What is the treatment for Leptospirosis?

Treatment of Leptospirosis

Start antibiotic therapy immediately upon clinical suspicion of leptospirosis without waiting for laboratory confirmation, using either intravenous penicillin or doxycycline for 7 days, as early treatment (within the first 4 days of symptoms) significantly reduces mortality and prevents progression to severe disease. 1, 2

Immediate Antibiotic Initiation

Treatment must begin within the first hour of recognizing severe leptospirosis or septic shock to reduce mortality, and should never be delayed while awaiting serological confirmation. 2 The critical window is the first 4 days of symptoms—antibiotics started after this period are substantially less effective. 1

Antibiotic Selection by Disease Severity

For mild to moderate leptospirosis (flu-like illness):

• Oral doxycycline or penicillin can be used 1
• Treatment should start as soon as possible upon clinical suspicion 1

For severe leptospirosis (Weil's disease with jaundice, hemorrhage, or hepato-renal failure):

• Intravenous penicillin is preferred over oral doxycycline 2
• Alternative effective antibiotics include cephalosporins, aminoglycosides (particularly streptomycin for short-term eradication), tetracyclines, and macrolides 3
• Streptomycin specifically exterminates leptospires with short-term treatment 3

Treatment Duration

• Standard course: 7 days 1, 2
• Extend to 10 days if clinical response is slow 1
• When using penicillin, cephalosporins, tetracyclines, or macrolides, large doses from early disease until antibody appearance may be required 3
• Do not discontinue antibiotics prematurely even with clinical improvement—complete the full course 1
• Reassess antimicrobial regimen daily for potential de-escalation 1

Supportive Care and Monitoring

Fluid Resuscitation

• Target systolic blood pressure >90 mmHg in adults with adequate tissue perfusion as the primary endpoint 1
• Monitor continuously for crepitations indicating fluid overload or impaired cardiac function during resuscitation 1
• Septic patients require continuous observation with frequent clinical examinations 1

ICU Admission Criteria

Admit to ICU if any of the following occur: 1

• Persistent or worsening tissue hypoperfusion despite initial fluid resuscitation
• Septic shock
• Severe organ dysfunction

Organ System Monitoring

Monitor closely for complications including: 2

• Renal function (acute kidney injury requiring dialysis may occur) 2
• Hepatic function (jaundice, elevated bilirubin with mild transaminase elevation) 1, 2
• Hematologic parameters (thrombocytopenia, anemia from hemorrhage) 1, 2
• Bleeding risk (disseminated intravascular coagulation possible) 2
• Cardiac function (myocarditis/pericarditis) 4
• Neurological status (meningitis, meningoencephalitis, seizures) 2, 4
• Pulmonary function (ARDS may develop) 4

Seizure Management

For patients with status epilepticus or seizures during the immune phase: 2

• Continue antiepileptic therapy as clinically indicated 2
• Neurological involvement indicates severe disease requiring intravenous penicillin 2

Clinical Recognition and Diagnosis

Key Clinical Features Suggesting Leptospirosis

Look for this constellation of findings: 1

• High fever (≥39°C) with chills 1
• Diffuse myalgias, especially in the calves 1
• Headache 1
• Conjunctival suffusion (highly suggestive sign) 1
• Jaundice 1
• Proteinuria and hematuria 1

Prognostic Factors for Severe Disease

Two factors independently predict progression to severe leptospirosis: 4

• Clinical jaundice 4
• Cardiac involvement (clinically or on ECG) 4

These can be identified at initial examination and should trigger more aggressive monitoring and management. 4

Common Pitfalls to Avoid

• Misdiagnosis as viral hepatitis: Leptospirosis presenting with fever and jaundice is frequently misdiagnosed as viral hepatitis—always consider leptospirosis in the differential diagnosis of febrile jaundice 1
• Waiting for laboratory confirmation: Clinical diagnosis is imperative; laboratory tests take too long and treatment delay increases mortality 5
• Missing the treatment window: Effectiveness drops significantly after day 4 of symptoms 1
• Inadequate source control: Consider source control measures within 12 hours if applicable 1

Diagnostic Confirmation (After Treatment Initiation)

While treatment should never be delayed, send these tests: 2

• Blood cultures (especially if within first 5 days, before antibiotics) 1
• IgM serology (titers >1:320 suggestive; 1:80-1:160 consistent with early infection) 1
• Convalescent serology >10 days after symptom onset 1, 2
• CSF and aerobic blood cultures to reference laboratory at room temperature 2
• Nucleic acid amplification testing (NAAT) with 1-2 hour turnaround time 1