Professional Documents
Culture Documents
Lepto Handout
Lepto Handout
Lepto Handout
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
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
LOW RISK
MODERATE RISK
HIGH RISK
Doxycycline 2 capsules 100 mg OD for 3-5 days started immediately w/in 24-72H from exposure
ALGORITHM FOR THE DIAGNOSIS & MANAGEMENT OF LEPTOSPIROSIS WITH PULMONARY COMPLICATIONS
Source: Phil. CPG on the Diagnosis, Management & prevention of Leptospirosis
Supected Leptospirosis
YES
NO
CXR bilateral infiltrates (quantify quadrants), PF Ratio <250 or SaO2 <90% at 6LPM O2
NO
YES
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
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
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
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
No No No No No No No No No
SYMPTOMS Cough Hemoptysis Dyspnea Decreased urine output Hematuria/tea-colored urine Melena Others_________________ _________________ _________________
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:____________________