How to Pulse Antibiotics For Lyme

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How to Pulse Antibiotics in a Lyme disease treatment image from Marty Ross MD

All About Pulsing Antibiotics in Lyme Disease

At times, In my Seattle practice, I pulsed antibiotics in Lyme treatments. This means I started and stopped the antibiotics at regular intervals, with periods on antibiotics followed by periods off. The purpose is to:

  • beat Lyme persister cells,
  • decrease biofilms,
  • decrease Lyme cysts,
  • decrease drug toxicity, and
  • limit intestinal yeast.

Persister Cells and Lyme Pulse Antibiotics

Lyme germs can turn into persister cells that are tolerant to antibiotics. In a persister state, metabolism of the germ slows down. In a sense the germ goes into hibernation. However, if the germ wakes up again, the antibiotics will work. So a persister state does not create a germ that is antibiotic resistant. Resistance would remain even when the germ wakes up and starts to grow. 

In 2015 researchers at Northeastern University in Boston showed on petri dish experiments that 20% of Lyme germs become persister cells. In the experiment 24 hours after antibiotics were stopped and washed off the germs the persister cells started to grow again. The researches showed that starting and stopping antibiotics (pulse antibiotics) 4 times killed all forms of Lyme germs. In the experiment, antibiotics were used for 5 days followed by 24 hours off.

For more information about persisters see How to Treat Persister Lyme. What Works?

Marty Ross MD Discusses Antibiotic Pulsing in Lyme

Dr. Ross discusses pulsing antibiotics based on the limited science and his history treating Lyme when he practiced in Seattle, Washington.

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Biofilms and Cysts Respond to Lyme Pulse Antibiotics

Lyme lives in two different forms, inside and outside of cells, and in biofilms. The two forms are spirochete and microscopic cyst form also sometimes called a round body or an L-form. When Lyme spirochetes are exposed to antibiotics they can morph into cyst forms or move into biofilm communities. Once antibiotics are stopped, Lyme comes out of biofilms where it is easier to treat. And cysts turn back into spirochetes, which are also easier to treat. So in a Lyme pulse antibiotic regimen, during the off periods Lyme can move back into a state which is easier to treat with antibiotics.

Toxicity and Yeast Do Better with Lyme Pulse Antibiotics

If a person is having intestinal yeast issues or problems with liver or kidney toxicity on antibiotics, consider changing to a Lyme pulse antibiotic regimen. Decreasing the amount of antibiotics decreases the chances of intestinal yeast overgrowth, and makes it easier for yeast treatments to work. Also lowering the total weakly load of antibiotics decreases the strain on the kidneys and liver caused by Lyme antibiotics.

All Antibiotics Are Not Good to Pulse

The Northeastern experiments showed in a lab persister cells require 24 hours before they wake up out of hibernation. In the experiment they literally washed the existing antibiotics off of the petri dish. In humans, we cannot just wash antibiotics out. It takes time for antibiotics to build up to an effective dose and time for the same antibiotic to get out of the body.

In pharmacy science each medicine has an elimination half-life. An elimination half-life is the time it takes to get half of a medicine out. Physicians use the elimination half-life for a drug to determine how long it takes to completely remove a drug or how long it takes to get the drug to a maximum level in the blood.

It takes 4 elimination half-lives to remove a medicine completely. It takes 4 elimination half-lives for a medicine to reach the highest drug level in the blood.

Long-half life medicines should not be pulsed. One of these antitibiotics is azithromycin (Zithromax). It has an elimination half-life of 68 hours. This means it takes 272 hours (11 days) to completely eliminate this medicine from the body once it is stopped. Of the current antibiotics most Lyme Literate Medical Doctors use, azithromycin is the only one that should not be pulsed.

Read more about Lyme antibiotic regimens in A Lyme Disease Antibiotic Guide.

An Effective Short Lyme Pulse Antibiotic Frequency

An effective pulse regimen is one that gives enough time to kill the Lyme germs and enough time for the persister cells to wake up. This keeps in mind also that most medicines require 24 to 48 hours to reach a level where they do not kill Lyme once they are stopped. It is best to pulse antibiotics for 4 days on followed by 3 days off.

Keep in mind there have not been any human experiments performed that look at the ultimate pulsing regimen. But the 4 day on 3 day off regimen is one that I found moves a treatment forward. I tried other ones that do not seem to work as well.

Lyme treatment regimens require at least 2 prescription antibiotics or 2 herbal antibiotics. Sometimes 3 are used. Each antibiotic in a regimen should be taken on the same days. So if a regimen includes clarithromycin to treat spirochete Lyme and intracellular Lyme along with metronidazole to treat cyst Lyme, both of these medicines should be taken on the same days.

Long Lyme Pulse Antibiotics

There is another way to pulse antibiotics based on the work of Lyme pioneer Joseph Burrascano MD. Before he left clinical practice years ago he found stopping antibiotics until a person became ill and then using them long enough to feel better could eliminate Lyme.

Overtime working with this idea I found a regimen using antibiotics for 2 months on followed by 2 months off would sometimes cause significant improvement. This seems to help about 40% of the time. It is OK to stop antibiotics longer term because Lyme replicates slowly. It takes weeks to months before the germ replicates enough to cause problems.

During the 2 months off of antibiotics the lyme germs come out of persister cells. I also suspect that Lyme which has moved into biofilms and into cyst forms also converts back into the spirochete forms which are easier to treat.

Mix Short and Long Lyme Pulse Antibiotics

In long pulse regimens, it is possible to do short Lyme pulse antibiotics. So during the 2 months of antibiotics a person takes the antibiotics for 4 days on followed by 3 days off.

Do Not Pulse Antibiotics for Co-infections

Co-infections like babesia and bartonella replicate quickly. For instance bartonella replicates every 24 hours. Lyme on the other hand has a very long replication cycle. The problem with stopping antibiotics that are also used in a bartonella treatment or babesia treatment is that during the off phase the bart or babesia will grow too much. So if a regimen for Lyme includes antibiotics that are also treating coinfections, it is best to use the antibiotics continuously rather than to pulse.

Final Word

Pulsing Lyme antibiotics does not always work. The idea to pulse antibiotics is based on tightly controlled laboratory experiments. We do not have any human experiments looking at either short pulse regimens or long pulse regimens compared to continuous regimens. Generally it takes short pulse regimens 4 months to see if they will work and long pulse regimens 3 to 4 rounds on the antibiotics.


The ideas and recommendations on this website and in this article are for informational purposes only. For more information about this, review the sitewide Terms & Conditions. 


View Citations

  1. Sharma B, Brown AV, Matluck NE, Hu LT, Lewis K. 2015. Borelia burgdoferi, the causative agent of Lyme disease, forms drug-tolerant persister cells. Anitimicrob Agents Chemother 59:4616-4624, doi:10.1128/AAC.00864-15. (View)
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About The Author

Marty Ross, MD is a passionate Lyme disease educator and clinical expert. He helps Lyme sufferers and their physicians see what really works based on his review of the science and extensive real-world experience. Dr. Ross is licensed to practice medicine in Washington State (License: MD00033296) where he has treated thousands of Lyme disease patients in his Seattle practice.

Marty Ross, MD is a graduate of Indiana University School of Medicine and Georgetown University Family Medicine Residency. He is a member of the International Lyme and Associated Disease Society (ILADS), The Institute for Functional Medicine, and The American Academy of Anti-Aging Medicine (A4M).

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