What is the treatment for Leptospirosis?

Treatment of Leptospirosis

Start antibiotic therapy immediately upon clinical suspicion of leptospirosis without waiting for laboratory confirmation, using penicillin or doxycycline for 7 days (extended to 10 days if slow clinical response), as treatment delay beyond 4 days significantly reduces effectiveness and increases mortality. 1

Immediate Antibiotic Initiation

• Begin antibiotics within the first hour of recognizing severe leptospirosis or septic shock (Grade 1B evidence), as mortality increases with delayed treatment 1
• Do not wait for serological confirmation or culture results before starting therapy, as diagnostic tests take too long and early treatment (before day 4 of illness) is critical for preventing complications 1, 2
• Treatment initiated after 4 days of symptoms may be less effective, making prompt clinical diagnosis essential 1

Antibiotic Selection by Disease Severity

Mild to Moderate Leptospirosis

• Use doxycycline or penicillin as first-line agents for outpatient management of flu-like presentations 1
• The World Health Organization recommends starting treatment as soon as possible with either penicillin or tetracyclines (doxycycline) 1
• Alternative agents include cephalosporins, aminoglycosides, and macrolides, though these are less commonly used 3

Severe Leptospirosis (Weil's Disease)

• Initiate IV penicillin or doxycycline immediately for patients with jaundice, hemorrhage, or hepato-renal failure 1
• Severe disease occurs in approximately 5-10% of infected individuals and requires aggressive early treatment 1
• Consider ICU admission for patients with persistent tissue hypoperfusion despite initial fluid resuscitation 1

Treatment Duration and Monitoring

• Standard antibiotic course is 7 days, but extend to 10 days in patients showing slow clinical response 1
• Reassess the antimicrobial regimen daily for potential de-escalation (Grade 1B) 1
• Do not discontinue antibiotics prematurely—complete the full course even with clinical improvement to ensure eradication 1
• Note that streptomycin provides short-term eradication, while penicillin, cephalosporins, tetracyclines, and macrolides may require longer therapy with larger doses from early disease until antibody appearance 3

Supportive Care for Severe Cases

• Provide aggressive fluid resuscitation targeting systolic blood pressure >90 mmHg in adults and normal vital signs in children 1
• Monitor continuously for crepitations indicating fluid overload or impaired cardiac function during resuscitation 1
• Ensure septic patients receive frequent clinical examinations and are never left alone 1
• Consider source control measures within 12 hours if applicable (Grade 1C) 1

Clinical Recognition Triggers

Key clinical features that should prompt immediate treatment:

• Fever (usually ≥39°C) with chills combined with diffuse myalgias, especially in the calves 1
• Conjunctival suffusion (highly suggestive sign) with headache 1
• Jaundice with renal dysfunction (elevated creatinine, proteinuria, hematuria) 1
• Laboratory findings: leukocytosis with polymorphonuclear cells, thrombocytopenia (<140 G/L in 65.5% of cases), elevated bilirubin with mild transaminase elevation 1, 4

Prognostic Indicators Requiring Aggressive Management

• Clinical jaundice independently predicts progression to severe disease (p=0.005) 4
• Cardiac involvement (clinical signs or ECG changes) independently predicts severe disease (p<0.02) 4
• These factors should trigger immediate hospitalization and intensive monitoring 4

Common Pitfalls to Avoid

• Never delay treatment while awaiting serological confirmation—IgM titers may not be positive until 10+ days after symptom onset 1
• Avoid misdiagnosing as viral hepatitis in patients presenting with fever and jaundice—always consider leptospirosis in the differential 1
• Do not use tetracyclines (including doxycycline) in children under 8 years due to permanent tooth discoloration risk 5
• Recognize that blood cultures are only useful if obtained within the first 5 days before antibiotics 1