Leptospirosis mangment
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WHO leptospirosis clinical management severe mild doxycycline penicillin guideline
Leptospirosis management
Treat immediately if clinical suspicion is high. Do not wait for confirmatory tests, especially in a patient with fever after exposure to floodwater, rodents, livestock, or contaminated fresh water. Early antibiotics may reduce illness duration and severity, according to the CDC clinical guidance.
1. Assess severity and admit if severe
Urgently refer/admit if there is any of the following:
- Jaundice, oliguria or acute kidney injury
- Breathlessness, hemoptysis, hypoxemia, pulmonary hemorrhage
- Hypotension, shock, altered mental status
- Meningitis, myocarditis, arrhythmia
- Bleeding, thrombocytopenia, severe vomiting, inability to take oral treatment
- Pregnancy, frailty, significant comorbidity
Severe disease is often called Weil disease and can involve renal, hepatic, pulmonary, and cardiovascular failure.
2. Antibiotics
| Clinical severity | Recommended treatment |
|---|---|
| Mild, outpatient adult disease | Doxycycline 100 mg orally twice daily for 7 days |
| If doxycycline unsuitable | Amoxicillin 500 mg orally every 6 hours, ampicillin 500-750 mg orally every 6 hours, or azithromycin 500 mg orally once daily for 3 days |
| Moderate or severe disease | IV benzylpenicillin (penicillin G) 1.5 million units every 6 hours for 7 days |
| Alternative for severe disease | Ceftriaxone 1 g IV once daily for 7 days or cefotaxime 1 g IV every 6 hours |
Doxycycline, amoxicillin, and ampicillin are options for mild disease; IV penicillin, ampicillin, or ceftriaxone is used for moderate to severe disease. Harrison’s Principles of Internal Medicine, 22e, Leptospirosis section. The CDC clinician factsheet provides the same adult regimens.
Notes
- Avoid doxycycline in pregnancy and in young children unless specialist advice supports its use.
- Modify dose/choice for renal dysfunction according to local prescribing guidance.
- Watch for a Jarisch-Herxheimer reaction in the first 24 hours after starting antibiotics: fever, chills, headache, myalgia, and transient clinical worsening. Give supportive care and do not routinely stop antimicrobial treatment.
3. Supportive care
- Monitor vital signs, urine output, fluid balance, CBC, creatinine/electrolytes, liver enzymes, bilirubin, coagulation profile, and oxygenation.
- Give cautious IV fluids and correct electrolytes. Avoid fluid overload, particularly with pulmonary involvement or renal failure.
- Use paracetamol/acetaminophen for fever and pain. Avoid NSAIDs when there is acute kidney injury, bleeding risk, or thrombocytopenia.
- Treat shock according to sepsis principles: cultures where feasible, fluid resuscitation with reassessment, and vasopressors if needed.
- Dialysis for severe/oliguric acute kidney injury, refractory hyperkalemia, severe acidosis, or fluid overload.
- Oxygen, noninvasive/invasive ventilation, and ICU care for respiratory failure or pulmonary hemorrhage.
- Give blood products if clinically significant bleeding or coagulopathy occurs.
4. Investigations, but do not delay therapy
- CBC, renal/liver function, electrolytes, urinalysis, ECG, chest radiograph if respiratory symptoms.
- PCR is most useful early in illness; serology may be negative in the first week and may need repeating with a convalescent sample.
- Obtain blood cultures and test for important mimics depending on location: dengue, malaria, viral hepatitis, rickettsial infection, sepsis, and acute viral illness.
5. Steroids
Do not use corticosteroids routinely. They have sometimes been considered in selected severe pulmonary hemorrhage cases under critical-care/infectious-disease supervision, but a 2025 Cochrane review found the evidence uncertain (PMID 40704556).
Evidence note
A 2024 Cochrane review found that comparative evidence for different antibiotics remains limited and uncertain (PMID 38483092). This does not mean withholding treatment: prompt antibiotics remain recommended by public-health and clinical guidance because delayed treatment in potentially severe leptospirosis is unsafe.
This is an emergency evaluation situation if the patient has jaundice, reduced urine, breathlessness, coughing blood, confusion, low blood pressure, or persistent vomiting.
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