LEPTOSPIROSIS

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RUBILYN C. NUEVA ESPANA, MD

LEPTOSPIROSIS CLINICAL COURSE
• Acute systemic zoonotic infection, caused by pathogenic
leptospires, caused by spirochetes of the genus
Leptospira, is primarily a disease of domesticated and
wild animals.
o This can occur when mucus membrane and skin
are contaminated by the urine of the infected
animals.
• The main carriers of leptospires are animals such as
rodents, dogs, cats and livestock.

EPIDEMIOLOGY
• This occurs worldwide but it is most common in tropical
and subtropical areas with high rainfall. Figure 2. Phases of Leptospirosis
• Highly endemic in the Philippines, found in flood-prone 1. Incubation period is usually 7-10 days, with a range of 2-
areas like Metro Manila especially during typhoon season 30 days.
(July-October) and in areas with poor housing and 2. After the incubation period, septicemic stage is
sanitation conditions. characterized by acute systemic infection (high grade
• This is 53% higher compared to the same time period last fever, headache, nausea and muscle pain). Leptospires
year. can be isolated in the blood, CSF and tissue
• Most of the cases were from REGION VI, CARAGA, 3. Interphase: 1-3 days resolution of symptoms
REGION X, REGION XI and NCR. 4. Immune phase/Second Stage is characterized by the
presence of circulating antibody and is associated with
TRANSMISSION recurrence of fever, severe headache jaundice,
• Transmitted directly or indirectly from animals to hemorrhage, Meningitis, Renal manifestations
humans (Hematuria, oliguria) and Weil’s Syndrome
o Direct contact with the urine or reproductive fluids
from infected animals. Weil’s Syndrome = Jaundice, Renal dysfunction, hemorrhagic
o Contact with urine-contaminated water (floodwater, diathesis and pulmonary dysfunction
rivers, streams, sewage) and wet soil.
o Ingestion of floodwater or water contaminated by Note: The typical course of leptospirosis starts with acute
urine. septicemic phase followed by the immune phase
o Transmission occurs through mucous membranes,
conjunctiva, and skin cuts or abrasions. ** The clinical course of leptospirosis varies but is generally
predicable and can be divided into 2:

• Anicteric leptospirosis (mild)
o Patient can present with fever, chills, persistent
headache, severe myalgias, abdominal pain and
nausea and vomiting.
o Flu-like syndrome
• Icteric leptospirosis (severe)
o Weil’s syndrome, impaired renal and hepatic
function, hemorrhage, vascular collapse, severe
alterations in consciousness.


Figure 3. Clinical course of Leptospirosis. See at the end of the trans


Figure 1. The different means of leptospirosis transmission.

Leptospirosis (October 25, 2018) 1

Dr. Nueva Espana
 CLASSIFICATION OF LEPTOSPIROSIS Table 3. Criteria for Hospital Admission
Table 1. Classification of Leptospirosis. See table at the end of the CRITERIA FOR HOSPITAL ADMISSION
trans
MILD LEPTOSPIROSIS MODERATE TO SEVERE
DIAGNOSIS LEPTOSPIROSIS
• Early recognition and treatment is important to prevent Out-Patient Setting Healthcare/Hospital Setting
complications of the disease
Stable vital signs Unstable vital signs
• Diagnosis can be based on the clinical assessment and
Anicteric sclerae Jaundice/Icteric sclerae
epidemiological history
Good urine output Oliguria/Anuria
• Antibiotic therapy should be started as soon as the
diagnosis of leptospirosis is suspected regardless of the No evidence of sepsis/septic Sepsis/Septic shock
phase of the disease or duration of symptoms shock
• Generally, it is not necessary to confirm the diagnosis or No evidence of Meningismus/Meningeal
wait for the result of the tests before starting treatment meningismus/meningeal Irritation
irritation
DIAGNOSTIC TESTS No difficulty of breathing Difficulty of breathing
DIRECT METHOD No Jaundice Abdominal Pain
• Culture and Isolation – GOLD STANDARD Can take oral medication Nausea, Vomiting, and
• Polymerase Chain Reaction (PCR) has the advantage of Diarrhea
early confirmation of the diagnosis especially during Altered Mental Status
acute leptospiremic phase (first week of illness) before Hemoptysis
the appearance of antibodies
PREVENTION AND CONTROL
INDIRECT METHOD PRIMARY PREVENTION
• Microagglutination Test (MAT) – a four-fold rise of the • The most effective preventive measure is avoidance of
titer from acute to convalescent sera is confirmatory of high risk exposure (i.e. wading in floods and
the diagnosis. In endemic areas like the Philippines, a contaminated water, contact with animal’s body fluid)
single titer of at least 1:1600 in symptomatic patients is o If avoidance is not possible, use protective clothing
indicative of leptospirosis such as gloves and boots
• Specific IgM Rapid Diagnostic Test like LeptoDipstick, • Avoidance of exposure to urine and tissues from infected
Leptospira IgM ELISA (PanBio), MCAT and Dridot false animals such as wading in flooded areas
negative results can be a problem if the tests are • Vaccination of animals
performed during early stage of the illness. A second • Rodent control
sample should be obtained for suspected cases with the • Chemoprophylaxis
initial negative or doubtful results.
PRE-EXPOSURE PROPHYLAXIS
TREATMENT Table 4. Recommended pre-exposure prophylaxis for adults and
pediatrics for Leptospirosis
Table 2. Dosages of Antibiotics Recommended for Leptospirosis
1,2 3,4
MILD LEPSTOSPIROSIS MODERATE-SEVERE ADULTS PEDIA
LEPTOSPIROSIS 200mg capsule taken >45kg <45kg
Antibiotics Dosage Antibiotics Dosage orally OD once a 100mg OD 4mg/kg/day OD
First Line Agent week once a week once a week
(i.e. two 100mg
Doxycycline 100mg BID PO Penicillin G 1.5mu q6-8h
(for 1 week) capsules taken as
Alternative Agents single oral dose)
1 For all adults including children 12 years of age
Amoxicillin 500mg q6 or Ampicillin IV 0.5-1g q6h
2 Excluding pregnant and breastfeeding mothers
1g q8 PO
Azithromycin 1g initially, Azithromycin 500mg OD for 5 3 For children between 8-12 years old
followed by days 4 Doxycycline is contraindicated for children <8 years old
500mg OD Ceftriaxone 1g q24h
for 2 more * Should be given 1-2 days prior to exposure and continued
Cefotaxime 1g q6h
days PO throughout the period of exposure
***Antibiotic therapy should be completed for 7 days, except
for azithromycin dehydrate which could be given for 3 days • Not routinely recommended
o Recommended in high-risk areas and for those
who are likely to be infected
o E.g. for rescuers, health care providers, soldiers
people residing in flooded areas or those engaged in
Leptospirosis 2
Dr. Nueva Espana
 water-related recreational and occupational
activities
• Short-term exposures
• However, Doxycycline is not available as syrup so
alternatives (i.e. amoxicillin or azithromycin) are given
to pediatric patients
o Doxycyline is available as 100mg capsules

POST-EXPOSURE PROPHYLAXIS
• For individuals with history of exposure to contaminated
water, soil and tissue
• Doxycycline (hydrochloride and hyclate) is the
recommended post exposure chemoprophylactic agent
for leptospirosis
• The duration of prophylaxis depends on the degree of
exposure and the presence of wounds.
• Not 100% effective: monitor for any untoward signs and
symptoms
• Individuals should continue to monitor themselves for
fever and other flu-like symptoms and should continue to Figure 4. Post-exposure Prophylaxis for Leptospirosis
wear personal protective measures since antibiotic
prophylaxis is not 100% effective Table 5. Post exposure prophylaxis Adult
DRUG OF CHOICE ALTERNATIVE
DEGREE OF RISK EXPOSURE Low Risk Exposure Doxycycline 200 mg single
1. LOW RISK EXPOSURE dose within 24-72 hours from
• Those individuals with a single history of wading in exposure
flood or contaminated water without wounds, cuts, Moderate Risk Exposure Doxycycline 200 mg once
or open lesions of the skin daily for 3-5 days within 24-
2. MODERATE RISK EXPOSURE 72 hours from exposure
• Those individuals with a single history of wading in High Risk Exposure Doxycycline 200 mg once
flood or contaminated water and the presence of weekly until the end of
wounds, cuts, or open lesions of the skin, OR exposure
accidental ingestion of contaminated water
3. HIGH RISK EXPOSURE Table 6. Post-exposure Prophylaxis for Pediatrics
• Those individuals with continuous exposure (those DRUG OF CHOICE ALTERNATIVE
having more than a single exposure or several days Doxycycline 4mg/kg as Azithromycin 10mg/kg as
such as those residing in flooded areas, rescuers, and single dose single dose
relief workers) of wading in flood or contaminated Max dose: 200mg Max dose: 500mg
water with or without wounds, cuts, or open lesions Amoxicillin 50mg/kg q6 for 3-
of the skins. 5 days
• Swimming in flooded waters especially in urban Max dose: 500mg q6
areas infested with domestic/sewer rats and If children are exposed for more than 7 days, the dose should
ingestion of contaminated water are also be repeated after 1 week
considered high risk exposure.
Table 4. Summary of Degree of Risk Exposure **Doxycycline is usually given in children 8 years old and
RISK EXPOSURE DEFINITION above. Usually in children less than 8 years old, the
LOW Single history (-) wounds or lesions in alternative drugs such as Amoxicillin and Azithromycin are
skin given.
MODERATE Single history (+) wounds; OR
(+) accidental ingestion of REFERENCES
contaminated water 1. Powerpoint
HIGH Continuous (+/-) wounds 2. Lecture Notes
exposure Swimming in 3. Recordings
contaminated flooded TRANSCRIBERS
waters especially in urban 1. TRANS GROUP: 4A
areas 2. SUBTRANSHEAD: Lance Cua

Ingestion of contaminated
water
Leptospirosis 3
Dr. Nueva Espana


Figure 3. Clinical course of Leptospirosis
Table 1. Classification of Leptospirosis.

Leptospirosis 4
Dr. Nueva Espana