Hydrocortisone Duration in Severe Leptospirosis
There is no evidence-based recommendation for hydrocortisone use in severe leptospirosis, and current data suggest it should not be routinely administered. The only randomized controlled trial examining high-dose corticosteroids in severe leptospirosis found them ineffective and potentially harmful, increasing the risk of nosocomial infections 1.
Evidence Against Corticosteroid Use in Leptospirosis
The available evidence does not support corticosteroid therapy for severe leptospirosis:
A systematic review identified only one randomized controlled trial, which demonstrated that corticosteroids are ineffective in severe leptospirosis and may increase nosocomial infection risk 1
Four observational studies suggested potential benefit when steroids were given early in disease with pulmonary involvement, but these had significant methodological limitations and cannot be relied upon for clinical decision-making 1
The systematic review concluded there is no robust evidence supporting high-dose corticosteroids in severe leptospirosis 1
Recommended Treatment Approach
Focus on proven therapies rather than corticosteroids:
Antibiotic Therapy
Ceftriaxone 1-2g IV daily for 7 days is the preferred antibiotic regimen for severe leptospirosis, showing equal efficacy to penicillin with superior convenience and safety profile 2, 3
Penicillin G 1.5 million units IV every 6 hours for 7 days is an alternative, though less convenient 3
Early antibiotic initiation is critical, as treatment should begin based on clinical suspicion before serological confirmation 4, 5
Supportive Care
Aggressive supportive management is the cornerstone of treatment, including renal support for hepatorenal syndrome and management of hemorrhagic complications 4, 6
Monitor for thrombocytopenia, renal failure, hepatic dysfunction, and pulmonary hemorrhage 4, 6
When Corticosteroids Might Be Considered
The only scenario where hydrocortisone has evidence-based support is if the patient develops septic shock with vasopressor-refractory hypotension:
If severe leptospirosis progresses to septic shock requiring vasopressors despite adequate fluid resuscitation, then hydrocortisone 200 mg/day IV for ≥3 days may be considered per septic shock guidelines 7, 8, 9
This indication is for the septic shock itself, not for leptospirosis-specific pathophysiology 4, 7
Taper hydrocortisone when vasopressors are discontinued rather than stopping abruptly 4
Critical Pitfalls to Avoid
Do not use corticosteroids as primary therapy for severe leptospirosis based on the rationale of immunosuppression, as the only RCT showed no benefit and potential harm 1
Do not delay antibiotic therapy while awaiting serological confirmation; treat empirically based on clinical presentation (fever, myalgia, conjunctival suffusion, jaundice, renal dysfunction) and epidemiological exposure 4, 5
Recognize that the immune phase of leptospirosis (occurring 1-3 days after initial symptoms) is when severe manifestations develop, but this does not justify corticosteroid use 4