What is the recommended management for leptospirosis according to Tintinalli's guidelines?

Leptospirosis Management According to Tintinalli

Immediate Antibiotic Therapy

For severe leptospirosis, start intravenous penicillin or ceftriaxone/cefotaxime immediately upon clinical suspicion without waiting for laboratory confirmation, as each hour of delay increases mortality. 1, 2

Antibiotic Selection by Disease Severity

Severe Disease (Weil's Disease with jaundice, renal failure, hemorrhage, or neurological involvement):

• First-line: Intravenous penicillin (preferred) or ceftriaxone/cefotaxime 1, 2, 3
• Start within 1 hour of recognition of severe sepsis or septic shock 1, 2
• Duration: 7 days standard, extend to 10 days if slow clinical response 1
• Do NOT delay treatment waiting for confirmatory serology 2

Mild to Moderate Disease:

• Oral doxycycline 100 mg twice daily for 7 days 1, 4
• Alternative: Oral penicillin 1
• Hospitalize patients with systemic signs even without severe disease criteria 1

Critical Timing Considerations

• Treatment initiated after 4 days of symptoms may be less effective 1
• Obtain blood cultures before antibiotics if this causes no delay (ideally <45 minutes), especially within first 5 days of illness 1
• The septicemic phase lasts 4-7 days, making early treatment crucial 1

Clinical Recognition

Key diagnostic features to identify leptospirosis:

• High fever (≥39°C) with diffuse myalgias, especially in calves 1
• Conjunctival suffusion (highly suggestive sign) 1
• Headache and jaundice 1
• History of water exposure or contact with animal urine 5

Laboratory findings:

• Elevated bilirubin with mild transaminase elevation (distinguishes from viral hepatitis) 1
• Proteinuria and hematuria 1
• Leukocytosis with polymorphonuclear predominance 1
• IgM titers >1:320 are suggestive; 1:80-1:160 consistent with early infection 1

Supportive Management

Fluid Resuscitation:

• Target systolic BP >90 mmHg in adults with adequate tissue perfusion 1
• Monitor for crepitations indicating fluid overload during resuscitation 1
• Continuous observation required for septic patients 1

ICU Admission Criteria:

• Persistent or worsening tissue hypoperfusion despite initial fluid resuscitation 1
• Severe manifestations requiring intensive organ support 2

Monitoring Requirements:

• Renal function (acute renal failure common) 2, 6
• Hepatic function 2
• Hematologic parameters and bleeding risk 2
• Seizure management if neurological involvement 2

Common Pitfalls to Avoid

• Do NOT mistake for viral hepatitis in patients with fever and jaundice—leptospirosis has mild transaminase elevation relative to bilirubin 1
• Do NOT discontinue antibiotics early—complete the full 7-day course even with clinical improvement 1
• Do NOT use doxycycline in children <8 years due to permanent tooth discoloration risk 5
• Do NOT delay antibiotics for diagnostic confirmation in severe disease 1, 2

Prophylaxis Considerations

Post-flood exposure:

• Single dose doxycycline 200 mg orally provides 76.8% protective efficacy 5
• Reserved for high-risk settings with attack rates >10 cases per 100 person-years 5
• Avoid contact with flood water, use protective equipment during unavoidable exposure 5