What is the treatment for Leptospirosis (Leptospirosis) affecting the Central Nervous System (CNS)?

Treatment of Leptospirosis with CNS Involvement

For leptospirosis affecting the central nervous system, immediate treatment with intravenous penicillin G at 1.5 million units every 6 hours for 7-10 days is strongly recommended as first-line therapy. 1

First-Line Treatment Options

• For severe leptospirosis with CNS manifestations, intravenous penicillin G at 1.5 million units every 6 hours for 7-10 days is the treatment of choice 1
• Alternative first-line options include:
  • Ceftriaxone: 1-2 g IV daily for 7-10 days 2
  • Cefotaxime: IV at appropriate doses for 7-10 days 2

Treatment Algorithm

Initial Management

• Initiate antibiotic therapy immediately upon clinical suspicion, without waiting for laboratory confirmation 1
• Perform lumbar puncture for CSF analysis to confirm leptospiral meningitis 1
• Obtain MRI of the affected spinal region for patients with spinal cord involvement 1

Antibiotic Selection Based on Severity

• For mild to moderate disease with CNS involvement:
  • Doxycycline: 100 mg orally twice daily for 7-10 days 1
• For severe disease with CNS involvement:
  • Penicillin G: 1.5 million units IV every 6 hours for 7-10 days 1
  • OR Ceftriaxone: 1-2 g IV daily for 7-10 days 2

Special Considerations

Timing of Treatment

• Early antibiotic therapy is most effective during the bacteremic phase (first 4-7 days of illness) 1
• The benefit of antibiotics may be limited in the later immunologic phase of the disease 1

Adjunctive Therapies

• For severe cases with significant inflammation, intravenous corticosteroids may be considered as adjunctive therapy 3
• Supportive care is essential, including:
  • Management of increased intracranial pressure 1
  • Treatment of seizures if present 1
  • Monitoring for other organ involvement (renal, hepatic, pulmonary) 4

Surgical Considerations

• Surgical intervention should be considered for patients with:
  • Progressive neurological deficits despite antibiotic therapy 1
  • Spinal instability 1
  • Spinal cord or nerve root compression 1

Monitoring and Follow-up

• Monitor systemic inflammatory markers (ESR, CRP) after approximately 4 weeks of antimicrobial therapy 1
• Consider follow-up MRI in patients with poor clinical response 1
• Assess for resolution of neurological symptoms 5

Treatment in Special Populations

• For pregnant patients with CNS leptospirosis, penicillin G remains the drug of choice 2
• For pediatric patients, adjust dosing based on weight while maintaining the same antibiotic choices 2

Diagnostic Considerations

• PCR testing of both blood and urine samples in the early phase of illness provides quick and reliable diagnosis 6
• Serological tests may be negative in early disease but should be repeated in 1-2 weeks if clinical suspicion is high 5

Common Pitfalls

• Delaying antibiotic therapy while waiting for confirmatory testing can worsen outcomes 1, 5
• Failing to consider leptospirosis in patients with aseptic meningitis, especially those with risk factors such as exposure to contaminated water or animal urine 1
• Inadequate duration of therapy may lead to treatment failure 2