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Wednesday, June 10, 2009

Cipro for Lyme: Back to the future

A 60 year old female came to my office over one year ago. She had been struggling with fibromyalgia, ulcerative colitis and depression for decades. She provided a multi-page list of symptoms. The highlights were: fatigue, pain, loss of sensations, symptoms related to special senses--hearing-vision, AND rather profound cognitive deficits. She was on a list of nutritional supplements which filled a full page. She had been a highly functional professional in the past. She suspected she might have chronic Lyme disease; this diagnosis had never been made.

She brought sheaves of lab work which was unhelpful. I found her to have an elevated rheumatoid factor-(174)-normal less then 14. Her white blood cell count was minimally depressed, 3.7. Her CD57 was slightly depressed, 50. Special Clongen labs showed positive 39 and 23 Western Blot bands. A wet mount exam showed round extracellular bacteria.

The initial physical exam revealed a fairly profound peripheral neuropathy.

Her treatment was complex; she was prescribed a number of antibiotic combinations.
I will not discuss all the antibiotics she has taken over time, except to say that she was aggressively treated for the known co-infections.

One drug which has been particularly efficacious is Cipro. When this was discontinued she has back-pedaled everytime: symptoms which had improved return.

When I started treating chronic Lyme in a serious way, several years ago, I was sent a paper written by Dr. Jemsek. He described a Lyme regimen in which he used Cipro with Doxycyline. He stated that the two drugs worked via an intracellular mechanism and were synergistic.

After reading this I jumped on the Cipro train. Old data on MICs(minimal inhibitory concentrations), showed that Cipro was reasonably active against Bb.

I used Doxy and Cipro and then began switching to Cipro and Amoxicillin.

Doxycyline works by inhibiting protein synthesis within bacteria. Cipro works by inhibiting DNA gyrase necessary for DNA synthesis. Rather than using two intracellular antibiotics I combined a cell wall inhibitor with an intracellular antibiotic with the belief that this might be more effective. This sort of thinking was espoused by many LLMDS if not this particular combination.

In those days I wasn't giving Bartonella much thought, but it is well known that Cipro has activity against Bartonella.

I had years of experience with Cipro prior to launching into the the waters of Lyme. The tendon rupture issue is much exaggerated in my experience. What I know about Cipro is that it is a very powerful antibiotic. It has been claimed that oral Cipro can provide tissue antibiotic levels rivaling that of IV antibiotics. Cipro is one of the few antibiotics able to cross the prostate/blood barrier. Very high tissue concentrations--in many organs, are achieved with oral doses.

As I look back at charts of patients treated with Cipro I find that many had excellent responses. Then I stopped using Cipro for the most part: it was not an LLMD recommended drug.

As of late I am using the drug more. It provides high tissue concentrations, is active against Bb- and also works for Bartonella-or Bartonella syndrome.

I start low: 250 mg daily-- and then increase to 250mg twice daily. This relatively low dose is frequently effective. Patients are warned about tendon/muscle pain. I generally institute it when these pains have already been controlled by other antibiotics. I have never seen a tendon rupture.

As aside, Cipro is also active against Mycoplasmas and Chlamydia pneumonia.

It works.


Shawn B. said...

Actually I've heard that Dr. Horowitz is seeing great success with gemifloxacin (Factive) and giving it to many of his patients now in a 5-day pulse fashion, either once or twice monthly. This drug has a lower MIC value than cipro for Bb and may be more effective.

Shawn B. said...

Antimicrob Agents Chemother. 2001 Sep;45(9):2486-94.

In vitro activities of fluoroquinolones against the spirochete Borrelia burgdorferi.
Kraiczy P, Weigand J, Wichelhaus TA, Heisig P, Backes H, Schäfer V, Acker G, Brade V, Hunfeld KP.

Institute of Medical Microbiology, University Hospital of Frankfurt, D-60596 Frankfurt/Main, Germany.

Little is known to date about the in vitro activity of fluoroquinolones against Borrelia species. Our study aimed at determining the in vitro activities of 15 quinolones against nine isolates of the Borrelia burgdorferi sensu lato complex in addition to one Borrelia valaisiana and one Borrelia bissettii tick isolate. For the determination of MICs, a standardized colorimetric microdilution method was applied. Determination of minimal borreliacidal concentrations providing 100% killing of the final inoculum (MBCs) after 72 h and time-kill experiments were performed by conventional culture in Barbour-Stoenner-Kelly medium in combination with dark-field microscopy. The rank order of potency on a microgram-per-milliliter basis for the substances with in vitro activity against B. burgdorferi was gemifloxacin (MIC at which 90% of the isolates tested are inhibited [MIC(90)], 0.12 microg/ml) > sitafloxacin (MIC(90), 0.5 microg/ml), grepafloxacin (MIC(90), 0.5 microg/ml) > gatifloxacin (MIC(90), 1 microg/ml), sparfloxacin (MIC(90), 1 microg/ml), trovafloxacin (MIC(90), 1 microg/ml) > moxifloxacin (MIC(90), 2 microg/ml), ciprofloxacin (MIC(90), 2 microg/ml) > levofloxacin (MIC(90), 4 microg/ml) > ofloxacin (MIC(90), 8 microg/ml), norfloxacin (MIC(90), 8 microg/ml) > fleroxacin (MIC(90), >16 microg/ml), and pefloxacin (MIC(90), 32 microg/ml) > nalidixic acid (MIC(90), 256 microg/ml). After 72 h of exposure, gemifloxacin was borreliacidal (100% killing) against the isolates investigated at a median MBC of 4 microg/ml. In the other compounds tested, median MBCs were higher (> or =8 microg/ml). Results of electron microscopy and time-kill studies clearly support an in vitro activity of some fluoroquinolones against borreliae. Our study demonstrates for the first time the enhanced in vitro effectiveness of some of the recently introduced 4-quinolones against B. burgdorferi.

PMID: 11502519

huffgarr said...
This comment has been removed by the author.
huffgarr said...

You proposed that Cipro is an effective treatment plan for mycoplasma infections. I'm one of the individuals that received the controversial "mycoplasma or hemobartonella" infection diagnosis from Fry laboratories. I was wondering if you suggest that I should propose Cipro in conjunction with current antibiotics to Dr Fry. Also, I have not been diagnosed with Lymes but wondered if you have made any posts strictly pertaining to mycoplasma infections and information about the condition(s). I have read your post concerning hemobartonella.

Unknown said...

My name is Laura, and both my mother and younger sister are currently suffering from Lyme. I have several questions that i would like to ask you, can you please contact me, i would really really really appreciate it.
thank you so much

LGT said...

Going to try gemifloxacin (Factive) myself for Bart+Lyme soon; benefit is that the risk of tendon rupture is lower when taking the drug only 5 days.

Still looking for better ways to deal with brain herxes before I try Factive, as I am afraid of being arrested--people in my apartment have called the police other times that I was herxing.

Any thoughts for decreasing the rage and combativeness? Reducing brain inflammation, better detoxification, liver support?

Lyme report: Montgomery County, MD said...

Qunilones can have neuror-psychiatric side effect-unrelated to effects on Lyme disease or Bartonella. Many patients experience vertigo, insomnia and strange dreams. Even so--If a drug causes a severe dangerous Herx, then in my opinion, the targeted micro-organism shoud be treated with less potent antibiotics, to lower the load of bacteria, be they Spirochetes or other bacteria. Paitents in my expericence are better able to tolerate the more antibiotics at that point.

I have not tried Factive yet. In my experience very low doses of Cipro can be very effective. The drug provides a range of dose levels. I typically start patient with only 250mg per day. If well tolerated I increase the dose to 250mg twice daily. If the reaction is excessive the dose can be lowered to one per day, one every other day or less frequently based on clinical response.

I no longer use medications first which have an increased likelyhood of adverse reactions. For example, I no longer use Minocin as a first drug do to excessive phsych Heres.

Here I will go out on a limb. This is very conjectural. I believe that subclinical Lyme infection is much more common than generally suspected.

Quinolones penetrate various tissues much better than other antibiotics. This would include tendons. Perhaps tendon rupture is the result of a localized Herx in these structures rarely leading to tendon rupture. I tend to use them later in treatment and gradually increase the dose.

Furthermore, I do not pulse antibiotics. I have found that continuous therapy is effective.

LGT said...

That's an interesting idea about lower doses of antibiotics.

I stopped several abx I used to take (Biaxin, Rifampin) because the herx or side effects were too great; I wonder if I'd be able to tolerate them at lower doses.

Do you find that patients are ok on low doses of Cipro, i.e. not too much tendon pain, depression, side effects, die off. I might bring this up with my LLMD.

Have you dealt with patients who are violent when herxing? Rage, losing control can be particularly bad with Bartonella. I live with my boyfriend who forbids me to herx any more while I am living here since I might accidentally throw something at him as I have done previous times; I have to wait a few weeks until I can visit my parents and herx there.

I am taking azithromycin (500mg/day) and Plaquenil (400mg/day), and it keeps whatever I have in check, and I seem to improve every month; however I relapse quickly if I stop the abx.

searchingforhealth said...

I am a patient and have been Rx'd Cipro. I have pain widespread from neuropathy, muscles and tendons. I have had a pos Ehrlichia and Bart test, which is why my LLMd prescribed it, he says it will kill both. I think he has severely overlooked my pain issues so I will not take it. I have take it prior to my Ld diagnosis for UTi's and had great success. Now with websites and youtube 'testimonials' of permanent damage and a black box warning issued from the FDA it becomes less likely I would ever use it again. Do you have any concerns about the reported perm damage ("floxing"). Also patients on NSAIDs shouldn't take cipro according to my pharmacist. I would think with all that in mind very few should be on cipro or any quinolone. Would love a response to this post.