Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mild disease

1st line – oral antibiotic therapy + supportive therapy

Back
ACUTE
|
mild disease
1st line – 

oral antibiotic therapy + supportive therapy

Effective management of leptospirosis involves a combination of antibiotic therapy and appropriate supportive therapy for patients with organ damage.

It is generally accepted that antibiotic therapy must be initiated as soon as possible, preferably during the first 5 days of the appearance of symptoms. The recommended oral antibiotic for adults and children with mild leptospirosis is doxycycline (not recommended in children 8 years of age or less), with ampicillin, azithromycin, or amoxicillin as alternative first-line agents.[50]

Patients must be carefully monitored for adverse reactions including the Jarisch-Herxheimer reaction, which can be fatal.[76]

The type and degree of supportive measures required in patients with leptospirosis are highly variable and assessed individually according to the organ involvement. Patients must be monitored for changes consistent with volume depletion and hemorrhage. Physicians should correct coagulopathy and electrolyte disturbances and ensure adequate hydration.

Antibiotic treatment course: 7 days (except azithromycin, for which treatment course is 3 days in adults and not established in children).

Primary options

doxycycline: children >8 years of age: 2-4 mg/kg/day orally given in divided doses every 12 hours, maximum 200 mg/day; adults: 100 mg orally every 12 hours

OR

azithromycin: children: 10 mg/kg (maximum 500 mg) orally once daily on day 1, followed by 5 mg/kg (maximum 250 mg) once daily; adults: 1000 mg orally once daily on day 1, followed by 500 mg once daily for 2 days

OR

ampicillin: children: 100-200 mg/kg/day orally given in divided doses every 6 hours, maximum 3000 mg/day; adults: 500-750 mg orally every 6 hours

OR

amoxicillin: children: 20-50 mg/kg/day orally given in divided doses every 8-12 hours; adults: 500 mg orally every 8-12 hours

moderate to severe disease

1st line – intravenous antibiotic therapy + supportive therapy

Back
ACUTE
|
moderate to severe disease
1st line – 

intravenous antibiotic therapy + supportive therapy

Effective management of leptospirosis involves a combination of antibiotic therapy and appropriate supportive therapy for patients with organ damage.

It is generally accepted that antibiotic therapy must be initiated as soon as possible, preferably during the first 5 days of the appearance of symptoms. Penicillin-G is recommended in adults and children first-line, with ceftriaxone or cefotaxime as alternative first-line agents.[50][74][75][78][79]​ Adults with penicillin and/or cephalosporin allergy should be treated with azithromycin (the intravenous formulation is not recommended below the age of 16 years) or doxycycline. Children with such an allergy should be treated with doxycycline.[75] Doxycycline and other tetracycline antibiotics may cause permanent tooth discoloration or enamel hypoplasia and are not recommended in children 8 years of age or less. However, their use in this patient group may be considered on a case-by-case basis in severe leptospirosis, where the clinician should evaluate the benefits and risks of such treatment. Erythromycin is a possible alternative and can be given to children below the age of 8 years.

Patients must be carefully monitored for adverse reactions including the Jarisch-Herxheimer reaction, which can be fatal.[76]

The type and degree of supportive measures required in patients with leptospirosis is highly variable and is assessed individually according to the organ involvement. Patients must be monitored for changes consistent with volume depletion and hemorrhage. Physicians should correct coagulopathy and electrolyte disturbances and ensure adequate hydration.

Antibiotic treatment course: 7 days.

Primary options

penicillin G sodium: children: 100,000 units/kg/day intravenously given in divided doses every 6 hours; adults: 1.5 million units intravenously every 6 hours

OR

ceftriaxone: children: 80-100 mg/kg/day intravenously given in divided doses every 12-24 hours, maximum 4000 mg/day; adults: 1-2 g intravenously every 12-24 hours

OR

cefotaxime: children >1 month of age: 150-200 mg/kg/day intravenously given in divided doses every 6-8 hours; adults: 1 g intravenously every 6 hours

Secondary options

doxycycline: children >8 years of age: 2-4 mg/kg/day intravenously given in divided doses every 12 hours, maximum 200 mg/day; adults: 100 mg intravenously every 12 hours

OR

azithromycin: children ≥16 years of age and adults: 500 mg intravenously on day 1, followed by 250 mg every 24 hours

OR

erythromycin lactobionate: children: 15-50 mg/kg/day intravenously given in divided doses every 6 hours, maximum 4000 mg/day; adults: 500-1000 mg intravenously every 6 hours

Plus – cardiac monitoring and arrhythmia management

Back
ACUTE
|
moderate to severe disease
|
with cardiac involvement
Plus – 

cardiac monitoring and arrhythmia management

Treatment recommended for ALL patients in selected patient group

Cardiac monitoring is recommended to timely identify arrhythmias secondary to cardiac irritability.

Cardiac arrhythmias should be managed according to recognized guidelines such as those from the American College of Cardiology (ACC), American Heart Association (AHA), and European Society of Cardiology (ESC).

Death may occur secondary to cardiac arrhythmias or cardiac failure.

Consider – mechanical ventilation ± intravenous methylprednisolone

Back
ACUTE
|
moderate to severe disease
|
with pulmonary involvement with or without hemorrhage
Consider – 

mechanical ventilation ± intravenous methylprednisolone

Treatment recommended for SOME patients in selected patient group

Severe disease is associated with the immune phase and may manifest with renal or hepatic failure, and/or pulmonary hemorrhages. These manifestations are treated with standard supportive therapy according to the presentation.

Patients with pulmonary involvement, with or without hemorrhage, may require mechanical ventilation.

Intravenous methylprednisolone has been used successfully in patients with pulmonary leptospirosis, but one systematic review found limited evidence; further trials are needed to determine whether corticosteroids should routinely be given to patients with severe leptospirosis and pulmonary involvement.[80][81]

Primary options

methylprednisolone: consult specialist for guidance on dose

Consider – acute dialysis

Back
ACUTE
|
moderate to severe disease
|
with renal involvement
Consider – 

acute dialysis

Treatment recommended for SOME patients in selected patient group

Severe disease is associated with the immune phase and may manifest with renal failure, hepatic failure, and/or pulmonary hemorrhages (Weil syndrome). These manifestations are treated with standard supportive therapy according to the presentation.

Patients with acute renal failure may require acute dialysis in severe disease, taking into consideration the symptoms of fluid overload, acidosis, and hyperkalemia. The decision must be made on a case-by-case basis.

Consider – liver dysfunction monitoring and supportive care

Back
ACUTE
|
moderate to severe disease
|
with hepatic failure
Consider – 

liver dysfunction monitoring and supportive care

Treatment recommended for SOME patients in selected patient group

Severe disease is associated with the immune phase and may manifest with renal failure, hepatic failure, and/or pulmonary hemorrhages (Weil syndrome). These manifestations are treated with standard supportive therapy according to the presentation.

Patients with hepatic failure usually only require intravenous antibiotic therapy and supportive care.

Hepatic failure that manifests in leptospirosis is reversible and is generally not a cause of death.

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer