Use IV ceftriaxone for severe CNS borreliosis

For parenchymal CNS involvement (encephalitis, myelitis, or cerebral vasculitis) caused by B. garinii, IV ceftriaxone at 2 g once daily for 14-28 days is the recommended treatment. This is also the standard approach when oral doxycycline is contraindicated or when the patient has failed oral therapy.

Why It Works

Ceftriaxone achieves the highest CSF bactericidal concentrations among available antibiotics for Borrelia. B. garinii is the most neurotropic Borrelia species and can cause chronic encephalopathy with cognitive deficits, speech and language disorders, and personality changes that require aggressive treatment.

Tips

• Alternative IV agents include cefotaxime (2 g every 8 hours) and penicillin G (20 million units/day)
• Monitor for biliary sludging with prolonged ceftriaxone courses
• Lumbar puncture with CSF analysis for intrathecal Borrelia antibody production confirms neuroborreliosis diagnosis
• Response may take weeks; neurological deficits can take months to fully resolve