What is the treatment for leptospirosis in children?

Treatment of Leptospirosis in Children

For mild to moderate leptospirosis in children, start doxycycline 100 mg orally twice daily for 7 days immediately upon clinical suspicion; however, avoid doxycycline in children under 8 years and use penicillin or ceftriaxone instead due to risk of permanent tooth discoloration. 1, 2

Initial Assessment and Diagnosis

Begin treatment immediately upon clinical suspicion without waiting for laboratory confirmation, as delay increases mortality. 1, 2

Key Clinical Features to Identify:

• Exposure history within 2-20 days: contact with flood water, contaminated fresh water, recreational water sports, or contact with rats, dogs, cattle, or other animals 1, 2
• Biphasic illness pattern: initial bacteremic phase (4-7 days) with high fever (≥39°C), severe myalgias especially in calves, and headache 1, 2
• Conjunctival suffusion (highly suggestive physical finding) 1, 2
• Severe disease indicators: jaundice, hemorrhagic manifestations, hepatomegaly, respiratory distress, or hypoxemia 1, 2, 3

Laboratory Workup:

• Blood cultures (ideally within first 5 days before antibiotics) 1, 2
• Complete blood count, comprehensive metabolic panel, urinalysis 2
• Serology: IgM ELISA with titer >1:320 diagnostic; titers 1:80-1:160 suggest early infection 1
• Convalescent serology (>10 days after symptom onset) for confirmation 1, 2

Treatment Algorithm

Mild to Moderate Disease (Outpatient or Hospitalized Without Severe Complications):

Children ≥8 years:

• Doxycycline 100 mg orally twice daily for 7 days (first-line) 1, 2

Children <8 years:

• Avoid doxycycline due to permanent tooth discoloration and enamel hypoplasia risk 2, 4
• Use penicillin or ceftriaxone instead 2
• Crystalline penicillin is considered the drug of choice for pediatric leptospirosis 5

Severe Disease (Weil's Disease with Jaundice, Renal Failure, Hemorrhage, or Respiratory Compromise):

Start antibiotics within 1 hour of recognition as each hour of delay increases mortality 1, 2

Preferred regimen:

• Ceftriaxone 2g IV daily for 7 days (or weight-based dosing in children) 2

Alternative:

• Penicillin G 1.5 million units IV every 6 hours for 7 days 2, 5

Duration considerations:

• Standard course is 7 days, but may extend to 10 days in patients with slow clinical response 1
• Do not discontinue antibiotics early despite clinical improvement 1, 2

Supportive Care for Severe Disease

Fluid Resuscitation:

• Aggressive IV fluid therapy with isotonic crystalloid or colloid solution up to 60 ml/kg as three boluses of 20 ml/kg, reassessing after each bolus if signs of shock present 2
• Target systolic blood pressure >90 mmHg in adults and normal heart rate/blood pressure in children 1
• Monitor closely for crepitations indicating fluid overload or impaired cardiac function 1

ICU Admission Criteria:

• Persistent or worsening tissue hypoperfusion despite initial fluid resuscitation 1
• Repeated fluid boluses required or signs of circulatory failure 2
• Pulmonary hemorrhage with respiratory failure 3

Additional Supportive Measures:

• Methylprednisolone 0.5-1.0 mg/kg IV daily for 1-2 weeks may be used for respiratory complications 2
• Continuous observation with frequent clinical examinations for septic patients 1

Clinical Outcomes and Monitoring

Antimicrobial therapy reduces the extent of renal failure and thrombocytopenia in children with severe leptospirosis. 3

Expected Disease Course:

• Jaundice occurs in 70% of hospitalized children 3
• Renal failure in 79%, thrombocytopenia in 65%, meningitis in 23% 3
• Pulmonary hemorrhage and respiratory failure are life-threatening complications 3
• Mortality occurs primarily from respiratory failure 3

Common Pitfalls to Avoid

• Do not wait for serological confirmation before starting antibiotics, as serology is often negative in the first week 2
• Do not mistake leptospirosis for viral hepatitis in patients with fever and jaundice 1, 2
• Do not use urine for culture, as it is not suitable for leptospira isolation 2
• Do not prescribe doxycycline to children under 8 years for any indication 2, 4
• Treatment initiated after 4 days of symptoms may be less effective, highlighting the need for prompt initiation 1

Prophylaxis Considerations

For post-flood exposure in high-risk settings:

• Doxycycline 200 mg single dose orally provides 76.8% protection for post-flood exposure prophylaxis 2, 4
• Reserve prophylaxis for settings where attack rates exceed 10 cases per 100 person-years 4
• Contraindicated in children under 8 years due to tooth discoloration risk 4