Leptospirosis Management
Immediate Treatment Approach
Start antibiotics immediately upon clinical suspicion of leptospirosis without waiting for laboratory confirmation, as each hour of delay increases mortality. 1
The treatment strategy depends on 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, 2
- Alternative oral antibiotics include amoxicillin or tetracycline if doxycycline is unavailable 1
- Treatment should be initiated within the first 4 days of symptoms for maximum effectiveness 1
- Clinical improvement should be expected within 3 days of starting antibiotics 1
- Complete the full 7-day course even with clinical improvement to prevent relapse 1
Severe Disease (Weil's Disease)
For severe leptospirosis with jaundice, hemorrhage, renal failure, or respiratory distress, use ceftriaxone 2g IV daily for 7 days. 1, 3
- Penicillin G 1.5 million units IV every 6 hours is an alternative for severe disease 1
- Ceftriaxone offers superior convenience and adverse effect profile compared to penicillin regimens 3
- Start antibiotics within 1 hour of recognizing severe disease or septic shock 1
- Extend treatment to 10 days in patients with slow clinical response 1
Supportive Care for Severe Disease
Aggressive IV fluid resuscitation is critical, targeting systolic blood pressure >90 mmHg in adults with isotonic crystalloid up to 60 mL/kg in three 20 mL/kg boluses. 1
- Monitor closely for crepitations indicating fluid overload or impaired cardiac function during resuscitation 1
- Consult ICU early if patient requires repeated fluid boluses or shows signs of circulatory failure 1
- Continuous observation with frequent clinical examinations is necessary—septic patients should never be left alone 1
- For respiratory complications, consider methylprednisolone 0.5-1.0 mg/kg IV daily for 1-2 weeks 1
Diagnostic Workup
Obtain blood cultures (ideally within first 5 days before antibiotics if this causes no significant delay <45 minutes), complete blood count, comprehensive metabolic panel, and urinalysis. 1
Key diagnostic features to assess:
- Exposure history: Contact with flood water, contaminated fresh water, or animals (rats, dogs, cattle) within past 2-20 days 1, 4
- Characteristic symptoms: Biphasic course with high fever (≥39°C), severe calf myalgias, headache 4
- Pathognomonic sign: Conjunctival suffusion (highly suggestive) 1, 4
- Severe disease indicators: Jaundice, hemorrhage, hepatomegaly, respiratory distress, hypoxemia 1, 4
Laboratory confirmation:
- IgM ELISA with titer >1:320 is diagnostic 1
- Convalescent serology (MAT) should be repeated >10 days after symptom onset, with fourfold increase confirming diagnosis 1, 4
- Blood cultures are most useful in first 5 days before antibiotics 4
Special Populations
Children <8 Years
Avoid doxycycline in children <8 years due to risk of permanent tooth discoloration; use penicillin or ceftriaxone instead. 1
Pregnant Women
Avoid tetracyclines and azoles in pregnancy; use penicillin or ceftriaxone for treatment. 1
Post-Exposure Prophylaxis
Doxycycline 200 mg single dose orally provides 76.8% protection for post-flood exposure prophylaxis and should be reserved for high-risk settings. 1
- A single dose at exposure to flood water has shown beneficial effect 5
- Weekly dosing of 200 mg doxycycline has not demonstrated significant benefit 5
Critical Pitfalls to Avoid
- Never wait for serological confirmation before starting antibiotics—serology is often negative in the first week 1
- Do not mistake leptospirosis for viral hepatitis in patients presenting with fever and jaundice 1
- Do not discontinue antibiotics early despite clinical improvement—complete the full course 1
- Do not use urine for culture—it is not suitable for leptospira isolation 1
- Do not delay treatment beyond 4 days of symptom onset, as efficacy decreases significantly 1