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Lyme Disease Prophylaxis – Adult/Pediatric – Ambulatory [122]

Lyme Disease Prophylaxis – Adult/Pediatric – Ambulatory [122] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols



Delegation Protocol Number: 122

Delegation Protocol Title: Lyme Disease Prophylaxis - Adult/Pediatric - Ambulatory

Delegation Protocol Applies To:
UW Healthline, UW Health Primary Care Clinics

Target Patient Population:
Adult and pediatric patients, ages 8 years and older, reporting a possible deer tick that was or still is embedded
for >/= 36 hours.

Delegation Protocol Champion:
Steven Tyska, MD – Department of Family Medicine, Urgent Care
Sheryl Henderson, MD – Department of Pediatrics – Infectious Diseases

Delegation Protocol Reviewers:
Nancy Fuller, MD – Department of Medicine – Internal Medicine
Kristin Lewicki, MD – Department of Medicine – Internal Medicine
Shobhina Chheda, MD – Department of Medicine – Internal Medicine
Gail Allen, MD – Department of Pediatrics - General
Elizabeth Kolk, RN, MBA - Internal Medicine – Women’s Health

Responsible Department:
Department of Family Medicine

Purpose Statement:
This protocol delegates authority from providers to Registered Nurses to place orders for doxycycline to
decrease the rate of transmission and lower the risk of Lyme disease from deer tick bites.

Who May Carry Out This Protocol:
Registered Nurses(RNs) who have been trained in the use of this delegation protocol.

Guidelines for Implementation:
1. This protocol is initiated when a patient contacts Healthline or the clinic reporting a possible deer tick bite.
2. The nurse will obtain a history of the tick exposure and review the medical record to determine if the
patient has any contraindications to the protocol.
3. If the patient has any contraindications to the protocol a provider will be consulted prior to placing any
orders. Contraindications include:
3.1. Allergies to tetracycline antibiotics including doxycycline, tetracycline or minocycline
3.2. Pregnancy
3.3. Lactation
3.4. Age less than 8 years
4. Inclusion criteria for eligible exposure:
4.1. Tick is identified as a deer tick
4.2. Tick is estimated to have been attached for >/= 36 hours by degree of engorgement or time of exposure
4.3. Prophylaxis is begun within 72 hours of tick removal
5. If the tick exposure meets the inclusion criteria and the patient has no contraindications the RN will place an
order for a single dose of doxycycline, 200 mg PO x1 (or 4.4 mg/kg if weight less than 45 kg).
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


6. The RN will educate the patient on the signs and symptoms of Lyme disease.

Order Mode: Protocol/Policy without cosign

References:
Nadelman RB, Nowakowski J, Fish D, et al. Prophylaxis with single-dose doxycycline for the prevention of Lyme
Disease after an Ixodes Scapularis tick bite. N Eng J Med 2001;345:79-84.
Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment and prevention of Lyme
Disease, human granulocytic anaplasmosis and babesiosis: Clinical practice guidelines by the Infectious Diseases
Society of America. Clin Infect Dis 2006;43:1089-1134.

Collateral Documents/Tools: NA

Approved By:
UW Health Ambulatory Protocol Committee: June 2015
UWHC Antimicrobial Use Subcommittee: July 2015
UWHC Pharmacy & Therapeutics Committee: August 2015
UWHC Medical Board: September 2015
UW Health Chief Medical Officer: September 2015

Effective Date: September 2015

Scheduled for Review: September 2017
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org