Leptospirosis Treatment Guidelines
Immediate Management Upon Clinical Suspicion
Start antibiotic treatment immediately upon clinical suspicion of leptospirosis without waiting for laboratory confirmation, as each hour of delay increases mortality. 1
Diagnostic Approach
Obtain exposure history within the past 2-20 days, specifically asking about contact with flood water, contaminated fresh water, recreational water sports, occupational exposure to animals, or contact with rats, dogs, or cattle 1, 2
Look for characteristic clinical features including:
Order initial laboratory workup including blood cultures (ideally within first 5 days before antibiotics), complete blood count, comprehensive metabolic panel, and urinalysis 1
Send serology (IgM ELISA) with titers >1:320 being diagnostic, though serology is often negative in the first week 1
Antibiotic Treatment by Disease Severity
Mild to Moderate Disease
Doxycycline 100 mg orally twice daily for 7 days is the treatment of choice for mild to moderate leptospirosis. 1, 3
- Alternative oral antibiotics include amoxicillin or tetracycline if doxycycline is unavailable 1, 4
- Expect clinical improvement within 3 days of antibiotic initiation 1
- Hospitalization is recommended for moderate disease with systemic signs, even without severe disease criteria 2
Severe Disease (Weil's Disease)
Ceftriaxone 2g IV daily for 7 days is the preferred regimen for severe leptospirosis. 1
- Alternative regimen: Penicillin G 1.5 million units IV every 6 hours for 7 days 1, 4
- Start antibiotics within 1 hour of recognizing severe disease or septic shock 2
- Obtain blood cultures before antibiotics if this causes no significant delay (<45 minutes) 2
- Standard course is 7 days, but may extend to 10 days in patients with slow clinical response 2
Supportive Care for Severe Disease
- Aggressive IV fluid resuscitation with isotonic crystalloid or colloid solution up to 60 mL/kg as three boluses of 20 mL/kg, reassessing after each bolus 1
- Target systolic blood pressure >90 mmHg in adults with adequate tissue perfusion 2
- Monitor closely for fluid overload by watching for development of crepitations indicating impaired cardiac function 2
- Consult ICU early if patient requires repeated fluid boluses or shows signs of circulatory failure 1
- Consider methylprednisolone 0.5-1.0 mg/kg IV daily for 1-2 weeks for respiratory complications 1
Special Populations
Children Under 8 Years
Avoid doxycycline in children <8 years due to risk of permanent tooth discoloration; use penicillin or ceftriaxone instead. 1, 5
Prophylaxis After Flood Exposure
- Doxycycline 200 mg single dose orally provides 76.8% protection for post-flood exposure prophylaxis 1, 5
- Reserve prophylaxis for high-risk settings where attack rates exceed 10 cases per 100 person-years 5
- Primary prevention: avoid contact with contaminated water and use protective equipment (boots, gloves) during high-risk activities 5
Critical Pitfalls to Avoid
- Do not wait for serological confirmation before starting antibiotics, as serology is often negative in the first week and delay increases mortality 1
- Do not mistake leptospirosis for viral hepatitis in patients presenting with fever and jaundice 1, 2
- Do not discontinue antibiotics early despite clinical improvement; complete the full 7-day course 1, 2
- Do not use urine for culture, as it is not suitable for leptospira isolation 1
- Do not delay treatment beyond 4 days of symptom onset, as antibiotic efficacy decreases significantly 2