, and psychological changes.
1. Stage: Local infection
After an incubation period of usually 5-29 days from transmission of the pathogen, a local infection of the skin may occur, which is accompanied by a characteristic skin rash, the Erythema (chronicum) migrans (migratory redness) accompanies.  A spot, bright red ring or even double ring, typically paler in the center than at the edge, expands outward from the site of the tick bite (hence the name). Apart from the fact that sometimes there is itching or even stinging, this redness (an erythema) does not hurt.
Migratory rash often appears together with nonspecific general symptoms such as fever, headache, or gastrointestinal complaints (s. u.). Classically, these symptoms together form the clinical stage I of Lyme disease. The Erythema migrans is a clear symptom of a Borrelia infection, but not in all cases of Lyme disease infection does a wandering redness occur; therefore, from the absence after a tick bite it cannot be concluded that no Lyme disease infection has occurred.   The erythema sometimes disappears without therapy, but may persist for months. A decrease in erythema migrans is not evidence of a cure, as the pathogen may have spread.
Typically, within 10-14 days after the borrelia infection, a so-called "Lyme flu" occurs with all symptoms of a flu except the usual signs of infection like rhinitis or coughing. Fever may or may not be present. Furthermore, significant feelings of fatigue and exhaustion or newly appearing and disappearing joint pains can be observed. Mostly there is a diffuse feeling of illness with impaired general condition, without a disease becoming really tangible. Intestinal symptoms are also not uncommon and are then diagnosed as summer intestinal flu, without the connection to the Borrelia infection being established. This is especially true for those cases that do not develop migratory rash. From the time of the Borrelia infection, vaccinations, anesthesia or banal infections are also tolerated much worse. 
In the first stage Lyme disease can still be treated well with antibiotics (doxycycline). What is necessary, however, is a sufficiently long. High enough doses of therapy. What is sufficient is disputed in science.
2. Stage: spread of the pathogen
After about 4 to 16 weeks,  according to other sources after 20 to 59 days  the pathogens spread throughout the body. The incubation-. Latency period can also be longer. The patient then suffers from flu-like symptoms such as fever and headache, which makes it difficult to recognize the disease. Characteristic are strong sweating. As it spreads through the body, it can affect the organs, joints, and muscles, as well as the central and peripheral nervous systems. Leading symptoms at this stage are often Bannwarth's syndrome with severe radiculitic pain and facial nerve palsy, which manifests itself in a crooked face. In addition, reactive benign hyperplasia of lymphoid cells is seen, which is visible in the form of swellings, especially in the area of the earlobes, and is referred to as lymphadenosis cutis benigna. Arthritides and myalgias jumping from joint to joint are also typical. Furthermore, there may be disturbances of the sense of touch, visual disturbances and cardiac problems, such as sinus tachycardia and carditis, sometimes manifested by palpitations and high blood prere as well as pulse acceleration. The immune system is often unable to cope with the infection at this stage. Borrelia bacteria only stay in the blood for a short time, but longer in the connective tie. Here they are from the immune system. Difficult to eliminate by antibiotics.
A problematic special case is the so-called neuroborreliosis, which can lead to various diseases of the peripheral nerves and, in about 10% of cases, also of the central nervous system. As a rule, it occurs in the early phase of the disease (up to about 10 weeks), in which no antibodies have yet been formed. Therefore, sufficient antibiotics must be given at this stage. The choice of antibiotic depends on the infestation and the form of the disease. If Lyme disease is not treated in time and sufficiently, the disease can progress and lead to permanent organ damage.
3. Stage: Late stage
After several months, infected persons who have not been treated or have not been treated sufficiently can develop severe and chronic symptoms. Months, but also years of symptom-free latency periods with subsequent flare-ups of the disease are possible. Thus, acrodermatitis chronica atrophicans Herxheimer (ACA) often appears after years. There may also be chronic recurrent Lyme arthritis with a variety of clinical pictures, or an attack on the central and peripheral nervous system (neuroborreliosis) with polyneuropathy, Borrelia meningitis, Lyme encephalomyelitis or encephalitis. Chronic diseases of the sensory organs and of the joints and muscles are also possible. The chronic disease of the joints is called Lyme arthritis. However, inflammatory bursitis or osteoarthritis may also occur. The different pathogens seem to trigger different clinical pictures: While in some patients almost only the joints are affected, in others there are mainly neurological disorders. In addition, there is also a group of patients who have heart problems usually associated with vascular inflammation. Mixed forms are possible. Many Lyme disease patients complain of rapid fatigue and chronic fatigue, which cannot be eliminated even by sufficient sleep.
Due to the possibility of multiple organ infestation, the treatment of Lyme disease represents an interdisciplinary challenge for the various medical disciplines. The prognosis after early antibiotic treatment in the first stage is good. The 95% "inconsequential" cure rate of neuroborreliosis quoted in some sources, however, only refers to the proportion of patients with acute neuroborreliosis who were symptom-free after one year. In contrast, in chronic neuroborreliosis, the proportion was only 66 %. 
Since especially in the Early stage apart from the migratory redness, no definite proof of the disease is possible, the occurrence of unspecific flu-like symptoms or joint pain shortly after a tick bite raises the question of weighing up the risks and side effects of a suspected, possibly unnecessary antibiotic therapy lasting several weeks on the one hand, and on the other hand – in the event of non-execution, but also of a conceivable failure of such a measure – the possible health, social and financial consequences of a chronic condition lasting for years, which in extreme cases can even lead to disability. In this context, the relatively safe therapeutic window of about four weeks from infection to the onset of II. stage, pathogen dispersion and onset of systemic disease, must be taken into account.
In the early stages of infection, tetracyclines such as doxycycline are the drugs of choice because of their cellular penetrability and their efficacy against other pathogens also transmitted by tick bites. Since the generation sequence of Borrelia is significantly longer than that of many other pathogens,  newer therapy recommendations such as those of the German Borreliosis Society of 2008 contain a minimum duration of 4 weeks for monotherapy with antibiotics. Dose is also higher than older therapy recommendations, for example, 400 mg doxycycline per day, to achieve required serum levels and tie concentrations. If the drug shows no effect in the presence of erythema, a change of antibiotic is recommended after two weeks at the latest. 
Furthermore, it must be taken into account that a Herxheimer reaction, which is produced by an effective antibiotic therapy, can occur.
The form of administration and length of antibiotic therapy depends on the stage of the disease, but especially on the manifestation of the disease. Here, individual risk factors of the patients (such as e. g. B. antibiotic allergy or renal insufficiency) must be taken into account. The longer a Borrelia infection lasts, the more difficult it becomes to achieve complete pathogen elimination. In principle, different antibiotics are available for the therapy. A distinction is made between extracellular (outside the cells of the body) and intracellular forms (in cells of connective tie, cartilage, adipose tie, and skin) of the pathogen. In laboratory experiments it has been shown that the pathogen can switch between both forms within hours.  The antibiotics are to be selected accordingly. These must also be "cell-permeable" in order to be able to kill the pathogens present in the body's cells.
Especially Late forms of Lyme disease (persistent) show intracellular pathogens. Cell passage is supported by simultaneous administration of hydroxychloroquine, which induces a basic state in the cells and supports the penetration of the antibiotic into the cells. Cellular antibiotics are clarithromycin. Azithromycin in combination with hydroxychloroquine. However, there are no convincing clinical studies on the efficacy of hydroxychloroquine.
An extracellular-acting antibiotic is ceftriaxone, given intravenously for 14-21 days at a dose of 2 g per day. In a meta-analysis of eight European studies with a total of 300 patients with definite neuroborreliosis, there was no statistically significant difference in treatment success between oral doxycycline therapy compared to intravenous therapy with penicillin G or ceftriaxone. Treatment failures are possible with all antibiotics. treatment regimens based on this have been established. However, the incidence is unclear, reported by some authors to be 10-20% and by others to be around 50%. There is insufficient study material on antibiotic treatment for more than 14 to 30 days in patients with Lyme borreliosis.
A recent placebo-controlled study was able to show only a temporary improvement in Lyme encephalopathy after 10 weeks of ceftriaxone treatment. However, it remained open whether these improvements were due to a direct effect or to "positive side effects" of the antibiotic.  Studies on the possible better efficacy of other classes of antibiotics in this clinical picture are not available.
As stated in the recommendations of the German Society of Neurology on neuroborreliosis, the optimal duration of treatment is unclear, especially with the intravenous antibiotics ceftriaxone and cefotaxime. However, a treatment duration of more than 3 weeks results in no additional effect. Antibiotics other than cephalosporins are now also used in advanced stages, including tetracyclines, because the β-lactam antibiotics (such as ceftriaxone, cefotaxime) are suspected of causing so-called cystic or cell wall-less forms and are not sufficiently effective when intracellular persistence occurs. Some treatments consist of a combination of intravenous and oral antibiotics, but overall there is no convincing evidence of benefit.
It is questionable whether Lyme borreliosis will be treated in the III. Stage nor curable. There is no scientific rationale for treating Lyme disease with cholestyramine, nor are there any arguments from controlled trials in this regard. Such treatment is not recommended.
As a practical guideline for physicians for the treatment of Lyme disease, there are medical guidelines of the "Infectious Diseases Society of America" (IDSA), which were published in 2006. The IDSA guidelines  were developed in consensus with other major U.S. professional societies and provide evidence-based recommendations for the diagnosis and treatment of this clinical picture, taking into account current studies. Internationally, these guidelines have had a significant impact on the treatment of Lyme disease. In Germany, several major medical societies have been working for some time to develop a joint guideline. Completion is planned for the end of 2012.  The guidelines of the German Society of Neurology for the treatment of neuroborreliosis are already available. Some physicians have also conducted, in the case of unclear symptoms. Diagnosed as "chronic" Lyme disease without evidence of Borrelia infection. This clinical picture is generally not recognized by the medical community, as there has been no evidence to date that continued infection with Borrelia actually plays a role in this type of condition.  Chronic symptoms following confirmed Lyme disease are therefore generally referred to as "post-Lyme syndrome". Nevertheless, some doctors advocate poorly proven therapy methods, which include long-term antibiotic therapies over months or years. Patient advocacy groups such as the International Lyme And Associated Diseases Society (ILADS) have therefore initiated a review of the existing guidelines in the USA (published by the IDSA). On 1. May 2008, Connecticut Attorney General Richard Blumenthal had these IDSA guidelines reviewed.  The investigation was motivated by his ministry's finding that the IDSA Guidelines Committee improperly ignored or minimized considerations and findings of dissenting medical opinions and evidence. In addition, influential members of the guidelines committee have been shown to have secretive financial interests and ties to insurance companies and pharmaceutical companies. To address the allegations, IDSA scheduled a reconsideration of the guidelines by an independent panel of physicians. After a re-examination of the current studies-. Data confirmed the validity of the IDSA guidelines in 2010.  .
Tick bite prevention
An absolutely safe method for tick bite prevention is not known. Protection against tick bites is limited to mechanical scanning, the use of repellent sprays as a preventive measure, and the wearing of clothing that should cover the body as much as possible. It makes sense not to give the ticks the opportunity to crawl into and under the clothing. When working intensively in bushes and tall grasses, you can spray both your skin and clothing with commercially available repellent sprays beforehand. The substances it contains can ward off and prevent tick infestation. Regular, careful body scanning – especially for children who play outdoors during the day – is the surest way to avoid tick bites. In addition, one should avoid walking lightly clothed through tall grass, bushes and shrubs during the tick months. Especially on slightly damp grass the ticks are lurking for their next host. In dry and hot weather ticks retreat.
Active and passive immunizations are not yet available for Europe. In the USA, an effective recombinant vaccine based on OspA (outer membrane protein of Bbsl) was approved for a few years, but the manufacturer withdrew it from the market for commercial reasons. Because of the heterogeneity of the strains (at least 7 OspA serotypes), the development of an effective vaccine for Europe is difficult, according to the Robert Koch Institute in 2007. In veterinary medicine, however, a vaccination against Borrelia is carried out in dogs also in Germany. Its effect is controversial, since the antibody levels induced by the vaccination drop rapidly and, due to the presence of a large number of endemic Borrelia strains, the build-up of cross-reacting and protective vaccine titers is questionable.
In principle, it is possible to insert the building instructions for the proteins of many vaccines into plant genetic material, so that plants modified in this way become vaccine producers. The tobacco plants modified in this way by the researchers produced a protein called Ospa, which is also found on the surface of the Lyme disease pathogens. An additional linkage of the mentioned protein with fatty acids, necessary for effectiveness, was also achieved by the plants. In trials with mice, the tobacco vaccine produced in this way proved to be similarly effective to vaccine obtained from bacterial cultures, but this has not yet been approved for use in humans.