What combination abx are best for pulsing in acute treatment?

An appeal for advice from my learned friends! My 16 yo developed a rash 9-12 days after walking in a deer tick area. No other symptoms then or since. He is about to complete 4 weeks of doxy (200mgs x2 daily) with azithromcyn added for the last 3 weeks @250 x 2 daily. He's tolerating the abx very well. Two LLMDs offering 2 different opinions. One says keep going with doxy for 6 weeks swapping azithromcyn for tatracycline. Then break for 2 weeks then pulse with same for 2 months. The others says, take a break after 4 weeks then pulse with tetracycline & another antibiotic for a couple of months. I'm overwhelmed by the steep learning curve & drowning in my own ignorance! Any advice on the following would be so very much appreciated: Which is best: Keep going or break before pulsing? What's the best combination to pulse with at this stage? Is there any point pulsing with tetracycline & doxy as they target the same thing - don't they? Consult is Monday so want to armed with a bit of information beforehand. Any thoughts/nuggets of wisdom would be so gratefully received. With warm regards & huge appreciation. F

What an incredibly kind human you are Garzie! I really appreciate the time & effort you took in your reply. Huge thanks. Are you aware of any difference in efficacy between keep going for 6 weeks or pause after 4, break & pulse? Although he'll have been on doxy for 4 weeks by Monday, he'll only have been on azithromycin for 3 weeks. Maybe we need to extend that? Don't feel obliged to answer. You've already helped so much & I really appreciate that. Huge thanks. F

there are few human clinical efficacy trials - and none that i am aware of that specifically compared pulsing to continuous use in humans.

almost all papers published are on acute treatment and used only continuous antibiotics - which is consistent with mainstream dogma that it is an acute illness only - not a chronic infection - and as such they do not recommended antibiotics at all for chronic symptoms ( the logic is broken - and the evidence against this dogma is overwhelming - but that is where we are at present ).

because short courses of antibiotics have a high failure rate in chronic patients and because they do not have large scale clinical trials of better alternatives to draw from - the LLMD's are basing their approaches mainly on laboratory studies to select potential antibiotic agents - and then their own trials experiences of patients outcomes in their clinical practice.
however, the protocols they develop for chronic patients are not necessarily needed or applicable to acute patients. the disease is easier to treat if caught in the first few months - before it has time to become fully entrenched and impact the hosts immune system.

if it were me i would just use 2 or more antibiotics continuously for acute illness - treat until there are no obvious symptoms - then monitor carefully for any resurgence in the following months and be prepared to restart if signs and symptoms re-occur - this may include having a supply of abx ready as a precaution.

in terms of overall success - i would also be very mindful that its the health of the hosts immune system that seems to be the largest factor in peoples ability to overcome the infection - and as such it is in my mind (and also in the mind of many leading LLMD's ) just as important to manage overall health and lifestyle over the long term, as selecting the right antibiotics to treat with in the short term, in order to reach remission and to remain symptom free

good health, and by extension health and proper functioning of the immune system, depends on simple but often overlooked principles that are in currently very poorly adhered to in western societies (especially by the younger generation).
-good sleep,
-good diet,
-regular exercise,
-actively managing stress,
-meaningful social engagement

many of us here only became ill with lyme in the first instance because one of more of these factors was severely disrupted in our lives - leaving us open to chronic infection.
as an example - in my case i had very good diet, exercised regularly, had good social engagement and purpose in my life - but my stress levels were extremely high and my sleep very poor.

i know its often difficult to impress the importance or even benefits of such principles on a teenager - but these principles are not only the foundation of a healthy immune system - and as such the best strategy for avoiding relapses of Lyme disease - but also form the foundations of a healthy and productive life.

so - in summary - its not all about the drugs - the overall health of the human organism is just as important - if not more so.

i hope its of some help

all the best

we cannot give medical advice as we are not qualified MD's and even if we were cannot know all the personal circumstances risk factors in any individual case.

all i can say is if it were me in the same position - unless there are contra indications in your sons case - and as long as the antibiotics are tolerated well - i think i would continue treating with 2 antibiotics for at least 30 days - and in any case continue till all symptoms have resolved and then a couple of weeks on top to be confident its beaten back - then monitor carefully

if treating beyond 30 days with multiple antibiotics is probably wise to have safety labs done each month
LFT, KFT and CBC as minimum is typical - perhaps discuss this with your doctor ref continuing past 30 days

Because your son has not presented with any symptoms other than the rash, he DOES NOT need treatment beyond the initial 4-6 weeks of abx:

https://www.ilads.org/patient-care/ilads-treatment-guidelines/