Assessment and Prescribing Algorithm for Pharmacists:

Antibiotic Prophylaxis to Prevent Lyme Disease

following a Tick Bite
Assessing the patient1
Is the patient symptomatic following a tick bite?
• Erythema migrans rash (“bull’s-eye” rash – refer to references for detailed YES Refer to a physician or
description2,3) nurse practitioner.
• Fever, chills, headache, stiff neck, fatigue, decreased appetite, muscle and
joint aches, joint swelling, swollen lymph nodes.

NO
Is the patient at high risk for developing Lyme disease?4
If all 4 criteria are not
(i.e. must meet ALL 4 of the following criteria)
met:
1. Tick has been removed within the past 72 hours. • Do not prescribe
(If the tick is still attached, advise the patient to safely remove.5) NO antibiotic prophylaxis.
2. Tick bite occurred in a higher risk area where blacklegged ticks have been • Educate patient to
identified. monitor for symptoms
for 30 days and see a
• Refer to the most recent Ontario Lyme Disease Map for estimated risk
physician or nurse
areas.6
practitioner if symptoms
• Refer to Ontario Health Clinical Guidance Document for examples of higher develop.
risk areas with a prevalence of ticks infected with Borrelia burgdorferi > 20%
(Box 5).2
3. Tick was likely attached for 24 hours or more
4. Doxycycline is not contraindicated (e.g. allergy).

YES Documentation & follow-up:

Prescribing antibiotic prophylaxis:
• Adults: doxycycline 200 mg by mouth x 1
dose
• Children: doxycycline 4 mg/kg (maximum
dose of 200 mg) by mouth x 1 dose (no age
restriction)
• Complete documentation & notify physician or nurse
practitioner.
• Educate all patients to monitor for signs and symptoms for
30 days and see a physician or nurse practitioner if they
develop symptoms.
• For surveillance purposes only, patients have the option to
submit photos of ticks to www.etick.ca for identification.

Prescribing Considerations:
• Doxycycline should be used for post-exposure prophylaxis in adults and children of all ages. Previously, doxycycline was
not recommended for children < 8 years of age however this guidance has changed as dental staining is uncommon with
short courses.7,8
• Previously, doxycycline was contraindicated in pregnant and lactating individuals however recent evidence has
demonstrated that a single dose of doxycycline is safe for this population.9
• If doxycycline is contraindicated (e.g. allergy), there are no alternatives. Do not prescribe other antibiotics for post-
exposure prophylaxis. Educate patient to monitor for symptoms for 30 days and see a physician or nurse practitioner if
symptoms develop.

References: 5. Centers for Disease Control and Prevention (CDC), National Center
for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of
1. Ontario College of Pharmacists. Community pharmacist practice
Vector-Borne Diseases (DVBD). Tick removal [Internet]. Atlanta, GA:
assessment criteria [Internet]. Toronto, ON: Ontario College of
CDC; 2022 [reviewed 2022 Mar 13; cited 2023 Mar 3]. Available
Pharmacists; 2017 [cited 2023 Mar 3]. Available from: https://www.
from: https://www.cdc.gov/ticks/removing_a_tick.html
ocpinfo.com/library/practice-related/download/
PracticeAssessmentCriteria.pdf 6. Ontario Agency for Health Protection and Promotion (Public Health
Ontario). Ontario Lyme disease map 2022: estimated risk areas
2. Ontario Health. Clinical guidance document: management of tick
[Internet]. Toronto, ON; King’s Printer for Ontario; 2022 [updated
bites and investigation of early localized Lyme disease [Internet].
2022 Dec 15; cited 2023 Mar 3]. Available from: https://www.
Toronto, ON: King’s Printer for Ontario; 2023 [cited 2023 Sep 29].
publichealthontario.ca/en/diseases-and-conditions/infectious-
Available from: https://www.hqontario.ca/Evidence-to-Improve-
diseases/vector-borne-zoonotic-diseases/lyme-disease
Care/Evidence-and-Health-Quality-Ontario/Guidance-Documents
7. Centers for Disease Control and Prevention (CDC), National Center
3. Health Canada. For health professionals: Lyme disease [Internet].
for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of
Ottawa, ON: Government of Canada; 2022 [modified 2022 Dec 22;
Vector-Borne Diseases (DVBD). Lyme disease prophylaxis after tick
cited 2023 Mar 3]. Available from: https://www.canada.ca/en/
bite [Internet]. Atlanta, GA: CDC; 2022 [reviewed 2022 Aug 5; cited
public-health/services/diseases/lyme-disease/health-professionals-
2023 Mar 3]. Available from: https://www.cdc.gov/ticks/
lyme-disease.html
tickbornediseases/tick-bite-prophylaxis.html
4. Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical Practice
8. Viel-Thériault I, Le Saux N. Lyme disease. In: Therapeutics [Internet].
Guidelines by the Infectious Diseases Society of America (IDSA),
Ottawa, ON: Canadian Pharmacists Association; 2021 [cited 2023
American Academy of Neurology (AAN), and American College of
Mar 3]. Available from: http://www.myrxtx.ca
Rheumatology (ACR): 2020 guidelines for the prevention, diagnosis
and treatment of Lyme disease. Clin Infect Dis. 2021;72(1):1-8. 9. Smith GN, et al. Committee opinion no. 399: management of tick
Available from: https://academic.oup.com/cid/article/72/1/ bites and Lyme disease during pregnancy. J Obstet Gynaecol Can.
e1/6010652 2020;42(5):644-53. Available from: https://doi.org/10.1016/j.
jogc.2020.01.001

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January 2024