What is the treatment and management of leptospirosis?

Leptospirosis Treatment and Management

Immediate Antibiotic Therapy

For suspected leptospirosis, start antibiotics immediately without waiting for laboratory confirmation, as early treatment (within the first 4 days of symptoms) is critical for preventing severe complications and reducing mortality. 1

Mild to Moderate Disease (Outpatient)

• Doxycycline 100 mg orally twice daily for 7 days is the first-line treatment for mild to moderate leptospirosis 1, 2
• Alternative: Penicillin can be used if doxycycline is contraindicated 1
• Hospitalization is recommended even for moderate cases with systemic signs of infection, despite not meeting criteria for severe disease 1

Severe Disease (Weil's Disease - Inpatient/ICU)

• Intravenous penicillin G or doxycycline for 7-10 days should be initiated within 1 hour of recognition 1, 3
• Standard course is 7 days, but extend to 10 days if clinical response is slow 1
• Treatment initiated after 4 days of symptoms may be significantly less effective 1

Clinical Classification and Recognition

Mild to Moderate Form (Most Common)

• Flu-like symptoms: high fever (≥39°C), diffuse myalgias (especially calves), headache, chills 1
• Conjunctival suffusion is a highly suggestive clinical sign 1
• Septicemic phase lasts 4-7 days 1

Severe Form (Weil's Disease - 5-10% of cases)

• Hemorrhage, jaundice, hepato-renal failure 1
• Acute kidney injury requiring hemodialysis 3
• Pulmonary hemorrhage, meningitis, cardiac arrhythmias 4
• Marked hyperbilirubinemia with mild transaminase elevation 1

Diagnostic Approach

Laboratory Confirmation

• Blood cultures: Obtain before antibiotics if no significant delay (<45 minutes), ideally within first 5 days 1
• Serology (most common method): IgM titers >1:320 are suggestive; titers 1:80-1:160 indicate early infection 1
• Convalescent serology (>10 days after symptom onset) confirms diagnosis 1
• Nucleic acid amplification testing (NAAT) has 1-2 hour turnaround time 1

Supportive Laboratory Findings

• Proteinuria and hematuria on urinalysis 1
• Leukocytosis with polymorphonuclear predominance 1
• Thrombocytopenia 4
• Elevated bilirubin with mild transaminase elevation 1
• Elevated creatinine and BUN 1

Supportive Care for Severe Disease

Fluid Resuscitation

• Target systolic blood pressure >90 mmHg in adults with adequate tissue perfusion 1
• Monitor closely for crepitations indicating fluid overload or cardiac dysfunction 1
• Continuous observation required—septic patients should never be left alone 1

Renal Replacement Therapy

• Temporary hemodialysis or hemodiafiltration for oliguric acute kidney injury 3, 5
• Plasma exchange should be considered for severe hyperbilirubinemia (>970 μmol/L) with acute renal failure not responding to conventional treatment, as it can ameliorate toxic effects on hepatocytes and renal tubular cells 5

ICU Admission Criteria

• Persistent or worsening tissue hypoperfusion despite initial fluid resuscitation 1
• Severe sepsis or septic shock 1

Prevention and Prophylaxis

Primary Prevention

• Avoid contact with contaminated water, especially during floods 6, 7
• Use protective equipment (boots, gloves) during high-risk agricultural or occupational activities 6
• Implement rodent control measures in endemic areas 6

Chemoprophylaxis

• Doxycycline 200 mg orally as a single dose provides 76.8% protective efficacy against infection and 86.3% against clinical disease in flood victims 6
• Reserve prophylaxis for settings with attack rates >10 cases per 100 person-years 6
• Contraindicated in children <8 years due to risk of permanent tooth discoloration and enamel hypoplasia 6

Critical Pitfalls to Avoid

• Do not delay antibiotics while waiting for laboratory confirmation—each hour increases mortality 1
• Do not discontinue antibiotics early—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; always consider leptospirosis in the differential 1
• Do not prescribe tetracyclines to children <8 years for any indication related to leptospirosis exposure 6
• Monitor for progression to chronic kidney disease after acute kidney injury, as some patients develop persistent renal impairment 3