Episode 619: Sequential Antibiotic Therapy for Chronic Lyme Disease – Dr. Louis Teulières | LIVE from ILADS

Could changing how antibiotics are administered help address some of the biggest challenges in treating chronic and disseminated Lyme disease? What if the timing, combination, and delivery of antibiotics matter as much as the medications themselves?

In this LIVE from ILADS interview, Tick Boot Camp co-host Rich reunites with Dr. Louis C. Teulières, MD, PhD, a French physician and Lyme disease researcher, to explore his approach to sequential antibiotic therapy, Borrelia persistence, biofilms, neurological Lyme disease, antibiotic combinations, and treatment-related inflammation.

Recorded at the 2025 International Lyme and Associated Diseases Society (ILADS) Conference in San Antonio, Texas, the conversation follows Dr. Teulières' presentation, Antibiotic Rotational Combination Sequential Therapies in Chronic and Disseminated Disease TBD.

Dr. Teulières challenges conventional approaches to prolonged antibiotic treatment and explains why he believes carefully structured treatment sequences may offer advantages for selected patients with complex tick-borne illnesses.

Rather than administering antibiotics continuously for extended periods, he describes a strategy involving shorter treatment windows, planned breaks, and carefully selected antibiotic combinations.

He also discusses the importance of matching antibiotics to the tissues affected by infection, considering the blood-brain barrier in neurological Lyme disease, and addressing potential complications involving the gut microbiome, liver, and kidneys.

Rich and Dr. Teulières explore three major questions:

• Can sequential antibiotic treatment help clinicians better evaluate treatment responses?
• Could planned treatment breaks reduce some of the burdens associated with prolonged antibiotic exposure?
• How might clinicians select antibiotic combinations based on bacterial behavior, tissue penetration, and patient symptoms?

The central message is that Lyme disease treatment requires thoughtful clinical decision-making, individualized care, and an understanding of both the potential benefits and risks of antimicrobial therapy.

The sequential antibiotic approach discussed in this interview represents Dr. Teulières' clinical perspective. Its effectiveness and safety compared with established Lyme disease treatment regimens have not been demonstrated in high-quality comparative clinical trials.

Meet Dr. Louis C. Teulières, MD, PhD

Dr. Louis C. Teulières, MD, PhD, is a French physician and researcher whose work includes infectious diseases, complex chronic illness, and approaches to treating Lyme and other tick-borne diseases.

At the 2025 ILADS Conference, Dr. Teulières presented Antibiotic Rotational Combination Sequential Therapies in Chronic and Disseminated Disease TBD.

His presentation explores the use of antibiotic combinations and sequential treatment strategies in patients with complex tick-borne illnesses.

In this interview, he explains his clinical reasoning and discusses why he believes antibiotic timing, medication selection, and treatment intervals deserve greater attention.

Dr. Teulières has been a returning guest on Tick Boot Camp, sharing his perspectives on Lyme disease treatment and the challenges of managing complex infections.

What Is Sequential Antibiotic Therapy for Lyme Disease?

One of the main topics of the interview is Dr. Teulières' proposed sequential antibiotic treatment strategy.

He distinguishes this approach from three other methods of administering antibiotics:

Continuous treatment: Antibiotics are administered without planned breaks for a prescribed period.

Pulsed treatment: Antibiotics are administered intermittently according to a predetermined schedule.

Rotational treatment: Different antibiotics are used in rotation.

Sequential treatment: Dr. Teulières describes administering selected antibiotic combinations for a defined period, followed by a treatment break, with subsequent treatment decisions informed by the patient's response.

During the interview, he discusses an example involving approximately 14 days of antibiotic therapy followed by a planned break of approximately 14 days.

He explains that these intervals may allow clinicians to assess symptoms, review treatment tolerance, and adjust medication combinations.

Dr. Teulières believes the strategy may also provide opportunities for supportive care between antibiotic courses.

However, this specific schedule has not been established as an effective or safer treatment protocol for persistent Lyme disease through controlled clinical trials.

Patients should never independently interrupt or modify prescribed antibiotic treatment.

Why Dr. Teulières Questions Long-Term Continuous Antibiotics

Dr. Teulières explains that he has concerns about prolonged, uninterrupted antibiotic exposure.

He identifies several potential challenges:

• Antibiotic-associated adverse effects
• Disruption of the intestinal microbiome
• Selection of antibiotic-resistant organisms
• Difficulty identifying which medications are producing benefits
• Possible bacterial survival mechanisms
• Additional physical stress during treatment

He believes these concerns warrant consideration of alternative dosing strategies.

His proposed sequential approach is intended to create opportunities for reassessment rather than maintaining the same treatment continuously.

The discussion highlights an important distinction between the established effectiveness of antibiotics for Lyme disease and ongoing debates about additional antimicrobial treatment for persistent symptoms after standard therapy.

Borrelia Persistence: Round Bodies, Biofilms, and Tissue Survival

Rich asks Dr. Teulières about the ability of Borrelia bacteria to survive under challenging conditions.

Dr. Teulières describes several mechanisms that he believes may contribute to bacterial persistence.

Round-Body Forms

He explains that Borrelia can change its morphology under certain environmental conditions.

These changes, sometimes described as round-body forms, have been observed in laboratory research.

Dr. Teulières believes such changes may influence bacterial susceptibility to antimicrobial treatment.

Biofilms

Dr. Teulières also discusses biofilms, which are structured communities of microorganisms surrounded by protective material.

Biofilms can influence how certain microorganisms respond to environmental conditions and antimicrobial exposure.

He raises the possibility that biofilm-related mechanisms could complicate treatment in some patients.

Tissue Localization

The interview explores whether bacteria occupying certain tissues may be less accessible to particular medications.

Dr. Teulières emphasizes that antibiotic selection should account for where an infection is located.

Although Borrelia morphology, biofilm formation, and persister states are active research topics, their role in persistent human Lyme disease symptoms remains incompletely understood.

Laboratory findings do not establish that these mechanisms explain every case of persistent symptoms or that sequential antibiotic treatment overcomes them in patients.

Antibiotic Resistance vs. Bacterial Persistence

Dr. Teulières discusses the possibility that prolonged antibiotic exposure may contribute to the selection of resistant organisms.

He also describes bacterial forms that may survive exposure through mechanisms distinct from conventional antibiotic resistance.

These concepts are related but not identical.

Antibiotic resistance involves mechanisms that allow bacteria to withstand antimicrobial activity.

Antibiotic tolerance or persistence can involve survival during treatment without conventional inherited resistance.

Dr. Teulières believes understanding these differences may help clinicians develop more targeted approaches.

The clinical significance of proposed Borrelia persister forms remains an area of investigation, and the interview does not establish that sequential therapy prevents antibiotic resistance.

Why Dr. Teulières Recommends Treatment Breaks

A central feature of Dr. Teulières' proposed strategy is incorporating planned intervals between antibiotic courses.

He identifies three potential advantages.

1. Allowing Time for Recovery

Dr. Teulières believes treatment breaks may allow patients to recover from some medication-related burdens.

He discusses the liver and kidneys, which play essential roles in processing and eliminating many medications and their metabolites.

He also describes the potential importance of reducing treatment-related discomfort.

2. Evaluating Treatment Response

Dr. Teulières believes a defined treatment period followed by observation may help clinicians determine whether a particular antibiotic combination is producing meaningful changes.

He suggests monitoring whether symptoms improve, remain unchanged, or return during a treatment break.

3. Adjusting Antibiotic Combinations

Sequential treatment may also provide opportunities to reassess the medications being used.

Dr. Teulières proposes adjusting combinations based on the patient's symptoms, suspected infections, and clinical response.

These are the potential advantages he describes, not benefits established through comparative clinical trials.

Scheduled antibiotic breaks have not been proven to provide a specific detoxification benefit or prevent organ injury.

What Happens When Antibiotics Kill Bacteria?

Rich asks Dr. Teulières why some patients experience increased symptoms during antimicrobial treatment.

Dr. Teulières describes how bacterial components can stimulate inflammatory responses as organisms are affected by treatment.

He discusses microbial debris and inflammatory molecules that may contribute to discomfort.

The conversation connects this process to concerns about treatment-related inflammation.

However, symptom worsening during Lyme disease treatment is not automatically evidence of bacterial die-off.

Medication reactions, allergic responses, unrelated illnesses, and other complications can produce similar symptoms.

A true Jarisch-Herxheimer reaction is a recognized acute inflammatory response associated with treatment of certain infections, including some spirochetal diseases.

Severe or persistent symptoms during treatment require medical evaluation rather than an assumption that the medication is working.

Bacteriostatic vs. Bactericidal Antibiotics

Dr. Teulières explains why he considers the mechanisms of different antibiotics when selecting treatment combinations.

Bacteriostatic Antibiotics

Bacteriostatic antibiotics primarily inhibit bacterial growth under particular conditions.

Some interfere with bacterial protein synthesis.

Dr. Teulières discusses azithromycin as an example.

Bactericidal Antibiotics

Bactericidal antibiotics kill susceptible bacteria under particular conditions.

Different medications accomplish this through different mechanisms, including disruption of bacterial cell wall synthesis.

Dr. Teulières discusses ceftriaxone as an example.

Why Combine Both Types?

Dr. Teulières proposes combining selected bacteriostatic and bactericidal medications.

He believes that targeting bacteria through different mechanisms may improve treatment effectiveness in certain circumstances.

He discusses combinations such as azithromycin and ceftriaxone to illustrate his approach.

However, combining these antibiotic categories does not automatically improve clinical outcomes.

Some combinations may introduce additional adverse effects or drug interactions, and certain combinations can interfere with one another.

Antibiotic selection must be based on the specific infection, patient characteristics, and available evidence.

Selecting Antibiotics Based on Tissue Penetration

Another important concept in the interview is the distribution of antibiotics throughout the body.

Dr. Teulières emphasizes that different medications reach different tissues at different concentrations.

He discusses selecting antibiotics according to the location of suspected infection.

Relevant considerations may include:

• Skin and connective tissue involvement
• Joint manifestations
• Neurological symptoms
• Central nervous system infection
• The presence of other diagnosed infections
• Medication absorption and distribution
• Patient-specific contraindications

Dr. Teulières believes these factors are especially important in patients with complex or disseminated disease.

The broader medical principle is that treatment selection should account for both the organism being treated and the anatomical site of infection.

Neurological Lyme Disease and the Blood-Brain Barrier

Rich and Dr. Teulières discuss how treatment decisions may differ when Lyme disease affects the nervous system.

Dr. Teulières emphasizes the importance of selecting antibiotics capable of reaching the relevant site of infection.

He identifies several antibiotic families and discusses their potential tissue penetration.

The blood-brain barrier helps regulate which substances enter the central nervous system.

Certain medications penetrate this barrier more effectively than others, depending on factors such as drug properties and inflammation.

However, neurological symptoms alone do not establish central nervous system infection.

Similarly, the ability of a medication to penetrate the blood-brain barrier does not automatically make it effective or appropriate for Lyme neuroborreliosis.

Treatment depends on the specific neurological manifestation and clinical evaluation.

For additional education, listen to Tick Boot Camp's interview with Dr. Medeya Tsnobiladze on the neurological and cardiovascular impacts of Lyme disease.

Oral vs. Intravenous vs. Intramuscular Antibiotics

Dr. Teulières discusses the advantages and limitations of different antibiotic administration routes.

Oral antibiotics are taken by mouth and absorbed through the gastrointestinal tract.

Intravenous antibiotics are delivered directly into a vein.

Intramuscular antibiotics are administered through injection into muscle tissue.

He explains that his proposed treatment strategy may involve different administration routes depending on the patient's symptoms and clinical circumstances.

Dr. Teulières expresses concern about the gastrointestinal effects of prolonged oral antibiotic use.

He also discusses considering injectable medications for certain neurological presentations.

However, intravenous or intramuscular antibiotics are not inherently more effective than oral medications.

For many manifestations of Lyme disease, appropriately selected oral antibiotics are effective.

Injectable therapies can introduce additional risks, including line infections, blood clots, and administration complications.

Protecting the Gut Microbiome During Lyme Disease Treatment

Dr. Teulières emphasizes the importance of considering intestinal microbiome health during antibiotic treatment.

The gut microbiome contains diverse microorganisms that contribute to digestion, metabolism, and other biological processes.

Antibiotics can disrupt these microbial communities.

Potential consequences may include gastrointestinal symptoms and antibiotic-associated infections.

Dr. Teulières believes his proposed treatment breaks may provide opportunities for the microbiome to recover.

However, evidence has not established that his sequential approach reliably prevents microbiome disruption.

The effects of antibiotics depend on the specific medication, duration, dose, and patient.

Treating Lyme Disease and Co-Infections

The conversation also addresses the possibility of multiple infections contributing to complex illness.

Dr. Teulières explains that clinicians may need to consider bacterial, parasitic, or viral conditions when evaluating patients.

He believes sequential treatment strategies could provide opportunities to address different diagnosed infections at different times.

However, the presence of Lyme disease does not automatically establish additional infections.

Each suspected infection requires appropriate evaluation.

Treatment choices should be based on clinical findings and reliable diagnostic information rather than assuming that every symptom represents an additional pathogen.

Can Antibiotics Have Antiviral Effects?

Dr. Teulières briefly discusses research into possible antiviral effects of certain antibiotic classes.

He specifically mentions macrolides.

Some antibiotics have demonstrated antiviral or immunomodulatory activity in laboratory settings.

However, these findings do not establish that antibiotics are effective clinical treatments for viral infections.

Antibiotics should not be used to treat viral illnesses without a specific evidence-supported indication.

This portion of the interview reflects an area of scientific interest rather than a validated treatment recommendation.

Intravenous Immunoglobulin and Complex Chronic Illness

Dr. Teulières also discusses the possibility of using intravenous immunoglobulin, or IVIG, alongside other treatments in selected patients.

IVIG is made from pooled antibodies collected from donated human plasma.

It is used for certain immune deficiencies, autoimmune conditions, and neurological disorders.

Dr. Teulières describes how intravenous treatment may allow clinicians to coordinate different therapies when medically appropriate.

However, IVIG is not a routine or established treatment for Lyme disease itself.

Its use requires a specific medical indication and careful consideration of risks.

Sequential Antibiotics and the Rehabilitation Process

Toward the end of the interview, Rich connects Dr. Teulières' approach to Tick Boot Camp's broader observations about chronic illness recovery.

Rich emphasizes that the goal of treatment should not be limited to reducing an infectious burden.

Patients may also need to recover from the physical and emotional consequences of prolonged illness.

He discusses how aggressive interventions can create additional challenges if they produce significant adverse effects or functional setbacks.

Dr. Teulières agrees that treatment should be used carefully and thoughtfully.

Their conversation reinforces the importance of balancing medical treatment with patient safety, tolerability, and quality of life.

How Does Dr. Teulières' Approach Compare With Lyme Disease Guidelines?

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