What is the treatment for Leptospira infection?

Treatment of Leptospirosis

For leptospirosis infection, treatment should be started as soon as possible with antibiotics such as penicillin or doxycycline, without waiting for laboratory confirmation in severe cases. 1, 2

Classification and Clinical Presentation

• Leptospirosis can be classified into two main clinical forms: mild to moderate (flu-like symptoms) and severe form (Weil's disease) characterized by hemorrhage, jaundice, and hepato-renal failure 1, 2
• The mild to moderate form presents with symptoms similar to flu and is the most common presentation 1
• The severe form (Weil's disease) occurs in approximately 5-10% of infected individuals and is characterized by hemorrhage, jaundice, and hepato-renal failure 1
• The disease typically presents in a biphasic pattern with an initial septicemic/bacteremic phase lasting 4-7 days 1, 2

Treatment Approach

Mild to Moderate Leptospirosis

• Treatment should be initiated as soon as possible with antibiotics 1
• Recommended antibiotics include:
  • Doxycycline (first-line option) 1, 3
  • Penicillin (alternative option) 1, 3
• Treatment should not be delayed while waiting for laboratory confirmation 1

Severe Leptospirosis (Weil's Disease)

• Immediate antibiotic therapy is crucial and should be started within the first hour of recognition of severe disease 1
• The standard course of antibiotic therapy is 7 days, but may need to be extended to 10 days in patients with slow clinical response 1
• Antibiotics should be administered intravenously in severe cases 1, 3
• Treatment initiated after 4 days of symptoms may be less effective, highlighting the need for prompt therapy 1

Supportive Care

• Fluid resuscitation targeting systolic arterial blood pressure >90 mmHg in adults 1
• Continuous monitoring for patients with severe disease 1
• Monitor for development of crepitations indicating fluid overload during resuscitation 1
• Patients with severe leptospirosis may require ICU admission if they have persistent or worsening tissue hypoperfusion despite initial fluid resuscitation 1

Important Clinical Considerations

• Early antibiotic administration is critical for effective treatment 1, 4
• The full course of antibiotics should be completed even with clinical improvement 1
• Despite widespread use of antibiotics for leptospirosis, recent meta-analyses show limited evidence for their effectiveness in reducing mortality compared to placebo 5, 4
• A single dose of doxycycline at exposure to flood water could have a beneficial prophylactic effect 5

Pitfalls and Caveats

• Leptospirosis may be misdiagnosed as viral hepatitis in patients with fever and jaundice 1
• Jarisch-Herxheimer reactions can occur in patients treated with antibiotics 6
• Discontinuing antibiotics too early should be avoided 1
• Despite limited evidence from randomized trials on mortality benefit, antibiotics remain the standard of care due to their potential to accelerate defervescence and reduce disease severity 5, 4, 6

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
• Oral administration of doxycycline once-weekly can provide short-term protection in high-risk environments 3