What is the management for leptospirosis?

Management of Leptospirosis

Antibiotic therapy should be initiated immediately for suspected leptospirosis, with doxycycline or penicillin for mild cases and ceftriaxone or penicillin for severe cases, without waiting for laboratory confirmation. 1, 2

Clinical Classification

• Leptospirosis presents in two main clinical forms:

  • Mild to moderate form: flu-like symptoms (most common presentation) 1, 2
  • Severe form (Weil's disease): characterized by hemorrhage, jaundice, and hepato-renal failure (occurs in 5-10% of infected individuals) 1, 2

• The septicemic/bacteremic phase lasts 4-7 days with high fever (≥39°C), diffuse myalgias (especially in calves), headache, and conjunctival suffusion 1, 2

Diagnosis

• Clinical diagnosis is suggested by:

  • Fever with chills
  • Diffuse myalgias
  • Headache
  • Jaundice
  • Conjunctival suffusion (highly suggestive sign) 1, 2

• Laboratory findings may include:

  • Proteinuria and hematuria
  • Leukocytosis with polymorphonuclear cells
  • Anemia (if significant hemorrhage)
  • Elevated bilirubin with mild elevation of transaminases
  • Alterations in renal function tests 1

• Diagnostic confirmation:

  • Serology is the most common method (IgM titers >1:320 are suggestive; 1:80-1:160 consistent with early infection)
  • Blood cultures (if taken in first 5 days, before antibiotics)
  • Convalescent serology (>10 days after symptom onset) 1, 2

Treatment Algorithm

1. Mild to Moderate Leptospirosis

• Start treatment immediately without waiting for confirmation 1, 2
• First-line options:
  • Doxycycline 100 mg twice daily for 7 days 1, 3
  • OR Penicillin (oral formulation) for 7 days 1, 4
  • OR Azithromycin (for less severe disease) 3

2. Severe Leptospirosis (Weil's disease)

• Start treatment immediately without waiting for laboratory confirmation 1, 2
• First-line options:
  • Ceftriaxone 2g IV daily for 7 days (may be preferred due to convenience and safety profile) 1, 5
  • OR Penicillin IV for 7 days 1, 4
  • Treatment duration may need to be extended to 10 days in patients with slow clinical response 1

3. Supportive Care for Severe Cases

• Fluid resuscitation targeting systolic BP >90 mmHg in adults 1
• Continuous observation and frequent clinical examinations 1
• Monitor for fluid overload or impaired cardiac function during resuscitation 1
• ICU admission for patients with persistent or worsening tissue hypoperfusion despite initial fluid resuscitation 1

Special Considerations

• Start antibiotics within the first hour of recognition of septic shock or severe sepsis 1
• Treatment initiated after 4 days of symptoms may be less effective 1
• Complete the full course of antibiotics even with clinical improvement 1
• Reassess antimicrobial regimen daily for potential de-escalation 1

Prevention

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

Common Pitfalls

• Delaying antibiotic treatment while waiting for laboratory confirmation increases mortality 1
• Misdiagnosing leptospirosis as viral hepatitis in patients with fever and jaundice 1
• Discontinuing antibiotics too early before completing the full course 1
• Failing to consider leptospirosis in the differential diagnosis of febrile illness with conjunctival suffusion 2