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Xenodiagnosis After Antibiotic Treatment for Lyme Disease

Primary Purpose

Lyme Disease

Status
Completed
Phase
Phase 1
Locations
United States
Study Type
Interventional
Intervention
Skin biopsy
Blood draw
Xenodiagnosis
Sponsored by
National Institute of Allergy and Infectious Diseases (NIAID)
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional diagnostic trial for Lyme Disease focused on measuring Lyme Disease, Ixodes scapularis, Borrelia Burgdorferi, Post treatment, Infection

Eligibility Criteria

18 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers
  • INCLUSION CRITERIA

Criteria for the diagnosis and therapy for Lyme disease can be found at The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America .

PATIENTS WITH LYME DISEASE, POST-THERAPY (N=100)

  1. Age 18 or older
  2. Lyme disease diagnosed in the previous 13 months, fulfilling the case definition of confirmed or probable Lyme disease by the US Centers for Disease Control and Prevention (CDC) (https://wwwn.cdc.gov/nndss/conditions/lyme-disease/case-definition/2017/).
  3. Completion of 1 course of antibiotics at least 3 months and up to 12 months between the end of the therapy and the xenodiagnostic procedure.
  4. Antibiotic treatment fulfills the Infectious Diseases Society of America guidelines for the recommended therapy for Lyme disease

PATIENTS WITH POST-LYME DISEASE COMPLAINTS AT LEAST 12 MONTHS FROM INITIAL TREATMENT (N=40)

  1. Age 18 or older.
  2. Diagnosed with confirmed or probable Lyme disease fulfilling the case definition of Lyme disease by the CDC (https://wwwn.cdc.gov/nndss/conditions/lyme-disease/case-definition/2017/).
  3. Received recommended antibiotic therapy for Lyme disease 5 at least 12 months between the end of the initial antibiotic therapy and the xenodiagnostic procedure.
  4. Persistent or recurrent symptoms that began or worsened within 6 months of the diagnosis and treatment for Lyme disease.

ACUTE EM (N=40)

  1. Age 18 or older.
  2. EM diagnosed by the study physician.
  3. Receiving antibiotic therapy for Lyme disease for less than 48 hours.

LYME ARTHRITIS (N=40)

  1. Age 18 or older.
  2. Lyme arthritis and have not received antibiotic therapy for the disease.

HEALTHY VOLUNTEERS (N=20)

  1. Age 18 or older.
  2. No prior history of Lyme disease.
  3. Negative whole cell enzyme-linked immunosorbent assay (ELISA) or C6-based antibody test for Lyme disease.

Patients with recently diagnosed (acute) EM (within 48 hours of starting antibiotic therapy) and patients with untreated Lyme arthritis will be recruited in an attempt to increase the chances of finding a positive result by xenodiagnosis (an attempt of a positive control ) While patients with acute untreated EM would be the best positive control group, it would be unethical to withhold therapy in these patients for the few days required for tick feeding, due to the risk of dissemination of the organism and possible morbidity. Patients with untreated Lyme arthritis will be recruited to establish whether xenodiagnosis can be used to identify infection in late stage Lyme patients where the bacterium is known to be present. These patients have been infected for months and will not be harmed for delaying therapy for a few days. Lyme arthritis is a late manifestation of B. burgdorferi infection, and hematogenous dissemination already occurred at this late stage. Studies have shown that the presence or absence of previous antibiotic treatment is more predictive than the duration of untreated arthritis for the success of antibiotic therapy in Lyme arthritis. Similarly, patients who just started therapy for EM may still have live Borrelia in the skin and xenodiagnosis may be able to recover the bacteria (but culture of skin biopsies from patients with EM become negative very quickly - within one dose - on antibiotic therapy).

While treatment for Lyme disease will not be offered under this protocol, it may be available via different clinical research protocols or regular medical care at the study site. If not, treatment will be prescribed by the patient s primary care. For patients with untreated early Lyme disease (erythema migrans), antibiotics can be started at the same day of tick placement. For patients with untreated Lyme arthritis, antibiotics can be started after collection of xenodiagnostic ticks (usually 4-5 days, up to 7 days). For patients with Lyme arthritis, if less than 14 ticks fed successfully and if the participant agrees, antibiotic treatment can be delayed until after the repeat procedure.

Patients with acute EM and untreated Lyme arthritis will be able to re-enroll as Patients with Lyme disease, post-therapy. Therefore, in case of positive results, we will be able to compare between the procedures.

Negative control patients will include healthy volunteers from Lyme endemic areas who have never been diagnosed with Lyme disease and have a negative B. burgdorferi ELISA and C6 antibody titer.

EXCLUSION CRITERIA

  1. No antibiotic therapy active against Lyme disease in the previous 3 months (except patients with acute EM). Prophylaxis with a single dose of doxycycline 200 mg is not an exclusion.
  2. History of allergy to surgical tape or dressing.
  3. History of severe reactions to tick bites (granuloma or systemic reactions).
  4. Inability to maintain the dressing for any reason.
  5. Pregnancy or lactation.
  6. Unwillingness to use an effective method of birth control for the duration of participation in the study (women of child-bearing potential only) and for at least 3 months following the last tick placement.
  7. Use of investigational therapy and devices during the time of the study and/or in the month prior to signing the informed consent.
  8. Active severe skin disease, uncontrolled diabetes, cancer other than non-melanoma skin cancers, autoimmune disease requiring immunosuppressive therapy, or history of HIV, chronic viral hepatitis, or syphilis.
  9. Oral or IV steroids in the previous 2 weeks (topical, nasal, inhaled, intra-articular, and replacement doses of steroids are not exclusions).
  10. Any other condition that, in the opinion of the investigator, would make the patient unsuitable for enrollment or could interfere with the patient participating in and completing the study.
  11. Refusal to participate in specimen collection and storage for future study related use.

EXCLUSION FROM SKIN BIOPSY PART OF THE PROTOCOL

  1. History of forming large thick scars (keloids) after skin injuries or surgery.
  2. History of excessive bleeding after cuts or procedures.
  3. Currently taking anticoagulants.
  4. History of allergy to lidocaine.

Sites / Locations

  • Mansfield Family Practice
  • National Institutes of Health Clinical Center, 9000 Rockville Pike
  • Tufts Medical Center
  • Stony Brook University (State University of New York)
  • New York Medical College

Arms of the Study

Arm 1

Arm 2

Arm 3

Arm 4

Arm 5

Arm Type

Active Comparator

Active Comparator

Active Comparator

Active Comparator

Active Comparator

Arm Label

1

2

3

4

5

Arm Description

Patients with Lyme disease, post treatment

Patients with post-Lyme disease complaints at least 12 months from initial treatment

Acute erythema migrans patients (possible positive control)

Lyme Arthritis patients (possible positive control)

Healthy Volunteers (negative control)

Outcomes

Primary Outcome Measures

Self-reported questionnaires
This study is powered to detect difference in the positivity rate between symptomatic and asymptomatic individuals.
Study participants will maintain a diary card and investigators will assess potential adverse events.
The study will continue to assess the safety of xenodiagnosis in humans.

Secondary Outcome Measures

Full Information

First Posted
May 13, 2015
Last Updated
March 2, 2023
Sponsor
National Institute of Allergy and Infectious Diseases (NIAID)
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1. Study Identification

Unique Protocol Identification Number
NCT02446626
Brief Title
Xenodiagnosis After Antibiotic Treatment for Lyme Disease
Official Title
Xenodiagnosis After Antibiotic Treatment for Lyme Disease - Phase II Study
Study Type
Interventional

2. Study Status

Record Verification Date
May 5, 2022
Overall Recruitment Status
Completed
Study Start Date
July 24, 2015 (Actual)
Primary Completion Date
May 4, 2022 (Actual)
Study Completion Date
May 4, 2022 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
National Institute of Allergy and Infectious Diseases (NIAID)

4. Oversight

Studies a U.S. FDA-regulated Drug Product
No
Studies a U.S. FDA-regulated Device Product
Yes
Device Product Not Approved or Cleared by U.S. FDA
Yes
Data Monitoring Committee
Yes

5. Study Description

Brief Summary
Background: The most common tick-borne illness in the United States, Lyme disease is caused by Borrelia burgdorferi bacteria that are transmitted to people by Ixodes scapularis ticks. Most cases of Lyme disease are cured by antibiotics, but some patients continue to experience symptoms despite the absence of detectable Lyme bacteria. Xenodiagnosis uses a vector to detect the presence of a disease-causing microbe.. Researchers will use live, laboratory-bred ticks to see if Lyme disease bacteria can be detected in people after completing antibiotic therapy and if that is more common in people who continue to experience symptoms such as fatigue and joint pain. Objectives: - To see if ticks can be used to detect B. burgdorferi in people who have had Lyme disease and received antibiotic therapy and if it correlates with persistent symptoms. Eligibility: Adults at least 18 years old who have: Untreated erythema migrans (the Lyme disease rash); OR Untreated Lyme arthritis; OR Continuing symptoms after treatment for Lyme disease; OR Had Lyme disease and antibiotic treatment within the past 12 months. Healthy volunteers Design: Participants will be screened with medical history, physical exam, and blood tests. Visit 1: Blood and urine tests, health questionnaire. Up to 30 laboratory-bred, pathogen-free, larval ticks (each smaller than a poppy seed) will be placed under a dressing. Participants may have two small biopsies of skin . 4 6 days later, Visit 2: Dressing will be removed and ticks will be collected. Participants will answer symptom questions. If many ticks are still attached, participants will have to come back the next day. If not enough ticks feed successfully, the procedure may be repeated. Participants will keep a diary of symptoms for 30 days. Over 3 months, they will be return to the clinic 3 times to see how they feel and answer questionnaires. Test results will be discussed.
Detailed Description
Lyme disease is the most common vector borne disease in the United States. Although antibiotic therapy is clinically effective in treating the symptoms of Lyme disease for most patients early in the course of disease, a significant number of patients who receive therapy report persistent symptoms. The cause of persistent symptoms after antibiotic therapy for Lyme disease is an area of great controversy. Recent studies have shown that the organism (Borrelia burgdorferi) may persist in animals after antibiotic therapy and can be detected by using the natural tick vector (Ixodes scapularis) to acquire the organism through feeding (xenodiagnosis). Whether this occurs in humans is unknown. Currently available tests for human Lyme disease do not allow determination of persistent infection after antibiotic therapy. We performed the first study of the use of I. scapularis larva for the xenodiagnosis of B. burgdorferi infection in humans. Our pilot study showed that xenodiagnosis was well tolerated with no severe adverse events (AEs). The most common AE was mild itching at the site. In this small pilot study, xenodiagnosis for B. burgdorferi was positive in 2 participants and indeterminate in 2 participants. Further studies are needed to determine the sensitivity of xenodiagnosis in evaluating the infection status of Lyme disease patients. In this proposal, we want to further investigate the utility of xenodiagnosis for identifying persistence of infection with B. burgdorferi in treated human Lyme disease. Our objectives include assessing the link between detection of B. burgdorferi by xenodiagnosis and persistence of symptoms in patients diagnosed with Lyme disease, within 1 year, post therapy; compare the rate of detection of B. burgdorferi by xenodiagnosis after therapy in participants with posttreatment Lyme disease symptoms; identify subject characteristics related to the likelihood of detecting B. burgdorferi by xenodiagnosis including: time from infection, time between infection and therapy, time from therapy; and continue to assess the safety of xenodiagnosis in humans. The results of study have the potential to resolve this long-standing controversy in Lyme disease pathogenesis. While xenodiagnosis is unlikely to be widely used in clinical practice due to the labor intensity and speed of testing, if our study shows a linkage between positive xenodiagnostic testing and persistence of symptoms after B. burgdorferi infection, it may prove to be a useful tool for testing new strategies for treatment and for correlation with more generally applicable diagnostic markers. Understanding the pathogenesis of persistent symptoms following Lyme disease, and identifying reliable diagnostic tests for determining the success of antibiotic therapy, is critical to the medical management of these patients.

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Lyme Disease
Keywords
Lyme Disease, Ixodes scapularis, Borrelia Burgdorferi, Post treatment, Infection

7. Study Design

Primary Purpose
Diagnostic
Study Phase
Phase 1, Phase 2
Interventional Study Model
Single Group Assignment
Masking
None (Open Label)
Allocation
N/A
Enrollment
72 (Actual)

8. Arms, Groups, and Interventions

Arm Title
1
Arm Type
Active Comparator
Arm Description
Patients with Lyme disease, post treatment
Arm Title
2
Arm Type
Active Comparator
Arm Description
Patients with post-Lyme disease complaints at least 12 months from initial treatment
Arm Title
3
Arm Type
Active Comparator
Arm Description
Acute erythema migrans patients (possible positive control)
Arm Title
4
Arm Type
Active Comparator
Arm Description
Lyme Arthritis patients (possible positive control)
Arm Title
5
Arm Type
Active Comparator
Arm Description
Healthy Volunteers (negative control)
Intervention Type
Procedure
Intervention Name(s)
Skin biopsy
Intervention Description
Optional 2-3mm skin punch biopsies will be performed.
Intervention Type
Procedure
Intervention Name(s)
Blood draw
Intervention Description
Peripheral blood draws will be performed.
Intervention Type
Device
Intervention Name(s)
Xenodiagnosis
Intervention Description
Larval ticks will be obtained from Dr. Sam Telford from a laboratory maintained tick colony at Tufts Veterinary School. These ticks are hatchedfrom eggs laid by ticks that have fed only on specific pathogen free laboratory animals that were purchased from established vendors. Between 25-30 larval ticks that have been aged and are known to be ready to attach will be placed on the study participant.
Primary Outcome Measure Information:
Title
Self-reported questionnaires
Description
This study is powered to detect difference in the positivity rate between symptomatic and asymptomatic individuals.
Time Frame
Tick placement visit, 4-6 weeks post tick removal visit, and approximately 3 months post tick removal visit. For the participants enrolled under the Lyme disease, post treatment group, the questionnaires will also be administered approximately 12 months
Title
Study participants will maintain a diary card and investigators will assess potential adverse events.
Description
The study will continue to assess the safety of xenodiagnosis in humans.
Time Frame
From the tick placement day thru 30 days post tick removal.

10. Eligibility

Sex
All
Minimum Age & Unit of Time
18 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
INCLUSION CRITERIA Criteria for the diagnosis and therapy for Lyme disease can be found at The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America . PATIENTS WITH LYME DISEASE, POST-THERAPY (N=100) Age 18 or older Lyme disease diagnosed in the previous 13 months, fulfilling the case definition of confirmed or probable Lyme disease by the US Centers for Disease Control and Prevention (CDC) (https://wwwn.cdc.gov/nndss/conditions/lyme-disease/case-definition/2017/). Completion of 1 course of antibiotics at least 3 months and up to 12 months between the end of the therapy and the xenodiagnostic procedure. Antibiotic treatment fulfills the Infectious Diseases Society of America guidelines for the recommended therapy for Lyme disease PATIENTS WITH POST-LYME DISEASE COMPLAINTS AT LEAST 12 MONTHS FROM INITIAL TREATMENT (N=40) Age 18 or older. Diagnosed with confirmed or probable Lyme disease fulfilling the case definition of Lyme disease by the CDC (https://wwwn.cdc.gov/nndss/conditions/lyme-disease/case-definition/2017/). Received recommended antibiotic therapy for Lyme disease 5 at least 12 months between the end of the initial antibiotic therapy and the xenodiagnostic procedure. Persistent or recurrent symptoms that began or worsened within 6 months of the diagnosis and treatment for Lyme disease. ACUTE EM (N=40) Age 18 or older. EM diagnosed by the study physician. Receiving antibiotic therapy for Lyme disease for less than 48 hours. LYME ARTHRITIS (N=40) Age 18 or older. Lyme arthritis and have not received antibiotic therapy for the disease. HEALTHY VOLUNTEERS (N=20) Age 18 or older. No prior history of Lyme disease. Negative whole cell enzyme-linked immunosorbent assay (ELISA) or C6-based antibody test for Lyme disease. Patients with recently diagnosed (acute) EM (within 48 hours of starting antibiotic therapy) and patients with untreated Lyme arthritis will be recruited in an attempt to increase the chances of finding a positive result by xenodiagnosis (an attempt of a positive control ) While patients with acute untreated EM would be the best positive control group, it would be unethical to withhold therapy in these patients for the few days required for tick feeding, due to the risk of dissemination of the organism and possible morbidity. Patients with untreated Lyme arthritis will be recruited to establish whether xenodiagnosis can be used to identify infection in late stage Lyme patients where the bacterium is known to be present. These patients have been infected for months and will not be harmed for delaying therapy for a few days. Lyme arthritis is a late manifestation of B. burgdorferi infection, and hematogenous dissemination already occurred at this late stage. Studies have shown that the presence or absence of previous antibiotic treatment is more predictive than the duration of untreated arthritis for the success of antibiotic therapy in Lyme arthritis. Similarly, patients who just started therapy for EM may still have live Borrelia in the skin and xenodiagnosis may be able to recover the bacteria (but culture of skin biopsies from patients with EM become negative very quickly - within one dose - on antibiotic therapy). While treatment for Lyme disease will not be offered under this protocol, it may be available via different clinical research protocols or regular medical care at the study site. If not, treatment will be prescribed by the patient s primary care. For patients with untreated early Lyme disease (erythema migrans), antibiotics can be started at the same day of tick placement. For patients with untreated Lyme arthritis, antibiotics can be started after collection of xenodiagnostic ticks (usually 4-5 days, up to 7 days). For patients with Lyme arthritis, if less than 14 ticks fed successfully and if the participant agrees, antibiotic treatment can be delayed until after the repeat procedure. Patients with acute EM and untreated Lyme arthritis will be able to re-enroll as Patients with Lyme disease, post-therapy. Therefore, in case of positive results, we will be able to compare between the procedures. Negative control patients will include healthy volunteers from Lyme endemic areas who have never been diagnosed with Lyme disease and have a negative B. burgdorferi ELISA and C6 antibody titer. EXCLUSION CRITERIA No antibiotic therapy active against Lyme disease in the previous 3 months (except patients with acute EM). Prophylaxis with a single dose of doxycycline 200 mg is not an exclusion. History of allergy to surgical tape or dressing. History of severe reactions to tick bites (granuloma or systemic reactions). Inability to maintain the dressing for any reason. Pregnancy or lactation. Unwillingness to use an effective method of birth control for the duration of participation in the study (women of child-bearing potential only) and for at least 3 months following the last tick placement. Use of investigational therapy and devices during the time of the study and/or in the month prior to signing the informed consent. Active severe skin disease, uncontrolled diabetes, cancer other than non-melanoma skin cancers, autoimmune disease requiring immunosuppressive therapy, or history of HIV, chronic viral hepatitis, or syphilis. Oral or IV steroids in the previous 2 weeks (topical, nasal, inhaled, intra-articular, and replacement doses of steroids are not exclusions). Any other condition that, in the opinion of the investigator, would make the patient unsuitable for enrollment or could interfere with the patient participating in and completing the study. Refusal to participate in specimen collection and storage for future study related use. EXCLUSION FROM SKIN BIOPSY PART OF THE PROTOCOL History of forming large thick scars (keloids) after skin injuries or surgery. History of excessive bleeding after cuts or procedures. Currently taking anticoagulants. History of allergy to lidocaine.
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Adriana R Marques, M.D.
Organizational Affiliation
National Institute of Allergy and Infectious Diseases (NIAID)
Official's Role
Principal Investigator
Facility Information:
Facility Name
Mansfield Family Practice
City
Storrs
State/Province
Connecticut
ZIP/Postal Code
06268
Country
United States
Facility Name
National Institutes of Health Clinical Center, 9000 Rockville Pike
City
Bethesda
State/Province
Maryland
ZIP/Postal Code
20892
Country
United States
Facility Name
Tufts Medical Center
City
Boston
State/Province
Massachusetts
ZIP/Postal Code
02111
Country
United States
Facility Name
Stony Brook University (State University of New York)
City
Stony Brook
State/Province
New York
ZIP/Postal Code
11794-8153
Country
United States
Facility Name
New York Medical College
City
Valhalla
State/Province
New York
ZIP/Postal Code
10595
Country
United States

12. IPD Sharing Statement

Citations:
PubMed Identifier
24523212
Citation
Marques A, Telford SR 3rd, Turk SP, Chung E, Williams C, Dardick K, Krause PJ, Brandeburg C, Crowder CD, Carolan HE, Eshoo MW, Shaw PA, Hu LT. Xenodiagnosis to detect Borrelia burgdorferi infection: a first-in-human study. Clin Infect Dis. 2014 Apr;58(7):937-45. doi: 10.1093/cid/cit939. Epub 2014 Feb 11.
Results Reference
background
PubMed Identifier
25301228
Citation
Telford SR 3rd, Hu LT, Marques A. Is there a place for xenodiagnosis in the clinic? Expert Rev Anti Infect Ther. 2014 Nov;12(11):1307-10. doi: 10.1586/14787210.2014.966084.
Results Reference
background
PubMed Identifier
24466286
Citation
Hodzic E, Imai D, Feng S, Barthold SW. Resurgence of persisting non-cultivable Borrelia burgdorferi following antibiotic treatment in mice. PLoS One. 2014 Jan 23;9(1):e86907. doi: 10.1371/journal.pone.0086907. eCollection 2014.
Results Reference
background
Links:
URL
https://clinicalstudies.info.nih.gov/cgi/detail.cgi?B_2015-I-0131.html
Description
NIH Clinical Center Detailed Web Page

Learn more about this trial

Xenodiagnosis After Antibiotic Treatment for Lyme Disease

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