What is the treatment for Weil's syndrome (leptospirosis)?

Treatment of Weil's Syndrome (Severe Leptospirosis)

Start antibiotics immediately upon clinical suspicion of Weil's syndrome without waiting for laboratory confirmation, as each hour of delay increases mortality. 1

Immediate Antibiotic Therapy

Initiate penicillin or doxycycline within the first hour of recognizing severe leptospirosis. 2, 1 The standard antibiotic course is 7 days, but extend to 10 days in patients with slow clinical response. 1

Antibiotic Options:

• Penicillin: Effective during the bacteremic phase and remains a first-line agent 2, 3
• Doxycycline: Equally effective alternative, with documented rapid clinical improvement in severe cases 4
• Streptomycin: Shows the best bactericidal action against leptospires in vitro and in vivo, with gentamicin, tobramycin, and isepamicin as alternatives 3

Critical timing consideration: Treatment initiated after 4 days of symptoms may be less effective, emphasizing the need for prompt empiric therapy. 1

Supportive Care and Monitoring

Fluid Resuscitation:

• Target systolic blood pressure >90 mmHg in adults with adequate tissue perfusion 1
• Monitor continuously for crepitations indicating fluid overload or impaired cardiac function 1
• Never leave septic patients alone; frequent clinical examinations are mandatory 1

Renal Support:

• Hemodialysis or hemodiafiltration is required for oliguric acute renal failure, which commonly complicates Weil's syndrome 5, 6, 7
• Continue dialysis until urine production resumes and renal function improves 4

Advanced Therapies for Refractory Cases:

Consider plasma exchange as adjunctive therapy for patients with severe hyperbilirubinemia (>970 μmol/L) and acute renal failure who fail to respond rapidly to conventional treatment. 5 Plasma exchange ameliorates toxic effects of hyperbilirubinemia on hepatocyte and renal tubular cell function. 5

Clinical Recognition

Key Diagnostic Features:

• Conjunctival suffusion (highly suggestive) 2, 7
• Jaundice with hemorrhagic manifestations 2, 6
• Severe calf myalgias 2
• Acute renal failure with proteinuria and hematuria 2, 4
• High bilirubin with mild transaminase elevation (distinguishes from viral hepatitis) 2, 1

Laboratory Confirmation:

• IgM titers >1:320 are diagnostic, though earliest positives appear 6-10 days after symptom onset 2, 1
• Blood cultures (if obtained within first 5 days before antibiotics) 2, 1
• Do not delay treatment waiting for serologic confirmation 1, 4

Common Pitfalls to Avoid

• Never withhold antibiotics while awaiting laboratory confirmation—clinical deterioration can occur within 72 hours, progressing to ARDS 4
• Do not discontinue antibiotics prematurely; complete the full 7-10 day course even with clinical improvement 1
• Do not misdiagnose as viral hepatitis in patients presenting with fever and jaundice—consider leptospirosis in the differential, especially with epidemiologic risk factors 1
• Obtain blood cultures before antibiotics if this causes no significant delay (<45 minutes), ideally within the first 5 days 1

ICU Admission Criteria

Admit to ICU if persistent or worsening tissue hypoperfusion despite initial fluid resuscitation, or if respiratory distress develops. 1 Weil's syndrome carries high mortality without aggressive supportive care. 5, 6