What is the treatment for severe leptospirosis?

Treatment of Severe Leptospirosis

For severe leptospirosis (Weil's disease), treatment should be initiated immediately without waiting for laboratory confirmation, with intravenous antibiotics such as penicillin or tetracyclines administered within the first hour of recognition. 1

Clinical Classification and Recognition

• Severe leptospirosis (Weil's disease) is characterized by hemorrhage, jaundice, and hepato-renal failure, occurring in approximately 5-10% of infected individuals 1
• Key clinical features include high fever (usually 39°C or higher), diffuse myalgias (especially in calves), headache, and conjunctival suffusion (a suggestive sign) 1
• Laboratory findings may include proteinuria, hematuria, leukocytosis, anemia (if significant hemorrhage), elevated bilirubin with mild elevation of transaminases, and alterations in renal function 1

Initial Management

• Administer effective intravenous antimicrobials within the first hour of recognition of septic shock (Grade 1B) or severe sepsis without septic shock (Grade 1C) 2, 1
• Do not delay treatment while waiting for laboratory confirmation as this increases mortality 1
• Obtain at least 2 sets of blood cultures (both aerobic and anaerobic bottles) before antimicrobial therapy if no significant delay (<45 min) in starting antibiotics 2

Antibiotic Selection

• Initial empiric anti-infective therapy should include one or more drugs that have activity against all likely pathogens and penetrate in adequate concentrations into tissues presumed to be the source of sepsis (Grade 1B) 2
• For severe leptospirosis, intravenous penicillin or tetracyclines (doxycycline) are recommended as first-line therapy 1
• Combination empirical therapy may be considered for patients with severe infections associated with respiratory failure and septic shock (Grade 2B) 2

Duration of Treatment

• Standard course of antibiotic therapy for severe leptospirosis is 7-10 days 1
• Longer courses may be appropriate in patients who have a slow clinical response, undrainable foci of infection, or immunologic deficiencies (Grade 2C) 2, 1
• Reassess antimicrobial regimen daily for potential de-escalation (Grade 1B) 2

Supportive Care

• Implement fluid resuscitation targeting systolic arterial blood pressure >90 mmHg in adults 1
• Monitor for development of crepitations indicating fluid overload or impaired cardiac function during resuscitation 1
• Consider ICU admission for patients with persistent or worsening tissue hypoperfusion despite initial fluid resuscitation 1
• For patients with severe complications such as pulmonary hemorrhage, mechanical ventilation and corticosteroid therapy may be required 3

Source Control

• Seek a specific anatomical diagnosis of infection requiring emergent source control and undertake intervention within the first 12 hours after diagnosis, if feasible (Grade 1C) 2
• If intravascular access devices are a possible source of severe sepsis or septic shock, remove them promptly after other vascular access has been established 2

Monitoring and Complications

• Perform continuous observation and frequent clinical examinations for septic patients 1
• Monitor for potential complications including diffuse alveolar hemorrhage, acute respiratory distress, renal injury, and gastrointestinal bleeding 3
• An integrated multidisciplinary team approach is essential to prevent complications and reduce mortality in severe cases 3

Pitfalls and Caveats

• Leptospirosis may be misdiagnosed as viral hepatitis in patients with fever and jaundice 1
• Early antibiotic administration is critical, as treatment initiated after 4 days of symptoms may be less effective 1
• Discontinuing antibiotics too early should be avoided; complete the full course even with clinical improvement 1
• Despite widespread use of antibiotic treatment for leptospirosis, recent systematic reviews indicate very low-certainty evidence regarding specific antibiotic choices 4