Philippine Clinical Practice Guidelines on the Diagnosis, Management and Prevention of LEPTOSPIROSIS in Adults 2010

Collaborative statement of the Philippine Society of Microbiology and Infectious Diseases, Inc. (PSMID) Philippine Society of Nephrology (PSN) Philippine College of Chest Physicians (PCCP) Council on Critical Care and Pulmonary Vascular Diseases

SUSPECTED LEPTOSPIROSIS CASE 1. Fever of 2 days 2. Residing in a flooded area OR has high risk exposure* 3. At least 2 of the following symptoms:  Myalgia > Abdominal pain  Calf tenderness > Headache  Conjunctival suffusion > Jaundice  Chills > Oliguria

High Risk Exposure :  Wading in flood and contaminated water  Swimming in flood water  Contact with animal fluids  Ingestion of contaminated water  With or without cuts or wounds MILD LEPTOSPIROSIS managed an OUT-PATIENT SETTING  Stable vital signs > No sepsis/septic shock  Anicteric sclera > No difficulty of breathing  Good urine output > No jaundice  No evidence of meningismus/meningeal irritation  Can take oral medications

MODERATE TO SEVERE LEPTOSPIROSIS managed in HEALTHCARE/HOSPITAL SETTING  Unstable vital signs >  Abdominal pain >  Vomiting >  Oliguria/anuria >  Sepsis/septic shock >  Difficulty of breathing >

Jaundice/icteric sclerae Nausea Diarrhea Meningismus/meningeal irritation Altered mental states Hemoptysis

TREATMENT  Antibiotic therapy should be started as soon as the diagnosis of leptospirosis is suspected regardless of the phase of the disease or duration of symptoms DOSAGES OF ANTIBIOTICS RECOMMENDED FOR LEPTOSPIROSIS Mild Leptospirosis Moderate to Severe Leptospirosis Managed as Out-Patient Setting Managed in Healthcare Hospital Setting Antibiotic Dosage Antibiotic Dosage First Line Agent Doxycycline 100 mg BID PO Penicillin G 1.5 MU q6-q8H (hydrochloride or hyclate) Alternative Agents Amoxicillin 500 mg q 6H or 1 g q8H PO Ampicillin IV 0.5-1.0 g q6H Azithromycin 1 g initially, followed by 500 Azithromycin dihydrate 500 mg OD IV for 5 days dihydrate mg OD for 2 more days PO Ceftriaxone 1 g OD IV Cefotaxime 1 g q6H IV *Step-down can be instituted once pt is clinically stable and able to tolerate oral meds. Any oral antibiotic under mild leptospirosis can be selected. *Antibiotics should be completed for 7 days except for Azithromycin which could be given for 3 days

DOSAGES OF ANTIOBIOTICS IN ADULTS WITH RENAL IMPAIRMENT Antibiotic Dose for Adjustment for Renal Failure Normal Renal Function Estimated Creatinine Clearance (CrCl, mL/min) 50-90 10-50 <10 Amoxicillin 500 mg q6H or 1 g q8H q8H q8-12H q24H Ampicillin 0.5 1.0 g q6H q6H q6-12H q12-24H Azithromycin dihydrate 500 mg OD No dose adjustment Cefotaxime 1 g q6H q8-12H q12-24H q24H Ceftriaxone 1 g q 24H No dose adjustment Doxycycline 100 mg BID No dose adjustment Penicillin G 1.5 MU q6H No dose adjustment *Antibiotics should be completed for 7 days except for Azithromycin which could be given for 3 days

ANTIBIOTIC PROPHYLAXIS RECOMMENDED PRE-EXPOSURE PROPHYLAXIS  Most effective preventive measure is avoidance of high-risk exposure  If high risk exposure in unavoidable, use appropriate personal protective equipment  Pre-exposure antibiotic prophylaxis is NOT routinely recommended  Indications: 1. Individuals who intend to visit highly endemic areas AND are likely to get exposed (travelers, soldiers, those engaged in water-related recreational and occupational activities) 2. For short-term exposure  For non-pregnant, non-lactating adult: Doxycycline 200 mg once weekly, to begin 1-2 days before exposure and continued throughout the period of exposure  NO recommended pre-exposure prophylaxis has been found safe for pregnant or lactating women POST-EXPOSURE PROPHYLAXIS Risk Definition Exposure Wounds/ Cuts/ Skin Lesions Low-Risk Single Absent Moderate-Risk Single Present

Treatment with Doxycycline 100 mg/cap

2 caps as single dose within 24-72H 2 caps OD for 3-5 days started immediately w/in 24-72H High-Risk Continuous* Absent/Present 2 caps once weekly until end of exposure *Continuous exposure - more than a single exposure or several days such as those residing in flooded areas, rescuers and relief-workers
POST-EXPOSURE PROPHYLAXIS FOR LEPTOSPIROSIS History of wading in flood

Single exposure (-) wounds / cuts /skin lesions (+)wounds / cuts /skin lesions

Continuous exposure (+/-)wounds / cuts /skin lesions

LOW RISK

MODERATE RISK

HIGH RISK

Doxycycline 2 capsules 100 mg as single dose within 24-72H

Doxycycline 2 capsules 100 mg OD for 3-5 days started immediately w/in 24-72H from exposure

Doxycycline 2 capsules 100 mg once weekly until end of exposure

ALGORITHM FOR THE DIAGNOSIS & MANAGEMENT OF LEPTOSPIROSIS WITH PULMONARY COMPLICATIONS
Source: Phil. CPG on the Diagnosis, Management & prevention of Leptospirosis

Supected Leptospirosis

Cough, dyspnea, hemoptysis, RR > 30

YES

Methylprednisolone 1 g IV bolus CXR, ABG, Pulse Oximetry

NO

CXR bilateral infiltrates (quantify quadrants), PF Ratio <250 or SaO2 <90% at 6LPM O2
NO

YES

Continue observation

Discontinue steroids Continue observation

 Intubate Initial MV Set-up: AC mode, FiO2 100%, TV 6 mL/kg BW, PEEP 5 cm H20 (adjust accordingly), RR - adjust accordingly Continue Methylprednisolone 1 g IV/day x 2 days then Prednisolone 1 mg/kg/day x 7 days

Oliguria -m <0.5 ml/kg/hr or <400 ml/day or self-report of low or no UO in 12H MAP 65 mmHg
NO YES

Start Norepinephrine & titrate to keep MAP > 65 mmHg FD pNSS 20 ml/kg/hr & reassess after 15 mins Continue hydration until euvolemic Adjust IVF rate to suit Pt needs UO 0.5 ml/kg/hr
YES

Assess fluid status Hypovolemic?

NO YES

Furosemide 40 mg IV bolus or Bumetanide 1 mg IV UO 0.5 ml/kg/hr

NO YES

Double dose of Furosemide (or Bumetanide) hourly up to max dose of 160 mg (or 4 mg) UO 0.5 ml/kg/hr
NO YES

Monitor hourly & adjust IVF rate to maintain euvolemia Reassess kidney status

Acute Renal Replacement Therapy

ALGORITHM FOR THE MANAGEMENT OF OLIGURIA IN LEPTOSPIROSIS

Source: Phil. CPG on the Diagnosis, Management & prevention of Leptospirosis

LEPTOSPIROSIS DATA COLLECTION FORM

PATIENT INFORMATION Name: ___________________,_______________________________________________
Last Name First Name Middle Name

Age:________ Sex: MMale Female Occupation:_______________________ Address:__________________________________________________________________ Contact #:_________________________________________________________________ Hospital:___________________ Hospital ID #:____________ Service: Private Charity Case ID #:_________________________________________________________________ CLINICAL INFORMATION Date of consult at hospital where form is being filled up: ___/___/___
Mo Day Year

Chief complaint:_______________ Date of onset of symptoms ___/___/___

Mo Day Year

History of previous consult: Yes No If YES Place:__________________ Diagnostics:_________________________ History of antibiotic treatment (within 4 weeks prior to consult): Yes No Indication: treatment prophylaxis others______________________ If YES, D Drug name:____________ Dosage: _________ Duration:___________ EXPOSURE HISTORY History of exposure (wading, swimming, submerged) in flood waters None Single Multiple Date of first exposure:_______________ Place of exposure:__________________ Contact with rodents, animal carcass, excreta, urine: Yes No Other members of household diagnosed with leptospirosis: 1 2

>4

Fever Malaise Headache Chills Muscle/joint pains Diarrhea Abdominal pain Nausea/vomiting Jaundice

Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No

SYMPTOMS Cough Hemoptysis Dyspnea Decreased urine output Hematuria/tea-colored urine Melena Others_________________ _________________ _________________

Yes Yes Yes Yes Yes Yes

No No No No No No

PHYSICAL FINDINGS on consult: Vital Signs: Temp:____________ BP:__________ HR:___________ RR:____________ Conjuctival suffusion Yes No Abdominal tenderness Yes No Meningismus Yes No Edema Yes No Icterisia/Jaundice Yes No Presence of wound/ Yes No Rales Yes No Skin lesions Wheezes Yes No Signs of dehydration Yes No Diarrhea Yes No Others_________________ Breath sounds Yes No _________________ Irregular Rhythm Yes No _________________ CO-MORBIDITIES Hypertension COPD Asthma Malignancy

Yes No Diabetes Yes No Yes No Existing CKD Yes No Yes No Liver Disease Yes No Yes No Others_________________ DIAGNOSTICS on Admission CBC: Hgb____ Hct____ WBC____ Neutrophils ____ Lymphocytes____ Platelet Count_____ Creatinine _____ mg/dL Serum K ____ mEq/L Serum Na ___ mEq/L Serum Ca ____ mEq/L Serum Mg ____mEq/L Amylase ____ u/L Lipase ____ u/L Bilirubin ____ u/L AST ____ ALT ____ CkMM _____ PT ____ PTT ____ ABG: pH _____ pCO2 ____ HCO3 ____ pO2_____ CXR:________________________________________ UA: color ______ pH ______ spec grav ______ Protein ______ Sugar______ WBC_______ RBC_________ Others _________ Leptospiral IgM determination: Date extracted: __/__/__ Result:______ Leptospiral PCR: Date extracted: __/__/__ Result:______ Leptospirosis MAT: Date extracted: __/__/__ Acute serum:______ Date extracted: __/__/__ Convalescent serum:______ Culture date: __/__/__ Blood:_____ Urine:______ CSF: _____

THERAPEUTICS Medicines given during admission (provide dose and duration) Penicillin G _______________ Ceftriaxone_____________________ Ampicillin _______________ Amoxicillin ____________________ Doxycycline_______________ Azithromycin___________________ Others___________________ Steroids Hydrocortisone_________ Methylprednisolone_____________ Prednisone_______________ Furosemide (total dose ______/day) Norepinephrine _____________ Dopamine_____________________ Others ___________ HAD ANY OF THE FOLLOWING Renal replacement therapy Hemodialysis No. of sessions: 1 2 3 4 5 6 7 >7 SLEDD CRRT Peritoneal dialysis Transfusion Whole blood pRBC FFP Platelet concentrate Intubation/Ventilatory support Ventilator days 1 2 3 4 5 6 7 >7 Pacemaker OUTCOME Complications Renal failure Pulmonary Hemorrhage Myocarditis GI Bleeding Meningitis Nosocomial Pneumonia Others_________________ ICU days 1 2 3 4 5 6 7 >7 Duration of hospital stay:_______ Date Discharged: _________________ Date Died: ___________________ Cause of death: Pulmonary Hemorrhage ARDS Multiorgan Dysfunction Renal Failure Others:____________________