“Diagnosis protocols and

case management of leptospirosis”

Muhammad Hussein Gasem, MD Dr. Kariadi Hospital,
Diponegoro University, Indonesia
Djati Sagoro, SpPD-Finasim Tarakan Province General Hospital,
Prov DKI Jakarta, Indonesia
Yupin Suputtamongkol, MD Faculty of Medicine Siriraj Hospital
Mahidol University, Bangkok, Thailand
 WHO, Subdit BREAK-OUT WHO, B2P2BRV,
BREAK-OUT SESSION Zoonosis/ BREAK-OUT SESSION 2: BLK, Subdit
WHO, Subdit Zoonosis/ SESSION 3:
Time 1: Laboratory methods - Kasi Diagnostics protocols and Kasi Pencegahan Surveillance, zoonosis/ B2P2BRV
Pencegahan (IV-V), BLK
technical training
(III)
clinical management epidemiological
Denpasar (VI-VIII)
research
Surveillance and
outbreak
National Guideline for detection and
C. Munoz-Zanzi
Leptospirosis Case investigation
8.30-9.00 Management in Indonesia Molecular
methods for
surveillance and C. Goarant?
Prof epidemiological
Laboratory diagnosis of
Farida/ M. Mohammad research
leptospirosis (hands on Epidemiologic
training)
Goris Hussein Gasem investigation and
9.00-9.30 Case studies for the source attribution J. Collins Emerson
/ or risk
improvement of clinical stratification
Epidemiological
management and research from a
9.30-10.00 diagnostics protocols One Health N. Vasantha
perspective in
Malaysia
10.00-10.30 -------------- Coffee Break ---------------------
Leptospirosis in
10.30-11.00 Global Update on the environment
A. Ko
Laboratory diagnosis of
Farida/ M. Diagnostics protocols and Prof Yupin
leptospirosis (hands on
Goris
11.00-12.00 training) clinical management Suputtamongkol Discussion Moderator TBD
guidelines
12.00-13.00 ------------------Lunch-------------------------
Epidemiological
Group discussion : investigation for
13.00-13.30 risk reduction:
A. Ko
1. Identification of suspected sanitation
leptospirosis and severe case
PCR and qPCR for
leptospirosis diagnosis
C. Goarant Facilitator :
2. Antibiotic Treatment Human and
13.30-14.00 3. Management of severe case Prof. Yupin Animal J. Benshop
vaccination

Porf. Gasem
Risk reduction
Dr. Djati through animal
14.00-14.30 Mode Group presentation leptospirosis
Y. Yupiana
rator control
TBD
Session 2 Group Summary Rodent control in
14.30—15.00 Indonesia
Ristiyanto
presentation
15.00- 15.30 --------------- Coffee break-------------------
Wrap up common training session: Presentations for each break-out parallel training session
15.30-16.15 Closing
Outcomes by 15.00 pm
4-5 slides presentation
- Lesson learned
- Gaps and challenges
- Proposed work plan including technical assistance needed
 Early Diagnosis of Leptospirosis
Acute fever/ Headache/ Myalgia

With History of possible exposure to leptospires No exposure

Additional History and Physical

Examination

Source of fever identified No obvious source of Fever

(Systemic Febrile Illness)

Plus at least one of these;

Diagnosis / treatment
- conjunctival suffusion or injection
- calf pain, jaundice , or stiff neck
- aseptic meningitis

CBC, RDT Lepto urine exam No Yes

Suspected Leptospirosis
 Early Diagnosis of Leptospirosis (cont.)
CBC, RDT lepto, urine exam

-ve tests Cause of Fever At least 1 of these;

identified
- leukocytosis >12,000/cu.mm.
- thrombocytopenia<
Specific therapy 100,000/cu.mm.
- albuminuria >2+
Not leptospirosis or
- Bilirubinuria
Non-severe leptospirosis

Symptomatic treatment, Suspected severe leptospirosis

advice for FU in the next 3 days

No antimicrobial drug Doxycycline or azithromycin

(treated as non-severe leptospirosis)
 Management of suspected leptospirosis
Suspected Leptospirosis Laboratory tests

Perform Initial Clinical Assessment

Any of the following?

- Pulse > 100/ min or irregular pulses
- hypotension ( BP < 90/60 mmHg) or No
Non-severe leptospirosis
pulse pressure < 20 mm.Hg
- RR > 24 /min or dyspnea or abnormal CXR
- Jaundice or total bilirubin > 2 mg/dl 1. Symptomatic treatment
2. Specific treatment
- Decreased or no urine in the previous 8 hrs
2.1 doxycycline 100 mg. twice after
meal or
or serum creatinine> 2 mg./dl 2.2 azithromycin 500 mg/d for 3 days
- Abnormal bleeding 3. Advice for possible complication
- Alteration of consciousness or stiff neck 4. Advice for FU in 2-3 days
- Platelet count < 100,000 /cum.
- WBC > 12,000 /cum.
Yes
In patient Management or Refer
 In- Patient management of suspected leptospirosis

In-Patient management of suspected

leptospirosis

Supportive treatment and monitoring Empirical Antimicrobial drug

Choices of antimicrobial therapy
- Volume replacement if
- Penicillin G Sodium 1.5 mu.q 6 hrs
hypotension
- Ceftriaxone 1-2 gm IV OD
- Monitor vital signs, urine out put
- Cefotaxime 1 gm IV q 6 hrs
etc.
- Azithromycin 500 mg IV OD
- Switch to oral drug to complete 7 days
- Advice for FU, and convalescence
serological tests if possible

Deterioration or develop severe complication

Refer or transfer for ICU Management

 Suspected leptospirosis
History, physical examination, clinical signs
CBC, chemistry panel, urinalysis

Rapid Lepto Test or

Leptospira spp.
antibody by ELISA or
Inconclusive case
MAT
No
qPCR test No Positive No No

Repeat Leptospira spp.

Yes
Positive antibody by MAT /ELISA

No Repeat Leptospira spp.

antibody by MAT or ELISA Yes
Yes

4-4 rising Antibody titer

Confirmed case
No
Yes
Probable case
Non-Lepto case
 Gaps, Challenges and Work plan
• Ketersediaan RDT leptospirosis yang teruji – tervalidasi untuk tingkat
Puskesmas, RS tipe D, RS tipe C, RS tipe B dan RS tipe A.
• Saat ini kita sudah memiliki algoritma awal yang telah disepakati.
• Pengembangan pedoman diagnosis dan tatalaksana leptospirosis
berdasarkan algoritma awal.
• Penambahan beberapa Laboratorium referensi pemeriksaan MAT
• Membuat sistem rujukan pemeriksaan MAT .
• Menambah pusat pemeriksaan PCR leptospirosis di setiap provinsi
TERIMAKASIH