The management of leptospirosis

Efficacy and safety of antibiotics for treatment of leptospirosis: a systematic review and network meta-analysis

BACKGROUND

Leptospirosis, an important zoonotic bacterial disease, commonly affects resource-poor populations and results in significant morbidity and mortality worldwide. The value of antibiotics in leptospirosis remains unclear, as evidenced by the conflicting opinions published.

METHODS

We conducted a search in the PubMed, Web of Science, and Cochrane Library databases for studies. These studies included clinical trials and retrospective studies that evaluated the efficacy or safety of antibiotics for leptospirosis treatment. The primary outcomes assessed were defervescence time, mortality rate, and hospital stays. Subgroup analyses were performed based on whether there were cases involving children and whether there were cases of severe jaundice. Safety was defined as the prevalence of adverse events associated with the use of antibiotics. p scores were utilized to rank the efficacy of the antibiotics.

RESULTS

There are included 9 randomized controlled trials (RCTs), 1 control trial (CT), and 3 retrospective studies (RS) involving 920 patients and 8 antibiotics. Six antibiotics resulted in significantly shorter defervescence times compared to the control, namely cefotaxime (MD, - 1.88; 95% CI =  - 2.60 to - 1.15), azithromycin (MD, - 1.74; 95% CI =  - 2.52 to - 0.95), doxycycline (MD, - 1.53; 95% CI =  - 2.05 to - 1.00), ceftriaxone (MD, - 1.22; 95% CI =  - 1.89 to - 0.55), penicillin (MD, - 1.22; 95% CI =  - 1.80 to - 0.64), and penicillin or ampicillin (MD, - 0.08; 95% CI =  - 1.01 to - 0.59). The antibiotics were not effective in reducing the mortality and hospital stays. Common adverse reactions to antibiotics included Jarisch-Herxheimer reaction, rash, headache, and digestive reactions (nausea, vomiting, diarrhea, abdominal pain, and others).

CONCLUSIONS

Findings recommend that leptospirosis patients be treated with antibiotics, which significantly reduced the leptospirosis defervescence time. Cephalosporins, doxycycline, and penicillin are suggested, and azithromycin may be a suitable alternative for drug-resistant cases.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022354938.

Hepatic Manifestations of Systemic Diseases

In addition to being the primary target of infections such as viral hepatitis, the liver may also be affected by systemic disease. These include bacterial, mycotic, and viral infections, as well as autoimmune and infiltrative diseases. These conditions generally manifest as abnormal liver biochemistries, often with a cholestatic profile, and may present with additional signs/symptoms such as jaundice and fever. A high index of suspicion and familiarity with potential causal entities is necessary to guide appropriate testing, diagnosis, and treatment.

Next Generation Sequencing for Diagnosis of Leptospirosis Combined With Multiple Organ Failure: A Case Report and Literature Review

Introduction

Leptospirosis poses a major threat to human life. The disease spectrum ranges from a nearly undetectable presentation to severe multi-organ dysfunction and death. Leptospirosis is difficult to diagnose by traditional antibody and culture tests. We here present a case of multiple organ failure associated with leptospirosis.

Material and Methods

A 64-year-old woman presented with fatigue and arthralgia, which developed rapidly into multiple organ injuries, and she eventually died of cerebral hemorrhage. Serum antibody test and cultures of blood, sputum, urine, and feces samples were all negative. The patient was diagnosed with leptospirosis by the next-generation sequencing (NGS).

Conclusion

We conclude that leptospirosis is a neglected zoonosis caused by pathogenic Leptospira species. New techniques such as NGS are highlighted for early diagnosis. Surveillance for pathogens during diagnosis can provide guidance for clinical treatment and improves prognosis.

Are Pathogenic Leptospira a Possible Cause of Aseptic Meningitis in Suspected Children in Sudan?

INTRODUCTION

Clinical presentations of leptospirosis are diverse, with meningitis easily confused with other microbial causes. We aimed to investigate the involvement of pathogenic leptospira in the cerebrospinal fluid (CSF) of meningitis-suspected children in Sudan.

METHODS

A total of 153 CSF specimens were collected over 5 months from patients attending a reference pediatric hospital in Omdurman, Sudan. All patients had provisionally been diagnosed with meningitis on admission. Demographic, clinical, and conventional laboratory findings were obtained. DNA was extracted using a QIAamp mini kit, and the secY gene investigated using real-time PCR.

RESULTS

Nine of 153 (6%) CSF specimens were positive for pathogenic leptospiral DNA. All these patients were male (seven infants and two toddlers aged ˂4 years). Typical conventional laboratory findings for aseptic meningitis (ie, CSF turbidity/pleocytosis, normal or reduced CSF glucose, normal or elevated proteins) were seen in five (56%). All patients presented with fever and seizures, 56% vomiting and stiff neck, and 29% bulging fontanel. Most (67%) patients presented in summer (March to May). Polymicrobial infections were identified in three patients (33%).

CONCLUSION

We conclude that pathogenic leptospira are probably a common cause of meningitis in children in Sudan; therefore, we recommend including leptospirosis in the differential diagnosis of CNS infections and other undifferentiated febrile illnesses in this country.

Clinical characteristics, outcomes, and predictors of leptospirosis in patients admitted to the medical intensive care unit: A retrospective analysis

BACKGROUND

Early diagnosis and detection of clinical deterioration of leptospirosis are challenges to all clinicians. This study aimed to report the characteristics and outcomes of patients admitted to the medical intensive care unit (MICU) for severe leptospirosis and to identify the clinical predictors of MICU admission.

METHODS

This was a 10-year retrospective study that included all patients diagnosed as leptospirosis, based on either serology or a Thai-Lepto score (TLS) of >4. All clinical characteristics and laboratory data were collected and compared between MICU cases and general ward cases. Binary logistic regression was applied to identify the independent factors for MICU admission.

RESULTS

Of the 68 patients who were diagnosed as leptospirosis based on inclusion criteria, 43 serologically-confirmed cases were subsequently analyzed. Fifty percent of the cases were admitted to the MICU and, compared with those admitted to the general ward, had higher Sequential Organ Failure Assessment (SOFA) score [10 (7-13) vs. 5 (2.2-5.6), p < 0.001]; higher TLS [7.5 (6.5-9.25) vs. 5.5 (3.5-6.5), p < 0.001]; lower mean arterial blood pressure (74.7 ± 15 mmHg vs. 84.2 ± 16.3 mmHg, p = 0.04); lower platelet count in ×10³ cell/mm³ [65 (52.8-105.8) vs. 159 (87.3-181.5), p = 0.008); higher total bilirubin level [4.4 (1.5-8.7) mg/dL vs. 1.2 (0.7-2.8) mg/dL, p = 0.01]; and required more inotropes and vasopressors (87% vs. 4.3%, p < 0.001), mechanical ventilator support (91.3% vs. 4.3%, p < 0.001), and renal replacement therapy (39.1% vs. 0%, p < 0.001). TLS, SOFA score, requirement for mechanical ventilation, and use of inotropes and vasopressors were the predictors of MICU admission. TLS > 6 and SOFA score >6 gave similar power to predict MICU admission.

CONCLUSION

Among patients with leptospirosis, TLS, SOFA score, inotrope or vasopressor requirement, and mechanical ventilator support were the independent predictors of MICU admission. TLS > 6 and SOFA score >6 indicated the need for MICU admission.

Leptospirosis: Report from the task force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine

Leptospirosis is a zoonosis caused by a gram negative aerobic spirochete of the genus Leptospira. It is acquired by contact with urine or reproductive fluids from infected animals, or by inoculation from contaminated water or soil. The disease has a global distribution, mainly in tropical and subtropical regions that have a humid, rainy climate and is also common in travelers returning from these regions. Clinical suspicion is critical for the diagnosis and it should be included in the differential diagnosis of any patient with a febrile hepatorenal syndrome in, or returning from endemic regions. The leptospiremic phase occurs early and thereafter there is an immunologic phase in which the most severe form, Weil's disease, occurs. In the latter, multiple organ dysfunction predominates. The appropriate diagnostic test depends on the stage of the disease and consists of direct and indirect detection methods and cultures. Severely ill patients need to be monitored in an ICU with appropriate anti-bacterial agents and early, aggressive and effective organ support. Antibiotic therapy consists of penicillins, macrolides or third generation cephalosporins.

The Use of Chemoprophylaxis after Floods to Reduce the Occurrence and Impact of Leptospirosis Outbreaks

Record-breaking and devastating rainfall events have occurred in the past decade. Rain and floods are considered the main risk factors for leptospirosis and several outbreaks have been reported following extreme weather events. In such situations, one possible intervention to prevent leptospirosis cases in high-risk groups is the use of chemoprophylaxis. However, not enough evidence of its effect is available. The objectives of this study were to review the literature on the current practices of chemoprophylaxis for leptospirosis and to explore, using a mathematical model, how various chemoprophylaxis scenarios may affect the progression of a leptospirosis outbreak. Twenty-six peer-reviewed publications were selected (10 quantitative studies, two systematic reviews and 14 articles of other types). Oral doxycycline was the most used antibiotic for chemoprophylaxis of leptospirosis. Post-exposure prophylaxis was assessed in four studies following a natural disaster. Although evidence of the effectiveness of post-exposure prophylaxis is inconsistent, the direction of association supported a protective effect for morbidity and mortality. The theoretical model showed how the assumed benefit of chemoprophylaxis was influenced by the time and rate of administration. Future models should consider the heterogeneity of affected communities, improved estimates of the effect of chemoprophylaxis on leptospirosis infection and disease, as well as potential detrimental impacts. Additional research is critical to provide clear evidence-based recommendations for leptospirosis control during an outbreak. The results of this study suggest that chemoprophylaxis may provide some protection in reducing the number of leptospirosis cases after a high-risk exposure; however, the effective benefit may depend on a variety of factors such as the timing and coverage of prophylaxis. The information summarized can be used to support decision-making during a high-risk event.

Atypical leptospirosis: an overlooked cause of aseptic meningitis

BACKGROUND

Leptospirosis, probably the most common zoonosis in the world, is caused by pathogenic Leptospira species. Clinical presentations range from nonspecific fevers to fulminant diseases such as Weil's syndrome. Neurological forms of leptospirosis (neuroleptospirosis) are usually underestimated, and many cases of leptospirosis are overlooked because of the lack of specificity of signs and symptoms. Diagnosis confirmation is difficult because of the challenges associated with isolating the organism and positive serologic testing. A comprehensive understanding of the clinical presentation of leptospirosis and risk factors for exposure to leptospirae are required for early diagnosis, in order to initiate appropriate treatment immediately.

CASE PRESENTATION

Here we present one male patient with anicteric leptospirosis that manifested as neuroleptospirosis with aseptic meningitis, although he did not have impaired kidney function or thrombocytopenia. He recovered well after an early investigation and treatment for leptospirosis based on suspected relevant risk factors and clinical manifestations.

CONCLUSION

To facilitate optimal use of antibiotic treatments and prevent lethal complications of leptospirosis, we report this case of leptospirosis, which highlights the importance of knowing the occupational history and environmental exposures of patients living in leptospirosis-endemic areas and presenting meningeal signs.

Corticosteroid in the treatment of moderate to severe thrombocytopenia due to leptospirosis

Background:

Thrombocytopenia is associated with a bad prognosis in Leptospirosis.

Objectives:

We investigated the effect of corticosteroids to improve thrombocytopenia due to leptospirosis.

Patients and Methods:

In a clinical trial, all patients admitted with leptospirosis in Razi Hospital of Ghaemshahr, north of Iran were enrolled in a 2-year study. Totally, 56 patients with moderate to severe thrombocytopenia were randomized to control and treatment groups. The treatment group received corticosteroid (prednisolone 1 mg/kg/day for maximum one week) in addition to the standard antibiotic therapy.

Results:

There was no significant difference regarding age and gender between the two groups (P = 0.254, P = 0.789, respectively). The mean duration to improve thrombocytopenia was 4.41 ± 0.197 days in the treatment group and 5.72 ± 0.318 days in the control group, which was significantly different (P = 0.003). Duration of hospitalization in the treatment group was 5.24 ± 0.244 days and 6.23 ± 0.329 days in the control group, which was significantly different (P = 0.028). The two groups had no significant difference regarding mortality, intubation, level of platelet, duration of ICU admission and pulmonary, renal or hepatic involvement.

Conclusions:

Corticosteroid therapy decreased the length of hospitalization only in severe subgroup thrombocytopenia, but not in the moderate subgroup.

Continuous progression of tubercular serpiginous-like choroiditis after initiating antituberculosis treatment

PURPOSE

To describe the frequency, risk factors, management, and outcome of eyes with tubercular serpiginous-like choroiditis showing continued progression following initiation of antituberculosis treatment.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

SETTING

Institutional.

PATIENT POPULATION

One hundred ten patients of serpiginous-like choroiditis with 1) complete records, 2) tuberculin skin test, 3) active lesions in at least 1 eye, and 4) minimum 18 months follow-up.

INTERVENTION

Based on the positivity of tuberculin skin test, the patients were categorized in Group A (84 patients with positive tuberculin test) and Group B (26 patients with negative tuberculin test). Of the 84 patients in Group A, 19 received systemic corticosteroids while 65 also received 4-drug antituberculosis treatment in addition. All patients in Group B received corticosteroids. Patients with continued progression received an increased dose of corticosteroids with or without immunosuppressive agents.

MAIN OUTCOME MEASURE

Development of continued progression.

RESULTS

There were 61 men and 23 women in Group A and 19 men and 7 women in Group B. Continued progression was observed in 12 patients (14.28%) in Group A and none in Group B (P = .04). Of the 12 patients in Group A showing progression, 11 (16.9%) were receiving antituberculosis treatment and corticosteroids. The lesions responded in all eyes, and final visual acuity of 20/40 or better could be achieved in 10 eyes (75%).

CONCLUSION

Continued progression of choroiditis lesions occurs in 14% of patients after initiating antituberculosis treatment in tubercular serpiginous-like choroiditis. Increased immunosuppression with continuation of antituberculosis treatment resulted in good outcome.

Aseptic meningitis caused by Leptospira spp diagnosed by polymerase chain reaction

Leptospirosis is a zoonotic disease caused by the pathogenic Leptospira spp. The clinical presentations are diverse, ranging from undifferentiated fever to fulminant disease including meningeal forms. The neurological leptospirosis forms are usually neglected. The aim of this study was to investigate leptospirosis as the cause of aseptic meningitis using different diagnostic techniques including the polymerase chain reaction (PCR). Thirty-nine cerebrospinal fluid (CSF) samples from patients presenting with meningeal abnormalities, predominance of lymphocytes and negative results by traditional microbiological tests were processed by leptospiral culture, anti-leptospiral antibody response and PCR. Leptospira spp DNA was detected in 23 (58.97%) of the CSF samples. Anti-leptospiral antibodies were found in 13 (33.33%) CSF samples. Twelve CSF samples were positive by PCR assay and negative by microscopic agglutination test (MAT) assay. Two CSF samples were positive by MAT and negative by PCR. The positive and negative agreement between both tests was 11 and 14, respectively. CSF samples from six cases of unknown diagnosis were positive by PCR assay. Eight cases showed positive results using PCR and MAT. Leptospirosis could be detected by PCR assay from the 3rd-26th day after illness onset. The sensitivity of the PCR was assessed with confirmed cases of leptospirosis (by MAT) and found to be 89.5%. All CSFs were negative by culture. PCR was found to be a powerful tool for diagnosing meningitis cases of leptospirosis. We recommend that it may be used as a supplementary diagnostic tool, especially in the early stages of the disease, when other diagnostic techniques such as serology are not sensitive.

The intersection between HIV and syphilis in men who have sex with men: some fresh perspectives

Syphilis is increasing in men who have sex with men and disproportionately affects HIV-infected men. Here we review the epidemiology, diagnostic techniques, treatment guidelines, follow-up procedures and control of syphilis. The difference in these factors in HIV-infected men and uninfected men and evidence for this is reviewed. We explain that HIV-infected men are at higher risk of syphilis acquisition as a result of different behavioral factors. Thus, some control strategies may be different for HIV-infected men owing to these factors and also because HIV-infected men are more closely linked with medical care. There is no strong evidence to suggest there should be any differences in diagnostic techniques, treatment guidelines or follow-up procedures between HIV-infected and uninfected men.

Fever of unknown origin in the returning traveler

The returning traveler with fever presents a diagnostic challenge for the health care provider. When evaluating such a patient, the highest priority should be given to diseases that are potentially fatal or may represent public health threats. A good history is paramount and needs to include destination, time and duration of travel, type of activity, onset of fever in relation to travel, associated comorbidities, and any associated symptoms. Pretravel immunizations and chemoprophylaxis may alter the natural course of disease and should be inquired about specifically. The fever pattern, presence of a rash or eschar, organomegaly, or neurologic findings are helpful physical findings. Laboratory abnormalities are nonspecific but when corroborated with clinical and epidemiologic data may offer a clue to diagnosis.

Human leptospirosis in eastern Croatia, 1969-2003: epidemiological, clinical, and serological features

This survey presents epidemiological, serological and clinical features of 270 patients (85% males, 18% children) treated for leptospirosis from 1969 to 2003 at the Clinic for Infective Diseases, University Hospital Osijek, Osijek, eastern Croatia. 75% of the admissions were between July and October. The route of transmission was mostly by indirect contact with domestic animals, less frequently by direct contact with urine or tissue of infected animals. Clinical presentation included signs and symptoms with expected and common frequency, with the exception of jaundice (62%) and aseptic meningitis (60%), which occurred with higher incidence than previously reported. Acute renal failure ensued in 53% of patients, 7% of whom required haemodialysis. No deaths were observed. Therapy consisted of antimicrobials (penicillin and doxycycline) and symptomatic measures. Diagnosis was confirmed by microscopic agglutination test (MAT). There were in total 18 serological types of Leptospira detected, and types L. sejroe, L.pomona, L. australis and L. icterohaemorrhagiae prevailed. During the last 10 y some new types were observed. Leptospirosis was not rare in the region of eastern Croatia, and its course could be life-threatening if not recognized and adequately treated.