Recommendation for management of I. scopularis bites draws mixed reactions.

To the Editor: I was disappointed with the review article “The Management of Ixodes scapularis Bites in the Upper Midwest” by Elizabeth Maloney, MD.1 When controversy regarding a condition or treatment results in wide variation in diagnostic and therapeutic approaches, “guidelines” for diagnosis and treatment, developed and published by an authoritative body using the best science available, may be developed in an effort to limit variation and improve outcome. The Infectious Disease Society of America (IDSA) developed such guidelines, as the author correctly points out and effectively reviews and summarizes. Amazingly, in spite of acknowledging that evidence supporting an “alternative recommendation” is limited, Dr Maloney proceeds to advocate such an alternative based on “deductive” reasoning. At the very least, I would expect some citation of evidence suggesting that the rate of identifiable disease associated with I scapularis bites is increased if not given prophylaxis. As limited as the research regarding tick-borne disease may be, and as limited as the IDSA Guidelines may be, I see no evidence offered by Dr Maloney suggesting the need or desirability of not following the IDSA guidelines.