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Empirical Parenteral Antibiotic Treatment of Patients with Fibromyalgia and Fatigue and a Positive Serologic Result for Lyme Disease: A Cost-Effectiveness Analysis

Robert W. Lightfoot, MD; Benjamin J. Luft, MD; Daniel W. Rahn, MD; Allen C. Steere, MD; Leonard H. Sigal, MD; David C. Zoschke, MD; Pierce Gardner, MD; Melvin C. Britton, MD; and Ronald L. Kaufman, MD
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From the University of Kentucky Medical Center, Lexington, Kentucky; the Health Sciences Center, SUNY at Stony Brook, Stony Brook, New York; the Medical College of Georgia, Augusta, Georgia; the New England Medical Center, Boston, Massachusetts; the Robert Wood Johnson Medical School, New Brunswick, New Jersey; the University of Minnesota, Minneapolis, Minnesota; the Palo Alto Medical Clinic, Palo Alto, California; the University of Southern California Medical Center, Los Angeles, California. Requests for Reprints: Robert W. Lightfoot, Jr, MD, Division of Rheumatology, Kentucky Clinic J515, University of Kentucky Medical Center, Lexington, KY 40536-0284. Acknowledgments: The authors thank David M. Eddy, MD, PhD, for his assistance in the conceptualization and early critique of this analysis.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;119(6):503-509. doi:10.7326/0003-4819-119-6-199309150-00010
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Purpose: To examine the cost-effectiveness of empirical, parenteral antibiotic treatment of patients with chronic fatigue and myalgia and a positive serologic result for Lyme disease who lack classic manifestations.

Data Sources: Peer-reviewed journals, opinion of experts in the field, and published epidemiologic reports.

Study Selection: Consensus by authors on articles that indicated methods for patient selection; on criteria used for diagnosis; on immunologic methods used for classifying patients; on the dose and duration of therapy; and on criteria by which responses to therapy were ascertained.

Data Extraction: In a cost-effectiveness model, the costs and benefits of empirical parenteral therapy for patients seropositive for Lyme disease were compared with a strategy in which only patients having classical symptoms of Lyme disease were treated.

Data Synthesis: In areas endemic for Lyme disease, the incidence of false-positive serologic results in patients with nonspecific myalgia or fatigue exceeds by four to one the incidence of true-positive results in patients with nonclassical infections. Treatment of the former group of patients costs $86 221 for each true-positive patient treated. The empirical strategy causes 29 cases of drug toxicity for every case in the more conservative strategy. If patients were willing to pay $3485 to eliminate anxiety about not treating possible true Lyme disease, the empirical strategy would break even.

Conclusion: For most patients with a positive Lyme antibody titer whose only symptoms are nonspecific myalgia or fatigue the risks and costs of empirical parenteral antibiotic therapy exceed the benefits. Only when the value of patient anxiety about leaving a positive test untreated exceeds the cost of such therapy is the empirical treatment cost-effective.





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