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Practice Guidelines

Lyme disease: summary of NICE guidance

BMJ 2018; 361 doi: (Published 12 April 2018) Cite this as: BMJ 2018;361:k1261
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Antibiotic choices when treating Lyme disease

A visual summary summarises latest NICE guidance

Re: Lyme disease: summary of NICE guidance - Congenital transmission

The NICE Guideline for Lyme disease, states: “The committee acknowledged that mother-to-baby transmission of Lyme disease is possible in theory. There was an absence of evidence, but the risk appears to be very low.”

The Treponema Pallidum spirochaete (Syphilis) has an unusually small genome, but it nevertheless evades immune clearance and disseminates to many organs and tissues. (1) The danger of congenital syphilis has been recognised for centuries and it now affects a million pregnancies each year worldwide. (2)

The Borrelia burgdorferi spirochaete (Lyme) has an exceptionally large genome. It has sophisticated immune evasion, adhesion, penetration and dissemination capabilities. It is much more virulent than Syphilis. (3)

Simple logic suggests that if an organism can penetrate the blood/brain barrier, infect cerebro-spinal fluid (CSF) and can even penetrate bone, that it will also have the ability to penetrate the amniotic sac and infect the foetus. The documentary evidence of this actually occurring is substantial. (4)

In women with undiagnosed Lyme disease, who have been infected for some time before becoming pregnant and whose symptoms are non-specific, the disseminated infection could have fully 9 months in which to infect the foetus.

A similar risk applies to diagnosed but inadequately treated mothers-to-be. In this scenario, the presumed safety-net of the pregnant woman’s health professionals being informed that, she ‘has had’ Lyme disease, has gaping holes in it thanks to the NICE guideline.

Firstly, there is the unsubstantiated opinion of the NICE committee that the risk of transmission: “appears to be very low”. Secondly, the NICE guideline also minimises the risk of an infection persisting beyond recommended treatment. So even if a woman’s healthcare professionals know that she has HAD Lyme disease, the NICE guideline deemphasises the risk to mother and foetus. This risk assessment is not based on any good quality evidence. It depends entirely on ‘low’ or ‘very low’ quality evidence and opinion. Opinion which appears to refute all that centuries of experience has taught medicine about congenital syphilis.

To put this in the form of a question: if it is the opinion of the NICE committee that the risk of Lyme disease to mother and child is so small, is it also their opinion that the risks of congenital syphilis are similarly small?

This is not rocket-science. When evidence is scarce it is natural to draw on experience to try and understand a new phenomenon. What is derived from old knowledge might not be perfect, but it can provide a good starting point, one which might be better than “low” or “very low quality” evidence, such as that which informs the NICE guideline.

Lyme disease could be more akin to infections with relapsing-fever spirochaetes than to syphilis, but common-sense dictates that medical science should derive everything it can from these related infections, for the protection of patients – including those who are not yet born.

Peter Kemp MA
Cofounder Member of VIRAS:


Competing interests: No competing interests

18 April 2018
Peter F Kemp
VIRAS colleagues
London, England