It is becoming clear to me that most patients have co-infections. The idea of combination therapy is morphing into combination therapy which transitions into co-infection therapy. Trying to treat "everything" at one times is counterproductive. Patients Herx too much. Let's take a typical mild/moderate case. We can start with Amoxil/Biaxin/Plaquenil. We have a cell wall agent, a protein synthesis blocker and a drug which is synergistic with Biaxin-reduces inflammation and may have some anti-cyst properties. If symptoms quiet down after some period of time we can transition into anti-Babesia therapy. Mepron and Artemesin can be added. To minimize the number of drugs Amoxil can be withdrawn. If "Lyme" symptoms recur, Amoxil can be reintroduced. I like Amoxil because of it's flexibility. The dose can be increased and Benemid can be added to increase serum levels if desired. Also, one can ease into Babesia therapy by introducing Artemesin before Mepron-or Malarone, to control secondary Herx responses. After Babesia symptoms clear the Mepron and Art are stopped. Bacteria in blood can be addressed(Bartonella, Mycoplasma and possibly Ehrlichia). Rifampin can be introduced. Plaquenil can be stopped. If needed, Levaquin or Cipro can be started. Amoxil would be stopped. Biaxin can be changed to Doxycycline to cover Mycoplasma and Ehrlicia better. We still have to address Cystic Lyme forms. If the patient is generally better, Lyme treatment can be resumed with Flagyl, Amoxil and Biaxin or Doxy. This can be continued until the patient has been asymptomatic for about two months. At that point, may be in remission. This can only be determined if the patient remains symptom free off therapy. The order of treatment can be modified based on a clinical sense of what is causing the mosts symptoms. Flagyl can be added early on for more agressive Lyme therapy or Bartonela/Mycoplasma can be treated first instead of Babesiosis. Bartonella and even Babesia do not always require therapy. They are opportunistic. Once Lyme has cleared the immune system may eliminate them.
All of these concepts are in a state of flux. The main idea is to overlap therapies which make transistions easier. It also important to attempt to reduce the total number of anti-microbials taken at any one time to minimize drug to drug interactions. One more comment: I find Biaxin to be more effective than Zithromax, but Zithro has less drug to drug interactions. Biaxin and Diflucan can cause prolongation of QT intervals and increase the likelyhood of heart block and even fatal arrythmias. EKG monitoring is advisable with these drugs.
The paradigm is complex and evolving.
Additional information: Clongen WBs are good. Clongen finds bacteria in blood smears and performs a variety of strains. A Bartonella PCR test is available for all strains. A PCR test for 15 strains of Babesia is under develpment.