PULSING ANTIBIOTICS
Updated: 4 days ago
Pulsing means taking antibiotics on and off on a set schedule, instead of every single day. It comes up a lot in our groups, and every Lyme literate doctor seems to do it a little differently. Here's what ILADS, trusted researchers and Lyme literate doctors share about how it works, when it may help, and when it may not, so you can talk it over with your doctor.
Short on time or energy? A quick-view graphic with the key points is at the bottom of this post.
Want to learn why most Lyme literate doctors use more than one antibiotic? See my sister post:
ANTIBIOTICS - WHY USING ONLY ONE IS NOT RECOMMENDED IN CHRONIC LYME
https://www.riseabovelyme.com/post/antibiotics-why-using-only-one-is-not-recommended-in-chronic-lyme
Want to understand the hidden forms of Lyme that pulsing is meant to reach?
CYST FORMS OF LYME
BIOFILMS EDUCATION
WHAT ILADS SAYS
-ILADS's 2014 treatment guideline doesn't mention pulsing. It says treatment for chronic Lyme should be individualized, and that doctors may adjust doses for each person with the goal of better results. (2014, older source, still worth reading.)
-ILADS explains that Lyme can go dormant, change shape, hide and form biofilms, and that repeating antibiotic courses that don't get past these defenses is likely to fail. Pulsing is one way some doctors try to get past them.
-Dr. Joe Burrascano, one of the founders of ILADS, uses two different on-and-off approaches, pulsing and cycling (explained below).
-In a 2024 article for ILADEF (ILADS's sister organization), Dr. Richard Horowitz shares that he started pulsing his dapsone combination protocol based on Northeastern University lab work showing pulses could reach persisters. He first used short, stronger 4-day pulses, then lengthened them to 6 days for Bartonella, and he has seen better results since adding 2-week pulses every few months.
HOW PULSING WORKS
-Antibiotics mostly kill Lyme while it's growing. Some Lyme goes into a dormant "persister" state and waits it out. The idea behind pulsing is that during the off days, the persisters become active and start growing again, so the next round can hit them.
-Dr. Marty Ross explains that during the off days, Lyme hiding in biofilms may come out and round "cyst" forms may turn back into spiral forms, which are easier to treat.
-Dr. Burrascano explains that Lyme is slow to die and slow to grow back, so it may not become active again for days to weeks after a round of antibiotics.
COMMON WAYS DOCTORS PULSE
-Short pulses within each week: Dr. Burrascano describes taking an antibiotic two or three days in a row, then nothing the rest of the week (for example, three days on and four off). Dr. Ross finds four days on and three days off works best for him, and says the other schedules he tried didn't seem to work as well.
-Long on-and-off cycles: Dr. Ross, building on Dr. Burrascano's work, used 2 months on antibiotics and 2 months off in his practice, and found it helped about 40 percent of the time. That's his clinical estimate, not a study. He sometimes used the 4-days-on, 3-days-off pattern during the 2 months on.
-Cycle therapy: Dr. Burrascano came up with this for people who improve and then stall. He stops antibiotics at the plateau. When the familiar Lyme symptoms come back, usually by the third or fourth week, he restarts full treatment for about five or six weeks to the next plateau, then repeats. He estimates it helped about 80 percent of those patients. That's his own estimate, not a study.
-High-dose pulses within a combination protocol: Dr. Horowitz uses 8 weeks of a dapsone combination, followed by one or more short high-dose pulses. For Bartonella, he usually needs at least four 2-week pulses, spaced about 6 to 8 weeks apart.
DAPSONE
METHYLENE BLUE
-Pulsing still uses combinations. Dr. Ross shares that his plans use at least two antibiotics, sometimes three, and all of them are taken on the same days.
WHY SOME DOCTORS LIKE IT
-It may be gentler. Dr. Burrascano explains that being on medicine less than half the time means less strain on the gut and gallbladder.
-It may allow stronger doses. Because the medicine is taken only part of the week, he shares that a stronger medicine or higher dose can be used.
-It may be safer for IV treatment. Dr. Burrascano explains that IV antibiotics given two days a week can use a short IV in the arm that comes out after each pulse, instead of a long PICC line, which lowers the risk of line infections and clots.
PICC LINES / IV ANTIBIOTICS
-It may help sensitive people. Dr. Burrascano uses short pulses for people who herx badly, so they have the rest of the week to recover. Dr. Horowitz also adjusts his protocol to pulsing for people who don't tolerate antibiotics well.
-Dr. Ross considers pulsing for people who get yeast overgrowth or liver or kidney strain on antibiotics, since a lower weekly amount of antibiotics may ease these.
WHEN PULSING MAY NOT FIT
-Not every antibiotic is a good fit. Dr. Ross explains that medicines that stay in the body a long time shouldn't be pulsed. Azithromycin (Zithromax) takes about 11 days to fully leave the body, so he doesn't pulse it.
ZITHROMAX / AZITHROMYCIN
-Co-infections: Dr. Ross doesn't pulse antibiotics that are also treating Babesia or Bartonella, because these grow much faster than Lyme (Bartonella every 24 hours) and could grow too much during the off days. Dr. Horowitz, on the other hand, uses longer high-dose pulses for Bartonella within his combination protocol. Doctors differ here, and that's okay.
BABESIA - POSSIBLE SOLUTIONS
BARTONELLA - POSSIBLE SOLUTIONS
-Dr. Bill Rawls tried pulsed antibiotics early in his own illness. He got sick on them, and everything came back when he stopped. He feels the off days give the bacteria time to rebound too, and each round of antibiotics still hits the gut. He prefers herbs, which don't need to be pulsed, and suggests that anyone who pulses antibiotics use herbs alongside them.
NATURAL ANTIBIOTICS
-In a 2021 article (older source, still worth reading), Global Lyme Alliance writer Jennifer Crystal shares that pulsing works great for some people but not for everyone. Some feel the bacteria build back up during the off periods, making the herx worse when the antibiotics restart.
-Dr. Steven Phillips shares that he used pulsing in his practice for many years and found it helped shorten treatment while working better. He adds that not every antibiotic can be pulsed, and that many of his patients had symptoms come back between the first several pulses.
WHAT RESEARCH SHOWS
-Dr. Ross points out there are still no good studies in people comparing pulsing with taking antibiotics every day, and that the idea comes from tightly controlled lab experiments. He finds it takes about 4 months to know whether short pulses are working, and 3 to 4 rounds for long pulses.
-2015 Tulane lab study (older source, still worth reading): Researchers gave Lyme doxycycline for 5 days, removed it, and repeated the cycle. The pulses didn't get rid of the persisters. They kept growing back after each round.
-2022 review co-written by Tulane's Dr. Monica Embers: It's still not clear whether pulsing lowers the number of antibiotic-tolerant Lyme bacteria, because lab studies pulsing doxycycline and ceftriaxone have found different results.
-2015 Northeastern University lab study (older source, still worth reading): After ceftriaxone killed most Lyme bacteria in a dish, the drug was washed away so the persisters could become active again, then added again. Four pulses wiped out all the live bacteria in the dish.
-2016 Johns Hopkins lab study (older source, still worth reading): Pulsed ceftriaxone killed the spiral and round forms, but not the tougher biofilm-like clumps found in older cultures. Antibiotics that kill bacteria (like ceftriaxone and cefuroxime) suited pulsing better than doxycycline, which mostly stops growth, or the persister drug daptomycin. Pulsing a combination worked better than pulsing one drug, but the best result came from a three-drug combination given without pulsing.
-2022 to 2024 reports by Dr. Horowitz (in people): In 25 patients, most of whom were still sick after his dapsone protocol, short high-dose pulses improved major Lyme symptoms for most, and the dose, not just the length, made a difference (2022). When Bartonella was present, 6 to 7 day pulses worked better than 4-day pulses (2023). In 3 patients with Lyme, Babesia and Bartonella, Bartonella needed one or more 6-day pulses to reach remission (2024). These are small reports from his own clinic, without a comparison group.
GOOD TO KNOW
-Herxing: pulsing is one way doctors may help people who herx hard. Global Lyme Alliance suggests telling your doctor how a herx is affecting your daily life, so you can decide together whether to pulse, switch antibiotics or adjust. To quote my doctor: "You are NOT meant to be tortured in treatment, you are meant to tolerate it. If it feels like it's too much to handle, it probably is time to back off."
HERX - POSSIBLE SOLUTIONS
HERX VS. FLARE EDUCATION
TOLERATING TREATMENT
-Gut: fewer antibiotic days may mean less stress on the gut and less yeast, but every round still affects gut bacteria. Probiotics are usually taken 2 to 3 hours apart from antibiotics, but Saccharomyces boulardii is a yeast, so antibiotics don't kill it and it can be taken with them.
PROBIOTICS AND SACCHAROMYCES BOULARDII
CANDIDA - POSSIBLE SOLUTIONS
-Keep a symptom diary. Dr. Burrascano has all his patients keep one, because Lyme symptoms tend to flare and ease about every four weeks, and the pattern helps guide when to stop or restart. A diary can also help you and your doctor see how a schedule is going.
ORGANIZING YOUR LYME TREATMENT AND SYMPTOM TRACKING
-Never stop, start or change your antibiotic schedule on your own. Pulsing is a plan made with your Lyme literate doctor.
MY EXPERIENCE
-What I was taught: if a herx feels like too much, it may be time to adjust or take a break for 2 to 3 days. When I was extra miserable, my doctor had me either back off or take a short break before continuing, and I did better when I restarted.
-I hated taking breaks, but over time I learned they helped me in the long run.
SOURCES
ILADS - Controversies and Challenges (updated September 2026)
ILADS - Cameron, Johnson and Maloney, Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease, Expert Review of Anti-infective Therapy (2014, older source, still worth reading)
ILADEF - Dr. Richard Horowitz, How Does Dapsone Work? (September 2024)
Bay Area Lyme Foundation - Dr. Joe Burrascano: A Masterclass on Tick-Borne Illness (August 2025)
Dr. Marty Ross, How to Pulse Antibiotics for Lyme (January 2025)
Dr. Marty Ross, A Lyme Disease Antibiotic Guide (first published June 2024)
LymeDisease.org - Dr. Richard Horowitz, Medical Detective: 2-week pulses of antibiotics for chronic bartonellosis (March 2025)
LymeDisease.org - Dr. Richard Horowitz, Medical Detective: Effective treatments for Bartonella infections (February 2025)
Antibiotics - Horowitz and Freeman, Efficacy of Short-Term High Dose Pulsed Dapsone Combination Therapy in the Treatment of Chronic Lyme Disease/Post-Treatment Lyme Disease Syndrome (PTLDS) and Associated Co-Infections: A Report of Three Cases and Literature Review (July 2022)
Microorganisms - Horowitz, Fallon and Freeman, Comparison of the Efficacy of Longer versus Shorter Pulsed High Dose Dapsone Combination Therapy in the Treatment of Chronic Lyme Disease/Post Treatment Lyme Disease Syndrome with Bartonellosis and Associated Coinfections (September 2023)
Microorganisms - Horowitz, Fallon and Freeman, Combining Double-Dose and High-Dose Pulsed Dapsone Combination Therapy for Chronic Lyme Disease/Post-Treatment Lyme Disease Syndrome and Co-Infections, Including Bartonella: A Report of 3 Cases and a Literature Review (April 2024)
mBio - Cabello, Embers, Newman and Godfrey, Borreliella burgdorferi Antimicrobial-Tolerant Persistence in Lyme Disease and Posttreatment Lyme Disease Syndromes (June 2022)
Global Lyme Alliance - Dear Lyme Warrior...Help! (Jennifer Crystal, September 2023)
Global Lyme Alliance - Dear Lyme Warrior...Help! Pulsing Antibiotics, Rashes, and Insomnia (Jennifer Crystal, May 2021, older source, still worth reading)
Dr. Bill Rawls, Are Pulsed Antibiotics Helpful for Lyme? (December 2022)
Dr. Steven Phillips, FAQs (no date shown)
Antimicrobial Agents and Chemotherapy - Caskey and Embers (Tulane), Persister Development by Borrelia burgdorferi Populations In Vitro (October 2015, older source, still worth reading)
Antimicrobial Agents and Chemotherapy - Sharma et al. (Northeastern University), Borrelia burgdorferi, the Causative Agent of Lyme Disease, Forms Drug-Tolerant Persister Cells (August 2015, older source, still worth reading)
Frontiers in Microbiology - Feng, Zhang, Shi and Zhang (Johns Hopkins), Ceftriaxone Pulse Dosing Fails to Eradicate Biofilm-Like Microcolony B. burgdorferi Persisters Which Are Sterilized by Daptomycin/Doxycycline/Cefuroxime without Pulse Dosing (November 2016, older source, still worth reading)
LymeDisease.org - LymeSci: Why persister cells matter with Lyme disease (January 2017, older source, still worth reading)
RELATED POSTS
ANTIBIOTICS - WHY USING ONLY ONE IS NOT RECOMMENDED IN CHRONIC LYME
https://www.riseabovelyme.com/post/antibiotics-why-using-only-one-is-not-recommended-in-chronic-lyme
CYST FORMS OF LYME - POSSIBLE SOLUTIONS
BIOFILMS - POSSIBLE SOLUTIONS
Disclaimer: Rise Above Lyme makes no claims about any possible benefit of using any product mentioned within this site. Always consult with your doctor before adding anything. The information shared is based on personal experience, years of accumulated researched resources from Lyme Literate doctors and polls conducted within Lyme groups from actual patient experience using these solution ideas.
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