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LEPTOSPIROSIS TASK FORCE (PSN/PSMID/PCCP) 2010

Suspected leptospirosis case [Grade A] 1. acute febrile illness of at least 2 days 2. residing in a flooded area or high-risk exposure (wading in floods and contaminated water, contact with animal fluids, swimming in flood water or ingestion of contaminated water) 3. presenting with at least two of the following symptoms: myalgia, calf tenderness, conjunctival suffusion, chills, abdominal pain, headache, jaundice, or oliguria

MILD LEPTOSPIROSIS 1. stable vital signs 2. anicteric sclerae 3. good urine output 4. no evidence of meningismus / meningeal irritation, sepsis, difficulty of breathing nor jaundice 5. can take oral medications 6. can be managed on an OUT-PATIENT SETTING [Grad e A]

MODERATE TO SEVERE LEPTOSPIROSIS 1. unstable vital signs 2. jaundice/icteric sclerae 3. abdominal pain, nausea, vomiting and diarrhea 4. oliguria/anuria 5. meningismus /meningeal irritation 6. sepsis / septic shock 7. altered mental states 8. difficulty of breathing and hemoptysis 9. BEST managed in a HEALTHCARE / HOSPITAL SETTING. [Grade A]

Diagnosis ? - generally, it is not necessary to confirm the diagnosis or wait for the result of the tests before starting treatment - the clinical assessment and epidemiologic history are more important - early recognition and treatment is MORE important to prevent complications and mortality

locally available diagnostic tests A. Direct Detection Method 1. Culture and isolation - GOLD standard - 6 to 8 weeks for the result 2. Polymerase Chain Reaction (PCR) - early confirmation of the diagnosis especially during the acute leptospiremic phase (first week of illness) - not generally available because of the cost-limiting nature of the test and the need for trained personnel

B. Indirect Detection Methods 1. Microagglutination Test (MAT) - highly sensitive and specific - time-consuming - hazardous to perform because of the risk of exposure to the live antigen 2. Specific IgM Rapid Diagnostic Tests l LeptoDipstick®, Leptospira IgM ELISA (PanBio), MCAT and Dridot® - serologic tests in a single test format for the quick detection of Leptospira genus-specific IgM antibodies in human sera 3. Nonspecific Rapid Diagnostic Tests like LAATS (Leptospira Antigen-Antibody Agglutination Test ) - This is used as a screening test but is NOT sensitive - A positive result should be confirmed with MAT

laboratory findings/markers of severe leptospirosis 1.CBC – leucocytosis (WBC>12,000 cells/cumm) neutrophilia and thrombocytopenia (<100,000 cells/cu mm) 2. Serum creatinine > 3 mg/dL (or CrCl < 20 ml/min) and BUN > 23 mg/dL 3. Liver function tests - AST/ALT ratio > 4x Bilirubin > 190 umol/L 4. prolonged prothrombin time (PT) < 85%

laboratory findings/markers of severe leptospirosis 5. Serum potassium > 4 mmol/L 6. ABG- severe metabolic acidosis (ph< 7.2, HCO3 < 10) hypoxemia (PaO2 < 60 mmHg, SaO2 < 90%) 7. Chest radiograph - extensive alveolar infiltrates 8. Electrocardiogram - heart block, myocarditis

Antibiotic Treatment : 1.Doxycycline - drug ofchoice - Alternative drugs : amoxicillin and azithromycin dihydrate. [Grade B] 2. For moderate-severe leptospirosis : - penicillin G - the drug of choice - Alternative drugs : parenteral ampicillin, 3rd generation cephalosporin (cefotaxime, ceftriaxone), and parenteral azithromycin dihydrate. [Grade A]

Antibiotic therapy should be completed for 7 days, except for azithromycin dihydrate which could be given for 3 days. [Grade A]

Any one of the following is an indication for dialysis : [Grade A] a. Uremic symptoms – Nausea, vomiting, altered mental status, seizure, coma b. Serum creatinine > 3mg /dL c. Serum K > 5 meq /L in an oliguric patient d. ARDS /pulmonary hemorrhage e. pH < 7.2 f. Fluid overload g. Oliguria despite measures following the algorithm

Algorithm for the Management of Oliguria in Leptospirosis Oliguria - <0.5 ml/kg/hr or <400 ml/day or self-report of low or no urine output in 12 hrs. Mean Arterial Pressure </=65 mm Hg Start Norepinephrine and titrate to keep MAP >65 mmHg Assess Fluid Status Hypovolemic? Fast drip Normal Saline Solution, 20 ml/kg/hr and reassess after 15 minutes Continue hydration till euvolemic Adjust IVF rate to suit patient needs YES NO YES NO

Furosemide 40 mg IV bolus or Bumetamide 1 mg IV Urine Output >/= 0.5ml/kg/hr? Double dose of furosemide (or Bumetamide) hourly up to a maximum of 160 mg (or 4 mg) Urine Output >/= 0.5ml/kg/hr? Acute Renal Replacement Therapy Urine Output >/= 0.5ml/kg/hr? Monitor hourly and adjust rate of IVF to maintain euvolemia Reassess kidney status Monitor hourly and adjust rate of IVF to maintain euvolemia Reassess kidney status Monitor hourly and adjust rate of IVF to maintain euvolemia Reassess kidney status Yes No Yes No Yes

PHILIPPINE SOCIETY OF NEPHROLOGY DISASTER RESPONSE TO CRUSH INJURY / CRUSH SYNDROME

Crush injury - a direct injury caused by collapsing material and debris resulting in manifest muscle swelling and/or neurological disturbances in the affected parts of the body Crush Syndrome - patients with crush injury and systemic manifestation due to muscle cell damage which would include: acute kidney injury, sepsis, acute respiratory distress syndrome, diffuse intravascular anticoagulation, bleeding, hypovolemic shock, cardiac failure, arrhythmias, electrolyte disturbances

Specific indications for nephrology referral: Elevated serum creatinine Hyperkalemia Hypocalcemia Hyperphosphatemia Hyperuricemia Metabolic acidosis Elevated total CK of > 5,000 IU/L Presence of reddish-brown urine / urine myoglobin Decreased urine output (<0.5 ml/kg/hr x 4 hours) Fluid overload

Indications for renal replacement therapy: Serum creatinine > 8 mg/dl Serum K > 6 mEq/L Serum pH < 7.1 or serum HCO 3 < 10 Pulmonary congestion / Edema Uremia Prophylactic dialysis may be indicated in rapidly progressing hyperkalemia even if the above parameters are not met

PRE-EXTRICATION MANAGEMENT OF POTENTIAL CRUSH INJURY VICTIM VICTIM UNDER THE RUBBLE VEIN IS AVAILABLE YES GIVE 1L/HR OF ISOTONIC SOLUTION FOR THE 1 ST 2 HRS. 2,10-13 NO ATTEMPT ORAL HYDRATION FOR THOSE THAT CAN BE REACHED GIVE SALINE AT 0.5 L/HR (REASSESS EVERY 2-4 HRS) YES IS IT SAFE TO HYDRATE THE VICTIM? LIMIT HYDRATION TO 1L/DAY NO CONTINUE MANAGEMENT UNTIL EXTRICATION WITH CONTINUOUS CLOSE MONITORING OF FLUID STATUS ONCE EXTRICATED PLEASE PROCEED TO POST-EXTRICATION ALGORITHM

POST –EXTRICATION MANAGEMENT OF POTENTIAL CRUSH INJURY VICTIM (PRE-HOSPITAL PHASE) EXTRICATED VICTIM PRIMARY SURVEY PRESENCE OF OTHER MEDICAL CONDITION DOES THE VICTIM NEED TO BE HYDRATED? VICTIM MAY BE DISCHARGED WITH PROPER ADVICE MULTIDISCIPLINARY REFERRAL (PLEASE REFER TO SPECIFIC INDICATIONS FOR NEPHROLOGY REFERRAL) INDICATIONS FOR NEPHROLOGY REFERRAL (Please see nephrology notes) 1.Hyperkalemia on ECG 2.Presence of reddish-brown urine 3.Decreased urine output (<0.5 ml/kg/hr x 4 hours) 4.Fluid overload GIVE 1L/HR OF ISOTONIC SOLUTION FOR 2HRS REASSESS AFTER 2HRS IS IT SAFE TO MAINTAIN HYDRATION? GIVE SALINE AT 0.5L/HR REASSESS EVERY 2-4 HRS LIMIT HYDRATION TO 1L/DAY MAY DO SECONDARY SURVEY AS NEEDED ADMIT TO HOSPITAL YES NO YES NO YES NO

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