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10/28/2015 Leptospirosis Treatment & Management: Approach Considerations, Diet and Activity, Transfer
http://emedicine.medscape.com/article/220563treatment 1/6
Leptospirosis Treatment & ManagementAuthor: Sandra G Gompf, MD, FACP, FIDSA; Chief Editor: Michael Stuart Bronze, MD more...
Updated: Apr 14, 2015
Approach ConsiderationsAntimicrobial therapy is indicated for the severe form of leptospirosis, but its use iscontroversial for the mild form of leptospirosis. A Cochrane Review foundinsufficient evidence to advocate for or against the use of antibiotics in the therapyfor leptospirosis.[42]
If antibiotics are used, they should be initiated as soon as the diagnosis ofleptospirosis is considered and should be continued for a full course despite initialserologic results, because most patients are diagnosed only through acute andconvalescent testing. Early treatment has been shown to offer the best clinicaloutcomes; results from controlled studies of treatment during the immune phasehave yielded mixed results.[43, 44]
Mild leptospirosis is treated with doxycycline, ampicillin, or amoxicillin. For severeleptospirosis, intravenous penicillin G has long been the drug of choice, althoughthe thirdgeneration cephalosporins cefotaxime and ceftriaxone have become widelyused. Alternative regimens are ampicillin, amoxicillin, or erythromycin. Several otherantibiotics may be useful—for example, broth microdilution testing has shownsensitivity to macrolides, fluoroquinolones, and carbapenems[45] —but clinicalexperience with these agents is more limited.
Severe cases of leptospirosis can affect any organ system and can lead tomultiorgan failure. Supportive therapy and careful management of renal, hepatic,hematologic, and central nervous system complications are important.
Patients should be managed in a monitored setting because their condition canrapidly progress to cardiovascular collapse and shock. Access to mechanicalventilation and airway protection should be available in the event of respiratorycompromise. Continuous cardiac monitoring should be attained; arrhythmias,including ventricular tachycardia and premature ventricular contractions, as well asatrial fibrillation, flutter, and tachycardia, can occur.
Renal function should be evaluated carefully and dialysis considered in cases ofrenal failure. In most cases, the renal damage is reversible if the patient survivesthe acute illness. A few cases in the literature have reported that plasma exchange,corticosteroids, and intravenous immunoglobulin may be beneficial in selectedpatients in whom conventional therapy does not elicit a response.[46, 47, 48]
Corticosteroid therapy with highdose pulsed methylprednisolone (30 mg/kg/d, not toexceed 1500 mg has been used successfully to treat patients with leptospiral renalfailure without dialysis. This approach may have an important role in areas of theworld with limited resources where dialysis treatment is unavailable and wouldinvolve lengthy medical transport. The use of renaldose dopamine in conjunctionwith steroids or diuretics has also been described.[23]
Pulsedose steroids may also play a role in the management of severe pulmonarydisease.[49, 47] Patients with Weil syndrome may need transfusions of whole blood,platelets, or both. Ophthalmic drops of mydriatics and corticosteroids have beenused for relief of ocular symptoms.[50]
Patients with severe disease should remain hospitalized until adequate resolution oforgan failure and clinical infection. Outpatient followup may include an assessmentof renal function to ensure ongoing reversal of any damage. A cardiac assessmentmay be indicated in patients with symptoms suggestive of heart involvement.
Diet and ActivityIn mild cases, patients should be encouraged to maintain adequate fluid intake toavoid volume depletion. In more severe cases, diets appropriate for the clinicalpicture should be ordered (eg, electrolyte and protein restriction in cases of renalinsufficiency). Patients with hypotension or clinical shock should not be fed enterallyuntil adequate perfusion is restored.
Patients with severe disease should be placed on bed rest until adequatelyresuscitated and treated. Those with mild disease can pursue activity as tolerated.
TransferTransfer to a facility with an appropriate level of care should be considered inpatients with severe disease. Leptospirosis has a regional epidemiology with highincidence of cases in remote regions that offer limited medical care. Althoughtransporting patients with severe disease to appropriate medical centers ispreferred, military physicians who have treated patients from Western Pacificislands averted the need for transoceanic transport for dialysis by administeringhighdose steroids.[38, 37]
ConsultationsIn severe cases of leptospirosis, several specialty consultations may aid in properpatient management. An infectious disease specialist may assist in differentiating
10/28/2015 Leptospirosis Treatment & Management: Approach Considerations, Diet and Activity, Transfer
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leptospirosis from diseases with similar presentations but that may have significantlydifferent treatments. A nephrologist should be alerted early in the course becausethe need for dialysis may develop rapidly. If available, critical care specialists maybe best prepared to manage patients with affected multiple systems.
For assistance with laboratory diagnosis, the Centers for Disease Control andPrevention (CDC) or the World Health Organization (WHO) can aid the clinician inobtaining samples and ordering tests.
Deterrence/PreventionPrevention of leptospirosis is difficult because the organism has not been eradicatedfrom wild animals, which constantly infect domestic animals. Important controlmeasures include control of livestock infection with good sanitation, immunization,and proper veterinary care.
Preventing infected animals from urinating in waters where humans have contact,disinfecting contaminated work areas, providing worker education, practicing goodpersonal hygiene, and using personal protective equipment (PPE) when handlinginfected animals or tissues are important actions for prevention of the disease.Examples of PPE include gloves and face shields for veterinarians and rubber bootsfor sewer workers and agricultural workers who wade in rodent urinecontaminatedwater.
Public health measures include investigation of cases in an effort to detect commonsource outbreaks and implementation of appropriate control measures to preventfurther cases. Other public health measures include identification of contaminatedwater supplies, rodent control, prohibition of swimming in streams where risk ofinfection may be high, and informing people of risk when they are involved inrecreational activities.
Vaccines are offered to highrisk workers in some European and Asian countries(eg, rice workers in Italy). Human vaccines are serovar specific and must berepeated yearly. They are associated with painful swelling, especially afterrevaccination. Vaccines are not used in the United States.
However, renal infection and persistent leptospiruria can occur in immunized dogs.Human infection has occurred from asymptomatic immunized dogs that still shedleptospires in their urine. Also, these animal vaccines are serovar specific and thusare useful only where one or a few serovars are present. Hence, the vaccine givenshould contain the serovars known to be prevalent in the area.
Doxycycline, in the dose of 200 mg every week, has demonstrated efficacy of 95%against leptospirosis and may help prevent the disease in exposed adults.[51, 52]This regimen is recommended for those with shortterm exposure and is not forrepeated or longterm exposure. The role of prophylaxis in children has not beenadequately studied.
Medication
Contributor Information and DisclosuresAuthorSandra G Gompf, MD, FACP, FIDSA Associate Professor of Infectious Diseases and International Medicine,University of South Florida College of Medicine; Chief, Infectious Diseases Section, Director, OccupationalHealth and Infection Control Programs, James A Haley Veterans Hospital
Sandra G Gompf, MD, FACP, FIDSA is a member of the following medical societies: American College ofPhysicians, Infectious Diseases Society of America
Disclosure: Nothing to disclose.
Coauthor(s)Judith GreenMcKenzie, MD, MPH, FACP, FACOEM Associate Professor, Director of Clinical Practice,Occupational Medicine Residency Director, University of Pennsylvania School of Medicine
Judith GreenMcKenzie, MD, MPH, FACP, FACOEM is a member of the following medical societies: AmericanCollege of Physicians, American College of Preventive Medicine, National Medical Association, AmericanCollege of Occupational and Environmental Medicine
Disclosure: Nothing to disclose.
Ana Paula Velez, MD Assistant Professor of Medicine, Division of Infectious Disease and InternationalMedicine, University of South Florida College of Medicine and James A Haley Veterans Affairs Medical Center;Attending Physician, Moffitt Cancer Center
Ana Paula Velez, MD is a member of the following medical societies: American College of PhysiciansAmericanSociety of Internal Medicine, American Medical Association, Infectious Diseases Society of America
Disclosure: Nothing to disclose.
Chief EditorMichael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart GWolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health ScienceCenter; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, AmericanMedical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation,Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America
Disclosure: Nothing to disclose.
AcknowledgementsDenise Demers, MD, FAAP Assistant Professor of Pediatrics, Uniformed Services University of the HealthSciences; Attending Physician, Division of Pediatric Infectious Diseases, Department of Pediatrics, Tripler ArmyMedical Center
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Disclosure: Nothing to disclose.
Juan D Diaz, DO Fellow in Infectious Diseases, University of South Florida College of Medicine, Tampa GeneralHospital, and James A Haley Veterans Hospital
Disclosure: Nothing to disclose.
Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics,Division of Infectious Diseases, State University of New York Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, AmericanAcademy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, PediatricInfectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.
Patrick W Hickey, MD, FAAP Assistant Professor of Pediatrics and Preventive Medicine, Uniformed ServicesUniversity of the Health Sciences; Consulting Staff, Department of Pediatrics, Division of Pediatric InfectiousDisease, Walter Reed Army Medical Center
Patrick W Hickey, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, AmericanAcademy of Pediatrics, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society ofAmerica, International Society of Travel Medicine, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.
Edmond A Hooker II, MD, DrPH, FAAEM Assistant Professor, Department of Emergency Medicine, Universityof Cincinnati College of Medicine; Associate Professor, Department of Health Services Administration, XavierUniversity
Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy ofEmergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, andSouthern Medical Association
Disclosure: Nothing to disclose.
Matthew R Jezior, MD Fellow, Department of Cardiology, Walter Reed Medical Center
Disclosure: Nothing to disclose.
Maria D Mileno, MD Associate Professor of Medicine, Division of Infectious Diseases, The Warren AlpertMedical School of Brown University
Maria D Mileno, MD is a member of the following medical societies: Alpha Omega Alpha, American College ofPhysicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America,International Society of Travel Medicine, and Sigma Xi
Disclosure: Nothing to disclose.
Joseph T Morris, MD Chief of Infectious Disease Service, Madigan Army Medical Center; Assistant Professor,Department of Internal Medicine, Uniformed Services University of the Health Sciences
Disclosure: Nothing to disclose.
Gary J Noel, MD Professor, Department of Pediatrics, Weill Cornell Medical College; Attending Pediatrician,New YorkPresbyterian Hospital
Gary J Noel, MD is a member of the following medical societies: Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.
Cecily K Peterson, MD Program Director, Clinical Faculty, Department of Medicine, Madigan Army MedicalCenter
Disclosure: Nothing to disclose.
Charles V Sanders, MD Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor ofMicrobiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans;Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans;Consulting Staff, Ochsner Medical Center
Charles V Sanders, MD is a member of the following medical societies: Alliance for the Prudent Use ofAntibiotics, Alpha Omega Alpha, American Association for the Advancement of Science, American Associationof University Professors, American Clinical and Climatological Association, American College of PhysicianExecutives, American College of Physicians, American Federation for Medical Research, American Foundationfor AIDS Research, AmericanGeriatricsSociety, American Lung Association, American Medical Association,American Society for Microbiology, American Thoracic Society, American Venereal Disease Association,Association for Professionals in Infection Control and Epidemiology, Association of American Medical Colleges,Association of American Physicians, Association of Professors of Medicine, Infectious Disease Society forObstetrics and Gynecology, InfectiousDiseases Societyof America, Louisiana State Medical Society, OrleansParish Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine,Southeastern Clinical Club, Southern Medical Association, Southern Society for Clinical Investigation, andSouthwestern Association of Clinical Microbiology
Disclosure: Nothing to disclose.
William H Shoff, MD, DTM&H Director, PENN Travel Medicine; Associate Professor, Department of EmergencyMedicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine
William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians,American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society forAcademic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.
Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center;Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics,American Association of Immunologists, American Pediatric Society, American Society for Microbiology,Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society,
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Society for Pediatric Research, and Southern Medical Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center Collegeof Pharmacy; EditorinChief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
Jeter (Jay) Pritchard Taylor III, MD Compliance Officer, Attending Physician, Emergency Medicine Residency,Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine;Medical Director, Department of Emergency Medicine, Palmetto Health Baptist
Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy ofEmergency Medicine, American College of Emergency Physicians, American Medical Association, and Societyfor Academic Emergency Medicine
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College ofPharmacy; EditorinChief, Medscape Drug Reference
Disclosure: Nothing to disclose.
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