What is the treatment for Leptospira infection?

Treatment of Leptospirosis

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

Classification of Leptospirosis

• Leptospirosis presents in 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 septicemic or bacteremic phase lasts 4-7 days with high fever, diffuse myalgias (especially in calves), headache, and conjunctival suffusion 1, 2
• Conjunctival suffusion is a suggestive clinical sign that should prompt consideration of leptospirosis 2

Treatment Approach Based on Disease Severity

Mild to Moderate Leptospirosis

• Treatment should be started as soon as possible with antibiotics such as penicillin or doxycycline 1
• Oral doxycycline is an effective option for mild cases 3
• The standard course of antibiotic therapy is typically 7 days 1

Severe Leptospirosis (Weil's Disease)

• Treatment should be initiated immediately without waiting for laboratory confirmation 1
• Antibiotics should be started within the first hour of recognition of septic shock (Grade 1B) or severe sepsis without septic shock (Grade 1C) 1
• Liposomal amphotericin B (L-AmB) may be considered in patients with severe disease not responding to first-line antibiotics 4

Specific Antibiotic Recommendations

• First-line options:
  • Penicillin: Effective for both mild and severe forms 1, 3
  • Doxycycline: Particularly useful for mild to moderate cases 1, 3
• Alternative options:
  • Cephalosporins (ceftriaxone, cefotaxime): Can be used as alternatives to penicillin 5
  • Azithromycin: Has been studied as an alternative to doxycycline 6

Duration of Treatment

• The standard course of antibiotic therapy for leptospirosis is 7 days 1
• Treatment may need to be extended to 10 days in patients with slow clinical response 1
• Early antibiotic administration is critical, and treatment initiated after 4 days of symptoms may be less effective 1

Supportive Care

• Fluid resuscitation targeting systolic arterial blood pressure >90 mmHg in adults 1
• Continuous observation and frequent clinical examinations for septic patients 1
• Monitor for development of crepitations indicating fluid overload during resuscitation 1
• Nutritional support, treatment of other concurrent infectious diseases, and blood transfusions as needed 4

Special Considerations

• Patients with severe leptospirosis may require ICU admission if they have persistent or worsening tissue hypoperfusion despite initial fluid resuscitation 1
• Leptospirosis may be misdiagnosed as viral hepatitis in patients with fever and jaundice 1
• The Jarisch-Herxheimer reaction may occur as an adverse effect of antibiotic treatment 7

Evidence Quality and Limitations

• Despite widespread use of antibiotics for leptospirosis, there is insufficient high-quality evidence to definitively determine their effectiveness 5
• A Cochrane review found very low-certainty evidence regarding the effects of antibiotics on all-cause mortality and adverse events in leptospirosis 5
• However, clinical practice guidelines still recommend early antibiotic therapy based on clinical experience and observational data 1

Prevention

• Avoid contact with urine from infected animals and contaminated water 1, 8
• Take precautions during water recreational activities, occupational exposure to animals or water, and during floods 1, 8
• Weekly doxycycline can provide short-term prophylaxis in high-risk environments 3