What is the recommended management for leptospirosis?

Leptospirosis Presentation and Management

The recommended management for leptospirosis includes prompt antibiotic therapy with penicillin or doxycycline for mild to moderate cases, and intravenous antibiotics such as ceftriaxone or penicillin for severe cases (Weil's disease), with treatment initiated as soon as possible without waiting for laboratory confirmation. 1, 2

Clinical Presentation and Classification

Leptospirosis presents as a biphasic illness with two main clinical forms:

• Mild to moderate form (most common): Flu-like symptoms including fever, headache, chills, myalgia, and conjunctival suffusion 1, 2
• Severe form (Weil's disease): Characterized by hemorrhage, jaundice, and hepato-renal failure, occurring in approximately 5-10% of infected individuals 1

Key Clinical Features

• Septicemic/bacteremic phase: Lasts 4-7 days with high fever (usually ≥39°C) 1
• Characteristic symptoms: Diffuse myalgias (especially in calves), headache, and conjunctival suffusion (a highly suggestive sign) 1, 2
• Laboratory findings: Proteinuria, hematuria, leukocytosis with polymorphonuclear cells, anemia (if hemorrhage occurs), elevated bilirubin with mild elevation of transaminases, and alterations in renal function 1

Diagnostic Approach

Diagnosis is based on clinical presentation and confirmed through laboratory testing:

• Clinical diagnosis: Consider leptospirosis in patients with fever, diffuse myalgias, headache, and conjunctival suffusion, especially with relevant exposure history 1, 2
• Confirmatory testing:
  • Isolation of Leptospira from clinical specimen
  • Fourfold or greater increase in Leptospira agglutination titer between acute and convalescent-phase serum specimens
  • IgM titers >1:320 are suggestive of leptospirosis
  • Blood cultures (if taken in first 5 days before antibiotics) 1, 2

Treatment Recommendations

Mild to Moderate Leptospirosis

• First-line therapy: Start antibiotics as soon as possible 1, 2
  • Doxycycline (oral): Effective and reasonable alternative 1, 3
  • Penicillin (oral): Traditional treatment of choice 1, 3
  • Azithromycin: Promising for less severe disease 3

Severe Leptospirosis (Weil's disease)

• Immediate treatment: Start without waiting for laboratory confirmation 1, 2
• Preferred regimens:
  • Ceftriaxone: 2g IV daily - offers convenience, efficacy and safety 4
  • Penicillin: IV administration - traditional first-line therapy 3, 5
  • Cefotaxime: Acceptable alternative 3

Treatment Duration

• Mild to moderate disease: 7 days for penicillin, doxycycline, and cephalosporins; 3 days for azithromycin 6
• Severe disease: Continue until clinical improvement, typically 7-10 days 5

Supportive Care

For patients with severe leptospirosis, aggressive supportive care is essential:

• Fluid resuscitation: Use adequate tissue perfusion as the principal endpoint of resuscitation 7
• Target parameters: Systolic arterial blood pressure >90 mmHg in adults, normal heart rate and arterial blood pressure in children 7
• Monitoring: Never leave septic patients alone; ensure continuous observation and perform clinical examinations several times per day 7

Special Considerations

Severe Cases

• ICU admission: Consider for patients with persistent or worsening tissue hypoperfusion despite initial fluid resuscitation 7
• Respiratory support: Monitor closely as aggressive fluid resuscitation can lead to respiratory impairment 7
• Renal support: May be necessary in cases of acute kidney injury

Evidence Limitations

• Despite widespread use of antibiotics for leptospirosis, recent systematic reviews note insufficient high-quality evidence to definitively determine their effectiveness 6, 8
• However, clinical practice and available evidence support antibiotic use, with penicillin showing potential to "cause more good than harm" 8

Prevention

• Avoid contact with urine from infected animals and contaminated water 1, 2
• Take precautions during water recreational activities, occupational exposure to animals or water, and during floods 1, 2

Pitfalls to Avoid

• Delayed treatment: Do not wait for laboratory confirmation before starting antibiotics in suspected severe cases 1, 2
• Inadequate monitoring: Ensure continuous observation of patients with severe disease 7
• Fluid overload: Monitor for development of crepitations indicating fluid overload or impaired cardiac function during resuscitation 7
• Misdiagnosis: Consider leptospirosis in patients with fever and jaundice, as it may be misdiagnosed as viral hepatitis 7