Leptospirosis Also known as Weil s disease, Mud fever, Canicola fever, Flood fever, Swineherds Disease, Japanese Seven

Days fever

Definition and Background A bacterial zoonotic disease caused by spirochaetes of the genus Leptospira that affects humans and a wide range of animals, including mammals, birds, amphibians, and reptiles. First described by Adolf Weil in 1886 when he reported an acute infectious disease with enlargement of spleen, jaundice and nephritis

Causative Agent bacteria of the genus Leptospira

Characteristics of Leptospira spirochete motile both gram-positive and gram-negative characteristics poor staining, therefore, dark-field or phase-contrast microscopy are necessary beta-hemolytic Leptospira-genus bacteria was isolated in 1907 from post mortem renal tissue slice.commonly found: Leptospira pyrogenes, Leptospira manilae, & other species like L. leterohemorrhagiae, L. canicola, L. batavia, L. Pomona, L. javinica Predisposing Factor age: < 15 years of age sex: male season: rainy months geographic: prevalent in slum areas

Source of Infection Infection comes from contaminated food and water, and infected wild life and domestic animals especially rodents. 1. Rats ( L. leterohemorrhagiae) are the source of Weils disease frequently observed among miners, sewer, and abattoir workers. 2. Dogs (L. canicola) can also be the source of infection among veterinarians, breeders, and owners of dogs. 3. Mice (L. grippotyphosa) may alos be a source of infection that attacks farmers and flax workers. 4. Rats (L. bataviae) are the source of infection that attacks rice field workers.

Modes of Transmission Wild mammals seem to serve as the primary reservoir of most leptospiral serovars. The organism has been found in more than 160 mammals, including rats, pigs, dogs, cats, raccoons, and cattle. Rats are considered the most important reservoir, as they are the most common source worldwide. Dogs are often carriers of leptospires, which can cause problems because of their close association with people. Transmission occurs by contamination of water, soil, or vegetation by urine excreted from infected animals. Humans can become infected upon contact of the contaminated material with abraded skin, mucous membranes, or when the contaminated material is ingested. Humans are considered incidental hosts to the disease because transmission of the disease between people is rare, at best. Humans are the end of the line of the disease, with very rare exceptions.

Incubation Period 6 15 days/ 2 8 weeks

Clinical Manifestations 1st stage: Septicemic/ Leptospiremic Phase (4 7 days) - onset of high remittent fever, chills, headache, anorexia, nausea & vomiting, abdominal pain, joint pains, muscle pains, myalgia, severe prostration, cough, respiratory distress, bloody sputum. 2nd stage: Immune/ Toxic Phase (4 30 days) - if severe, death may occur between the 9th & 16th day 2 types: Anicteric (without jaundice) return of fever of a lower degree with rash, conjunctival injection, headache, meningeal manifestations like disorientation, convulsions & signs of meningeal irritations (with CSF finding of aseptic meningitis) Icteric (with jaundice) Weil syndrome; hepatic & renal manifestations: hemorrhage, hepatomegaly, hyperbilirubinemia, oliguria, anuria with progressive renal failure; shock, coma & congestive heart failure in severe cases 3rd stage: Convalescence Phase - Relapses may occur during 4th or 5th week Diagnosis Diagnosis can be made from culturing the Leptospira bacteria from: Bodily fluids days 1-7 Cerebrospinal fluiddays 4-10 Urineafter the 10th day Prognosis cause of death: renal & hepatic failure disease usually last 1 3 weeks but may be more prolonged; relapse may occur

Treatment Specific measures: beneficial if done < 4 days of dse Aqueous penicillin G (50,000 units/kg/day in 4-6 divided doses intravenously for 7-10 days Tetracycline (20-40 mg/kg/day in 4 doses); may not be given to children < 8 years old General measures symptomatic & supportive care administration of fluid, electrolytes & blood as indicated peritoneal dialysis (for renal failure) Nursing Interventions Monitoring of strict fluid intake and output. Promptly report the occurrence of dyspnea oliguria or hemorrhage. Severely ill patients should be nursed in propped-up position to lessen the risk of secondary pulmonary complications. Patients with vomiting should be managed by I/V fluids and electrolyte replacement. Monitor weight daily Isolation of patient: urine must be properly disposed Health teachings: keep a clean environment

Drug Study

Tetracycline hydrochloride Brand Name: Apo-Tetra (CAN), Novo-Tetra (CAN), Nu-Tetra (CAN),Panmycin, Sumycin, Tetracap, Tetracyn, Tetralan, Topicycline Pregnancy Category D, Pregnancy Category B (Topicycline only) Drug classes: Antibiotic, Tetracycline Therapeutic actions Bacteriostatic: inhibits protein synthesis of susceptible bacteria, preventing cell replication. Indications Systemic administration Infections caused by rickettsiae; Mycoplasma pneumoniae;agents of psittacosis, ornithosis, lymphogranuloma venereum andgranuloma inguinale; Borrelia recurrentis, Haemophilus ducreyi,Yersinia pestis, Yersinia tularensis, Bartonella bacilliformis,Bacteroides, Vibrio cholerae, Campylobacter fetus, Brucella, Escherichia coli, Enterobacter aerogenes, Shigella,Acinetobacter calcoaceticus, Haemoph ilus influenzae,Klebsiella, Streptococcus pneumoniae When penicillin is contraindicated, infections caused by Neisseriagonorrhoeae, Treponema pallidum, Treponema pertenue,Listeria monocytogenes, Clostridium, Bacillus anthracis,Fusobacterium fusiforme, Actinomyces, Neisseria meningiti dis Adjunct to amebicides in acute intestinal amebiasis

 Treatment of acne (oral) Uncomplicated urethral, endocervical or rectal infections in adults caused by Chlamydia trachomatis Instilled in a chest tube, unlabeled use: pleural sclerosing agent in malignant pleural effusions Treatment of trachoma Contraindications Systemic administration and dermatologic solution Contraindicated with allergy to any of the tetracyclines; allergy totartrazine (in 250-mg capsules of Panmycin); pregnancy (toxic to the fetus); lactation (causes damage to the teeth of infant). Adverse effects Phototoxic reactions, rash, exfoliative dermatitis Discoloring and inadequate calcification of primary teeth of fetus if used by pregnant women, discoloring and inadequate calcification of permanent teeth if used during period of dental development, fatty liver, liver failure, anorexia, nausea, vomiting, diarrhea, glossitis, dysphagia,enterocolitis, esophageal ulcers Hemolytic anemia, thrombocytopenia, neutropenia, eosinophilia,leukocytosis, leukopenia Reactions from urticaria to anaphylaxis, including intracranial hypertension Superinfections, local irritation at parenteral injection sites Drug Interactions: Decreased absorption with calcium salts, magnesium salts, zinc salts, aluminum salts, bismuth salts, iron, urinary alkalinizers, food, dairy products, charcoal Increased digoxin toxicity Increased nephrotoxicity with methoxyflurane

 Decreased effectiveness of hormonal contraceptives, though rare, has been reported with a risk of breakthrough bleeding or pregnancy Decreased activity of penicillins Nursing considerations Administer oral medication on an empty stomach, 1 hr before or 23 hr after meals. Do not give with antacids. If antacids must be used, give them 3 hr after the dose of tetracycline. Culture infection before beginning drug therapy. Do not administer during pregnancy; drug is toxic to the fetus. Do not use outdated drugs; degraded drug is highly nephrotoxicand should not be used. Do not give oral drug with meals, antacids, or food. Arrange for regular renal function tests with long-term therapy. Use topical preparations of this drug only when clearly indicated. Sensitization from the topical use may preclude its later use in serious infections. Topical preparations containing antibiotics that are not ordinarily given systemically are preferable.

Penicillin G Brand names: Pfizerpen, Penicillin G Benzathine, Bicillin L-A, Crystapen (Canada), procaine penicillin G

Pregnancy Category Category B Therapeutic Class anti-infectives Pharmacologic Class penicillins Indications Treatment of a wide variety of infections including: Pneumococcal pneumonia, Streptococcal pharyngitis, Syphilis, Gonorrhea strains. Treatment of enterococcal infections (requires the addition of an aminoglycoside). Prevention of rheumatic fever. Should not be used as a single agent to treat anthrax. Unlabeled Use(s): Treatment of Lyme disease, prevention of recurrent Streptococcal pneumoniae septicemia in children with sickle-cell disease.
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Action Bind to bacterial cell wall, resulting in cell death.

Therapeutic Effect(s): Bactericidal action against susceptible bacteria. Active against:

Most gram-positive organisms, including many streptococci (Streptococcus pneumoniae, group A beta-hemolytic streptococci), staphylococci (nonpenicillinase-producing strains) and Bacillus anthracis, Some gram-negative organisms, such as Neisseria meningitidis and N. gonorrhoeae (only penicillin susceptible strains),

Pharmacokinetics Absorption: Variably absorbed from the GI tract. Procaine and benzathine penicillin GIM absorption is delayed and prolonged and results in sustained therapeutic blood levels. Distribution: Widely distributed, although CNS penetration is poor in the presence of normal (uninflamed) meninges. Crosses the placenta and enters breast milk. Protein Binding: 60%. Metabolism and Excretion: Minimally metabolized by the liver, excreted mainly unchanged by the kidneys. Half-life: 3060 min. TIME/ACTION PROFILE (blood levels) ROUTE Penicillin G IM Benzathine penicillin IM Procaine penicillin IM Penicillin G IV ONSET PEAK rapid DURATI ON 3 wk 12 hr 46 hr

0.250.5 hr 46 hr

delaye 1224 hr d delaye 14 hr d rapid end of infusion

Contraindication/Precautions Contraindicated in: Previous hypersensitivity to penicillins (cross-sensitivity exists with cephalosporins and other beta-lactam antibiotics) Hypersensitivity to procaine or benzathine (procaine and benzathine preparations only) Some products may contain tartrazine and should be avoided in patients with known hypersensitivity. Use Cautiously in: Severe renal insufficiency (dosage reduction recommended) OB: Although safety not established, has been used safely Lactation: Safety not established

Geri: Consider decreased body mass, age-related decrease in renal/hepatic/cardiac function, intercurrent diseases and drug therapy.

Adverse Reactions/Side Effects CNS: SEIZURES GI: diarrhea, epigastric distress, nausea, vomiting, pseudomembranous colitis GU: interstitial nephritis Derm: rash, urticaria Hemat: eosinophilia, leukopenia Local: pain at IM site, phlebitis at IV site Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS AND SERUM SICKNESS, superinfection * CAPITALS indicate life-threatening. Italics indicate most frequent.

Interactions Drug-Drug Penicillin may effectiveness of oral contraceptive agents. Probenecid renal excretion and blood levels of penicillin (therapy may be combined for this purpose). Neomycin may absorption of penicillin. Concurrent use with methotrexate methotrexate elimination and risk of serious toxicity.

Route/Dosage Aqueous Penicillin G IM: IV: (Adults) Most infections15 million units q 46 hr. IM: IV: Children 833316,667 units/kg q 4 hr; 12,55025,000 units/kg q 6 hr; up to 250,000 units/kg/day in divided doses, some infections may require up to 300,000 units/kg/day. IV: (Infants >7 days): 75,000 units/kg/day in divided doses every 8 hr; meningitis200,000300,000 units/kg/day in divided doses q 6 hr. IV: (Infants <7 days): 50,000 units/kg/day in divided doses q 12 hr; Streptococcus B, meningitis100,000150,000 units/kg/day in divided doses.

Assessment

Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy. Obtain a history to determine previous use of and reactions to penicillins, cephalosporins, or other beta-lactam antibiotics. Persons with a negative history of penicillin sensitivity may still have an allergic response. Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results. Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify physician or other health care professional immediately if these symptoms occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of an anaphylactic reaction. Lab Test Considerations:

May cause positive direct Coombs' test results. Hyperkalemia may develop after large doses of penicillin G potassium. Monitor serum sodium concentrations in patient with hypertension or HF. Hypernatremia may develop after large doses of penicillin sodium. May cause AST, ALT, LDH, and serum alkaline phosphatase concentrations. May cause leukopenia and neutropenia, especially with prolonged therapy or hepatic impairment. Potential Diagnoses

Risk for infection Noncompliance

Implementation Do not confuse penicillin with penicillamine. Do not confuse penicillin G aqueous (potassium/sodium salts) with penicillin G procaine or benzathine. Penicillin G Potassium Y-Site Compatibility o acyclovir o amiodarone o cyclophosphamide o diltiazem o enalaprilat o esmolol o fluconazole o foscarnet o heparin o hydromorphone o labetalol o magnesium sulfate o meperidine o morphine o nicardipine

perphenazine potassium chloride tacrolimus theophylline verapamil vitamin B complex with C Y-Site Incompatibility Additive IncompatibilityIncompatible with aminoglycosides; do not admix. Additive IncompatibilityIncompatible with aminoglycosides; do not admix. Penicillin G Sodium Y-Site Incompatibility Additive IncompatibilityIncompatible with aminoglycosides; do not admix.
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Nursing Considerations Instruct patient to take medication around the clock and to finish drug completely as directed, even if feeling better. Advise patient that sharing this medication may be dangerous.

Advise patient to report signs of superinfection (black, furry overgrowth on tongue; vaginal itching or discharge; loose or foul-smelling stools) and allergy. Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. Instruct patient to notify health care professional if symptoms do not improve. Advise patient taking oral contraceptives to use an additional nonhormonal method of contraception during therapy with penicillin and until next menstrual period. Patient with an allergy to penicillin should be instructed to always carry an identification card with this information.