Leptospirosis Protocol for NABH accredition - prepared for Institute of Internal Medicine, Madras Medical College.

1. LEPTOSPIROSIS - DIAGNOSIS & MANAGEMENT GUIDELINES
MODIFIED FAINE’S CRITERIA (2012)
PRESUMPTIVE DIAGNOSIS: PART A or PART (A+B) = 26 or more
PART (A+B+C) = 25 or more
POSSIBLE DIAGNOSIS: Scores between 20 and 25
CASE DEFINITION (ICMR & WHO-SEAR)
Suspected case Acute febrile illness with:
Myalgia (especially calf tenderness)
Conjunctival su
ff
usion
Headache
Prostration
History of exposure to possible leptospira-contaminated environment
Probable case Suspected case with:
Rapid diagnostic test positivity (IgM ELISA or MSAT)
Con
fi
rmed case Suspected or Probable case with:
Isolation of leptospira in culture or
PCR positivity or
MAT (single titre of 1:400 or above / fourfold rise in serial titres)
CLINICAL
(PART-A)
EPIDEMIOLOGICAL
(PART-B)
LABORATORY
(PART-C)
Headache 2 Rainfall 5 Isolation by
culture**
DIAGNOSIS
CERTAIN
Fever 2 Contact with
contaminated
environment
4 Positive PCR 25
Temperature
> 39* C
2 Animal contact 1 ELISA IgM
Positive*
15
Conjunctival
su
ff
usion
4 MSAT Positive* 15
Meningism 4 MAT*
(Single high
titre or Rising
titre - 4x rise)
15
Myalgia 4
Conjunctival
su
ff
usion +
Meningism +
Myalgia
10 *any one of the
tests only should
be considered
for scoring
Jaundice 1
Albuminuria /
Azotemia
2
Hemoptysis /
Dyspnea
2
**Ideal time for culture
Blood - Within 10 days
Urine - 10 to 30 days
CSF - Within 5 to 10 days

2. Leptospirosis - Suspected / Probable / Con
fi
rmed
90% of cases are
Mild Leptospirosis
(Fever, myalgia,
conjunctival suffusion,
headache BUT NO
JAUNDICE)
Around 10% cases are
Moderate / Severe Leptospirosis
(Fever, myalgia, conjunctival suffusion, headache + JAUNDICE +/-
Multi-organ involvement
Based on clinical
spectrum
OP Treatment
Doxycycline 100mg PO
BD x 7 days or
Amoxicillin 500mg PO
TDS x 7 days or
Ampicillin 500mg
PO TDS x 7days or
Azithromycin 500mg PO
OD x 3 days
Other supportive Rx*
*advise adequate
hydration, bed rest,
antipyretics etc.
RED FLAG SIGNS
(tachypnea, tachycardia
disproportionate to fever,
shock, altered sensorium,
oliguria, bleeding
manifestations etc.)
IP Treatment (Antibiotic Rx +/- Organ speci
fi
c Rx)
Antibiotic therapy:
Penicillin 1.5 million units IV QID x 7 days or
Ceftriaxone 1g IV BD x 7 days or
Doxycycline 200mg IV stat, then 100mg IV BD x 7days
(Doxycycline contraindicated in pregnancy)
Organ speci
fi
c therapy:
RENAL: renal involvement is common.
Mild - only proteinuria and no RFT derangement: No intervention
Severe - AKI: Fluid management +/- diuretics, electrolyte correction,
avoid nephrotoxic drugs, avoid hypotension and hypovolemia +/- RRT (if
indicated by standard RRT guidelines)
HEPATIC: acute liver failure is rare.
Avoid precipitating factors of hepatic encephalopathy - drugs
(hepatotoxic drugs, sedatives etc.), hypovolemia, hypokalemia,
alkalosis, constipation, UGI bleeding.
Jaundice, Hepatomegaly: No intervention
Hepatic encephalopathy: lactulose, rifaximin etc.
LUNG: Most dangerous complication
ARDS / Pulmonary hemorrhage: Continuous O2 therapy, Mechanical
ventilation (if indicated)
HEART:
Myocarditis / Arrhythmia: treatment of speci
fi
c arrhythmia
Shock: treat hypovolemia with
fl
uid replacement. If not responding, add
dopamine or dobutamine.
HEMATOLOGICAL:
Thrombocytopenia: Platelet transfusion (if indicated)
Coagulopathy: Vit.K 5-10mg IV x 3 days +/- Fresh Frozen Plasma
DIC: FFP +/- blood transfusion
NEUROLOGICAL:
Aseptic meningitis: Symptomatic and supportive management.
Hypokalemic paralysis: IV Potassium supplementation
MUSCULOSKELETAL:
Myalgia / Myositis / Rhabdomyolysis : Monitor CPK levels, adequate
hydration, monitor urine output and serum electrolytes.
Arthralgia: No intervention +/- analgesic-antipyretics
All Absent
Any one or more is
present
Always rule out other tropical diseases.
Mixed infections are common.
Important differential diagnosis include:
-Malaria
-Scrub typhus
-Dengue
-Hepatitis
-Enteric fever etc.

3. Leptospirosis
 Zoonotic
 Pathogenic spirochete – Leptospira interrogans
 Rodents and Cattle excrete these organisms in their urine, which contaminates soil and
waterbodies
 Mode of transmission: contact of abraded skin or mucous membrane with contaminated
environment
 Incubation period: Average 5-14 days with a range 2- 30 days
 Risk factors:
o Heavy rainfall and water logging
o Natural disasters like floods
o Seasonal – at the onset of monsoon
o Farmers
o Agricultural field workers
o Fishermen
o Sewer workers
o Livestock handlers
o Mason
o Residence in endemic area
 Presentation spectrum:
o Anicteric Leptospirosis: (90%) – Mild form presents like Acute undifferentiated fever
o Icteric Leptospirosis: (5-10%) – Moderate-Severe form
o Weil’s Disease (0-5%) – Severe form
 When to suspect Leptospirosis?
o Acute febrile illness + Risk factors + one or more of the following:
 Headache
 Myalgia
 Prostration
 Calf muscle tenderness
 Conjunctival suffusion
 Oliguria / Frothy urine
 Jaundice
 Haemorrhagic manifestations
 Meningeal irritation
 Nausea, Vomiting, Abdominal pain, Diarrhoea
 Lab investigations to support diagnosis: (Blood, CSF, Urine sample)
o MAT titre of 100/200/400 or above based on endemicity (preferred)
o IgM based immune assays
o Seroconversion or Four-fold rise in MAT titre between acute and convalescent sera
o Direct isolation of organism
o PCR test

4.  Lab investigations to assess severity:
o CBC, ESR
o RFT, LFT
o S. Electrolytes
o Urine Routine examination
o CPK
o CXR, ABG
 Management:
o IVF and correction of electrolytes
o Mild cases:
 Tab. Doxycycline 100mg PO BD X 7 days (preferred) or
 Tab. Azithromycin 500mg PO OD X 3 days
o Moderate / Severe cases:
 Inj. Penicillin 1.5 million units IV or IM Q6H X 7 days or
 Inj. Ceftriaxone 2g IV OD X 7 days
o Chemoprophylaxis:
 Tab. Doxycycline 200mg PO once a week or
 Tab. Azithromycin 250mg PO once/ twice a week

5. DIAGNOSTIC:
A + B = /> 26
OR
A + B + C = /> 25
POSSIBLE:
A + B = Between 20 to 25
CRITERIA