Leptospirosis CPG 2019

DOH
GUIDELINES for
LEPTOSPIROSIS
for HOSPITALS
2019 Edition
DOH GUIDELINES for
LEPTOSPIROSIS for HOSPITALS
2019 Edition
DOH Guidelines for Leptospirosis for Hospitals
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FOREWORD
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TECHNICAL WORKING GROUP
Research Institute for Tropical Medicine

Celia C. Carlos, MD
Arthur Dessi E. Roman, MD
National Kidney and Transplant Institute

Romina A. Danguilan, MD
Mel-Hatra I. Arakama, MD
CONTRIBUTORS
Amang Rodriguez Memorial Medical Center Imelda M. Mateo, MD
Dr.Jose Fabella Memorial Hospital Esmeraldo T. Ilem, MD
East Avenue Medical Center Alfonso G. Nuñez III, MD
Jose R. Reyes Memorial Medical Center Emmanuel F. Montaña Jr., MD
National Center for Mental Health Alan Baquir, MD
National Children’s Hospital Epifania S. Simbul, MD
National Kidney and Transplant Institute Rose Marie R. Liquete, MD
Joselito R. Chavez, MD
Philippine Orthopedic Center Jose Brittanio S. Pujalte Jr., MD
Quirino Memorial Medical Center Evelyn Victoria E. Reside, MD
Rizal Medical Center Relito M. Saquilayan, MD
San Lazaro Hospital Edmundo B. Lopez, MD
Benjamin D. Estrella Jr., MD
Rontgene M. Solante, MD
Tondo Medical Center Maria Isabelita M. Estrella, MD
Dr. Jose N. Rodriguez Memorial Hospital Alfonso Victorino H. Famaran, MD
Las Piñas General Hospital and Rodrigo H. Hao, MD
Satellite Trauma Center
San Lorenzo Ruiz Women’s Hospital Marilou T. Nery, MD
Valenzuela Medical Center Maria Estrella B. Litam, MD
DOH-TRC Bicutan Alfonso A. Villaroman, MD
DOH-NCR Corazon I. Flores, MD
Ma. Paz P. Corrales, MD
DOH-FICT NCR Emmanuel A. Tiongson, MD
Ruben C. Flores, MD
Francisco A. Valdez, MD
A Project of FICT Team NCR in cooperation with NKTI under the supervision of
Asec. Elmer G. Punzalan.
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TABLE OF CONTENTS
Chapter 1: MANAGEMENT PROTOCOL FOR LEPTOSPIROSIS
I. Introduction 1
II. Criteria for Diagnosis 5
III. Indications for Admission and Guidelines on

Site-of-Care Decisions 5
IV. Laboratory Work Up

Leptospiral Tests 7
Non-Leptospiral Tests 8
V. General Guidelines in the Management of Leptospirosis 9
VI. Antibiotic Management 9
VII. Steroid Therapy 11
VIII. Pulmonary Complications of Leptospirosis

Diagnosis of Pulmonary Complications of Leptospirosis 11
Management of Pulmonary Complications of Leptospirosis 12
Extracorporeal Membrane Oxygenation in leptospirosis 15
IX. Renal Complications of Leptospirosis 15
X. Prevention and Control 18
XI. Chemoprophylaxis
Pre-exposure Prophylaxis 18
Post-exposure Prophylaxis 19
XII. References 20
Appendices
Appendix A. Modified Faine’s Criteria (2012) 21
Appendix B. Guidelines in Specimen Collection, Storage,
Transport and Submission 22
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Chapter 2: UPSURGE POLICIES AND PROCEDURES
I. Statement of Purpose and Scope

Purpose 25
Scope 25
II. Key Policies

Criteria for Activation of Leptospirosis Emergency Policy 25
Person Responsible for Activation of the Leptospirosis Upsurge Policy 26
During Office Hours 26
After Office Hours 27
Activation of the Leptospirosis Upsurge Management Team 27
Critical Bed Status Procedure 28
Standards for Admission of Leptospirosis Patients 28
III. Roles and Responsibilities of the Various Departments/ Divisions/Sections

in the Management of a Leptospirosis Upsurge
Emergency Room 29
Division of Internal Medicine 30
Divisions of Adult and Pediatric Nephrology 31
HEMB Team 32
Division of Organ Transplantation and Vascular Surgery 32
Department of Pathology and Laboratory Medicine 32
Section of Pulmonary Medicine 32
Department of Medical Imaging and Therapeutic Radiology 32
Nursing Services 33
Hemodialysis Unit 33
Peritoneal Dialysis Unit 34
Infection Prevention and Control Committee 35
Medical Social Services Division 35
Pharmacy Division 35
Housekeeping Section 36
Procurement and Supply Management Divisions 36
Central Supply and Sterilization Unit 37
Billing and Claims Division 37
Admitting and Discharge Section 37
Information Resource Management Division 38
Nutrition and Dietetics Division 38
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IV. Setting up a Leptospirosis Ward 39
V. Staffing Requirements in the Leptospirosis Ward

Medical Staffing 40
Nurses Staffing 41
VI. Health Care Provider Network 42
VII. Antibiotic Prophylaxis for Leptospirosis

For Adults 43
For Pregnant Women 43
For Children 43
Appendices
Appendix A. Treatment Algorithm for Leptospirosis 45
Appendix B. Leptospirosis Prophylaxis Survey 47
Appendix C. Treatment Algorithm for Leptospirosis (Pediatric Patients) 48
Appendix D. Leptospirosis Census Format for Reporting 51
Appendix E. Criteria for Assisted Ventilation for Leptospirosis Patients 52
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Chapter 1: MANAGEMENT PROTOCOL FOR LEPTOSPIROSIS
I. INTRODUCTION
Leptospirosis is a zoonotic infection caused by pathogenic spirochetes of the

genus Leptospira. Ten (10) out of the 22 identified species under this genus are
considered pathogenic, while the remaining 7 and 5 are non-pathogenic, free-living
saprophytes (e.g. Leptospira biflexa) or of unclear pathogenicity, respectively.1 An
older system has been used to classify them into serovars (based on serology) so
isolates are currently identified using two systems, e.g. Leptospira
icterohemorrhagiae serovar manilae. Over 250 serotypes of pathogenic leptospires
have been recognized and the severe form of leptospirosis have been reported to
be caused by all of these.2 Leptospira icterohaemorrhagiae, by far, has been
commonly associated with severe disease. In the Philippines, earlier studies
reported that the major serovars affecting humans in Metro Manila and neighboring
provinces were Manilae, Losbanos, Tarassovi, and Poi.3
In Philippines, leptospirosis tends to occur frequently in urban flood-prone

areas such as Metro Manila. This disease gained much attention after an outbreak
following typhoon Ondoy in October of 2009. About two weeks following this heavy
rainfall typhoon that left many areas of Metro Manila flooded, the Department of
Health reported 2,894 probable and confirmed cases of leptospirosis with 210
deaths.4
From January 1, 2018 to December 31, 2018, a total of 5,232 cases were
reported to the Department of Health with a case fatality rate of 9.65%. This is a
71% increase in the total number of cases compared to 2017.5 In fact, in July of
2018, the Department of Health has declared an outbreak of leptospirosis in certain
areas of Metro Manila. Outbreaks of leptospirosis in the Philippines are expected to
occur with increasing incidents of heavy rainfall, rapid urbanization (dramatic
increase in populations), deforestation, increasing number of flood-prone areas,
poor infrastructures, among many other factors.
Leptospirosis is primarily a disease of domesticated and wild animals. Humans

are infected through direct and indirect contact with these animals. The source of
infection is water or soil contaminated with infected urine, infected urine or tissues
from infected animals. The leptospires enter through cuts and abrasions in the skin
or mucosal surfaces, the conjunctiva, or by inhalation (into the lungs) of droplets or
aerosols of fluid containing leptospires. After penetrating intact mucous membranes
or abraded skin, leptospires enter the blood stream and are rapidly carried to all
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parts of the body (including the cerebrospinal fluid [CSF] and the eyes) presenting
as an acute, systemic disease is characterized by extensive vasculitis.
The incubation generally is 5-14 days but a range of 2 to 30 days has been
noted. The incubation period does not vary significantly among serotypes. It may
present as influenza-like illness with headache and myalgia in its mild form and may
present with jaundice, renal dysfunction and hemorrhage (Weil’s Syndrome) when it
presents as severe form.
Leptospirosis presents in two (2) forms: anicteric (mild) or icteric (severe)

leptospirosis. Anicteric (mild) leptospirosis is often characterized by abrupt onset
of fever, headache, severe muscle aches, malaise and prostration. High intermittent
fever, chills, persistent headache, severe myalgias, abdominal pain and nausea and
vomiting persist for 4-7 days. Death almost NEVER occurs during this stage. In
anicteric infections, the second stage may not occur. On the other hand, icteric
(severe) leptospirosis or Weil Syndrome may present with impaired renal and
hepatic function, hemorrhage, vascular collapse, and even severe alterations in
consciousness. This form has a high mortality rate.
The clinical course of leptospirosis varies but it is generally predictable. Both

forms of leptospirosis follow a biphasic course:
1. The LEPTOSPIREMIC PHASE (or ACUTE stage) is characterized by an
acute systemic infection. The onset of symptoms is abrupt and resolves
after 4-7 days. Symptomatic improvement and lysis of the fever coincide
with the disappearance of leptospires from the blood, cerebrospinal fluid
and all other tissue with the EXCEPTION of the aqueous humor (resolves
in 4-30 days) and renal parenchyma (persists for 1-4 weeks in the urine).
Antibody titers to leptospires develop rapidly. This immune response
heralds the second or immune stage of the illness.
2. The IMMUNE PHASE (sometimes LEPTOSPIRURIC PHASE,

CONVALESCENT STAGE) is the second stage and lasts 4-30 days.
Occasionally, there is a brief asymptomatic period of 2-3 days between the
two stages. Leptospiruria continues for 1 week to 1 month. Generally, this
phase is not affected by antibiotic therapy. This phase is characterized by
the presence of circulating antibody and development of meningitis, uveitis,
rash, and (in severe cases) hepatic and renal involvement. In icteric cases,
leptospires can sometimes be isolated from the blood for 24-48 hours after
the appearance of jaundice.1
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In the Philippines, majority of the symptoms of Leptospirosis is non-specific,

which indicates that the initial impression could be viral rather than bacterial. Table 1
lists down the percentage frequencies of signs and symptoms of leptospirosis seen
in our local setting. A comparison of two studies from the Philippine 2009 outbreak
reported that the most common clinical features include fever, myalgia, conjunctival
suffusion, malaise, headache, abdominal pain, oliguria, and jaundice.
Table 1. Clinical Features of Leptospirosis after a flood, National Capital Region, 2009
Sign or Symptom 9 Manila Hospitals, 20096 San Lazaro Hospital, 20097
Number of patients 259 confirmed leptospirosis cases 471 cases
Fever 98.5 100*
Myalgia/calf-tenderness 78.1 76.7
Malaise 74.9 44.2
Headache 55.6 52.2
Chills 44.8 NR
Conjunctival suffusion 59.3 78.1
Hypotension 23.6 NR
Abdominal pain 52.7 61.2
Nausea/vomiting 52.0 57.8
Diarrhea 39.0 40.8
Jaundice 38.0 47.8
GI bleeding 16.1 NR
Oliguria 56.6 60.7
Hematuria 22.3 33.1
Cough 30.5 17.6
Dyspnea 21.6 NR
Crackles/rales 23.3 NR
Hemoptysis 14.9 3.2
Hemorrhagic signs 14.6 0.4
*part of inclusion criteria; NR – no report
These clinical findings are consistent with prior local studies done in Metro
Manila since the 1970s (Table 2).
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Table 2. Clinical features of seasonal leptospirosis admitted at various hospitals in Metro Manila compared with the 2009 outbreak 8
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II. CRITERIA FOR DIAGNOSIS
Leptospirosis should be suspected in an individual with:

 An acute febrile illness of at least 2 days AND
 Two or more of the following symptoms: myalgia, calf tenderness,
conjunctival suffusion, chills, abdominal pain, headache, jaundice, or
oliguria AND
 Any risk factor for acquiring the disease which includes:
- residing in a flooded area
- wading or swimming in floods and contaminated water, with or
without cuts or wounds
- contact with animal fluids especially carcass
- ingestion of contaminated water
A checklist for diagnosing leptospirosis for frontliners have been developed

(See Appendix A). The checklist consists of three parts: Clinical data,
Epidemiologic factors and Bacteriologic and laboratory findings. Using paired MAT
as the gold standard, the estimated sensitivity and specificity of the WHO criteria
were 33% and 66% respectively.9 Studies on the clinical utility of this criteria are
were probably limited by the small sample size.
III. INDICATIONS FOR ADMISSION AND GUIDELINES ON

SITE-OF-CARE DECISIONS
Patients with suspected leptospirosis presenting with MILD symptoms can be

managed on an OUT-PATIENT SETTING. These include patients with stable vital
signs, anicteric sclerae, no jaundice, with good urine output, no evidence of
meningismus/ meningeal irritation, no dyspnea, no tachypnea, no hemoptysis, no
bleeding, not in sepsis / septic shock, and can take oral medications.
On the other hand, patients with suspected MODERATE to SEVERE

LEPTOSPIROSIS should be admitted in a healthcare facility for proper diagnosis
and appropriate monitoring and management. The presence of the following signs
and symptoms will classify a patient to have moderate to severe leptospirosis and
will require admission:
 Unstable vital signs
 Jaundice / Icteric sclerae
 Abdominal pain
 Nausea, vomiting and diarrhea
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 Oliguria or anuria
 Bleeding
 Meningismus / meningeal irritation
 Sepsis / septic shock
 Altered mental status
 Difficulty of breathing or hemoptysis
Patients with leptospirosis who are suspected to have pulmonary

complications such as pulmonary hemorrhage or acute respiratory distress
syndrome (ARDS) require special attention because these conditions have been
consistently associated with increased mortality. These patients present with
dyspnea, tachypnea, chest x-ray findings of localized or multilobar infiltrates or
pleural effusion. The decision to admit a leptospirosis patient with pulmonary
complications will depend on the level of hypoxemia (see Table 6).
Moderate hypoxemia: 100<PaO2/FiO2<200 with PEEP≥ 5 cmH2O

Severe Hypoxemia: PaO2/FiO2 < 100 with PEEP ≥ 10cmH2O
Patients with moderate to severe hypoxemia need to be admitted to the

INTENSIVE CARE UNIT for closer monitoring and/or invasive ventilation. Patients
with mild hypoxemia may be admitted in a step down unit or monitored closely in the
wards.
IV. LABORATORY WORK UP
Given the generally low sensitivity and long turnaround times of diagnostics for
leptospirosis, it is not necessary to confirm the diagnosis or wait for the result of
these tests before initiating treatment. Clinical diagnosis especially in the context of
an epidemiologic risk factor and a high index of suspicion are more important. Early
recognition and treatment are important to prevent complications of the severe
disease and mortality. However, if definitive or confirmatory diagnosis is warranted
in suspected cases and for epidemiological and public health reasons, these are the
locally available diagnostic tests for leptospirosis.
The DEFINITIVE diagnosis depends on laboratory findings. Criteria for definite

diagnosis of leptospirosis are either:
 Isolation of the leptospires from the patient’s body fluid or tissue OR
 Seroconversion or a rise in antibody titer in the microscopic agglutination test
(MAT) in the presence of compatible clinical illness
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PRESUMPTIVE diagnosis of Leptospirosis may be based on the following

findings:
 positive dark field examination;
 presentation of clinical symptoms that are compatible with leptospirosis and a
microscopic agglutination titer of 1:100 or greater;
 a positive macroscopic agglutination slide test reaction on a single specimen
obtained after the onset of symptoms; and
 stable microscopic agglutination titer of 1:100 or greater in two or more serum
specimens obtained after the onset of symptoms
A. LEPTOSPIRAL TESTS
1. Microbiologic Test: Culture Method (definitive)
Culture of leptospires can be done using blood or cerebrospinal fluid (CSF)
obtained during the septicemic stage of illness or urine during the immune
and convalescent stage. Additionally, tissue sections obtained by biopsy or
at necropsy, can be submitted for culture of Leptospira. The media used
for culture are Fletcher semisolid medium or Ellinghausen-McCullough -
Johnson-Harris (EMJH) semisolid medium or Tween 80 - albumin medium
(OAC) or Korthoff medium. Cultures are incubated at 28-30oC in the dark
for 6 weeks or longer.
2. Microbiologic Test: Non-culture Method

a. Dark field microscopy – recommended as an aid that may suggest BUT
NOT establish the diagnosis of Leptospirosis
b. PCR for detection of leptospiral nucleic acid in blood or urine (definitive)
3. Serologic Tests
a. Microscopic Agglutination Test (MAT) – detects agglutinating antibodies
against live leptospires using darkfield microscopy. The 21-serovar MAT
is considered the "reference standard" or cornerstone of serodiagnosis
of leptospirosis. However, a genus-specific MAT using a non-
pathogenic Leptospira patoc I strain are being performed by some
centers.
Interpretation:
Single specimen: Titer > 1:800 (probable)
Paired specimen (using acute and convalescent sera): four-fold increase
(definitive)
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b. Rapid leptospiral diagnostic kits (i.e. immunochromatographic tests or

ICTs) - useful rapid tests in the early diagnosis of leptospirosis among
patients with compatible signs and symptoms. There is an increasing
number of tertiary healthcare facilities that are offering these rapid tests
already.
c. IgM ELISA- simple, with acceptable sensitivity that is quite variable
depending on the method of ELISA performed
Table 3. Appropriate timing of Specimen collection for specific leptospiral tests

Timing 0-7 days 7-14 days 14-28 days
(from onset of illness)
Specimen and leptospiral CSF for culture or darkfield
test microscopy
Dialysate for leptospiral
culture
Heparinized blood for
culture and or PCR
Serum (acute specimen) Serum for serologic tests (rapid ICTs, IgM
for MAT ELISA) and MAT (convalescent specimen)
Urine for culture
Refer to Annex B: Guidelines on Specimen collection, storage and transport

for leptospiral tests.
B. NON-LEPTOSPIRA TEST
a. MILD
1. CBC with quantitative platelet count
2. Urinalysis
3. BUN and Creatinine
4. Liver function tests (SGPT, SGOT)
b. MODERATE to SEVERE (request each test if clinically indicated)

1. Serum sodium and potassium
2. Bilirubins (Total Bilirubin, direct and indirect bilirubin)
3. PT/PTT
4. Total protein with A/G, Alkaline phosphatase
5. Chest X-ray
6. 12-Lead ECG
7. Arterial blood gas (ABG) - severe metabolic acidosis (ph< 7.2,
HCO3 <10) and hypoxemia (PaO2 < 60 mmHg, SaO2 < 90%, PF ratio
<250)
8. Total CPK with fractionated CPK-MM determination
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V. GENERAL GUIDELINES IN THE MANAGEMENT OF LEPTOSPIROSIS
Most cases of leptospirosis will be mild and self-limited. A suspicion of

leptospirosis should warrant management as such even without evidence from
leptospiral diagnostics.
 Supportive management with hydration and analgesic/antipyretic therapy with
paracetamol are recommended.
 Correct electrolyte derangements.
 Knowledge on the clinical indicators of progression from an undifferentiated
fever to severe leptospiral disease is very limited. Thus, it is recommended
that any illness [regardless of severity, duration or phase of the disease] that
prompts a patient to seek medical consult and leptospirosis is suspected,
antibiotic therapy should be administered to shorten the duration of illness
and reduce shedding of organisms in the urine.
 When the disease is classified as severe, the management is generally the
same as in the management of organ failure from sepsis. Supportive care
with renal replacement therapy, ventilatory support, and blood products may
be required. Consequently, timely referrals to specialists and facilities who
can provide such services are also recommended to prevent delays and
progression of anticipated complications.
The subsequent chapters will discuss the specific recommendations in the

various aspects of leptospirosis management.
VI. ANTIBIOTIC MANAGEMENT
All patients with suspected leptospirosis should be started on antimicrobial

therapy regardless of the phase of the disease of duration of symptoms to shorten
the duration of illness. While there is insufficient evidence on the use of antibiotics
in preventing death from leptospirosis, its use has been shown to have beneficial
effects on several clinically relevant and important outcomes (e.g. decreased the
duration of clinical illness by 2-4 days).10
Treatment with effective antibiotics should be initiated as soon as the

diagnosis of leptospirosis is suspected. Antibiotic administration should not be
delayed regardless of the need for renal replacement therapy.
Doxycycline 5 mg/kg/day PO in 2 divided doses (max 200mg/day) x 1 week.
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Table 4. Recommended Antibiotic Regimens for Leptospirosis

MILD LEPTOSPIROSIS
ADULT CHILDREN
First line
Doxycycline 100 mg BID PO for 10 days Amoxicillin 30-50 mg/kg/day in 3 divided

doses. Maximum of 2 grams per day

Alternative
Amoxicillin 500mg QID or 1g q8h

 Azithromycin dihydrate 1 g initially, Erythromycin 10 mg/kg/day orally in four
followed by 500 mg OD for 2 more divided doses for 1 week
days
SEVERE LEPTOSPIROSIS (WEIL SYNDROME)
ADULT CHILDREN
 Penicillin G 1.5 million units IV q 6  Aqueous penicillin G 6-8 million U/m2/day
regimen
Primary
hrs for 7 days in 6 divided doses for 1 week

 Ceftriaxone 1gm q24h for 7 days  Ampicillin 100 mg/kg/day IV every 6 hours
 Ampicillin 0.5-1.0 gm q6h  Tetracycline 25-50 mg/kg/day orally in four

 Azithromycin dihydrate 500 mg OD divided doses or IV tetracycline 10-
for 5 days 20mg/kg/day IV in four divided doses, max
 Cefotaxime 1 gm q6h 3 g/day, avoid in children < 9 years
Alternative
 Doxycycline 5 mg/kg/day PO in 2 divided

doses (max 200mg/day) x 1 week
 Ampicillin 100 mg/kg/day IV every 6 hours
or
 Erythromycin 10 mg/kg/day orally in four
divided doses for 1 week
Note: Step-down therapy can be instituted once patient is clinically stable and able to tolerate oral
medication. Any oral antibiotic can be selected.
Table 5. Dosage of Antibiotics 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 500mg q6h or 1g q8h Q8h Q8-12h Q24h
Ampicillin 0.5-1gm q6h Q6h Q6-12h Q12-24h
Azithromycin 500 mg OD No dose adjustment
Dehydrate
Cefotaxime 1 gm q6h Q8-12h Q12-24h Q24h
Ceftriaxone 1 gm q24h No dose adjustment
Doxycycline 100mg BID No dose adjustment
Penicillin G 1.5 MU q6h No dose adjustment
Table adapted from: Collaborative Statement of the Philippine Society for Microbiology and
Infectious Diseases, Philippine Society of Nephrology and the Philippine College of Chest
Physicians Council on Critical Care and Pulmonary Vascular Diseases. (2010). The Philippine
Clinical Practice Guidelines on the Diagnosis, Treatment and Prevention of Leptospirosis in Adults
2010.
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VII. STEROID THERAPY
Steroids have been reported to reduce or delay the need for ventilator support,
improve PTT or mortality among patients with leptospirosis. While the evidence for
its use is not overwhelming, steroid therapy has found relevance in clinical practice
given the devastating complications of severe leptospirosis, particularly pulmonary
hemorrhage. Thus, steroid therapy is suggested for:
(1) patients at high-risk of pulmonary hemorrhage, and
(2) AKI PLUS any of the following:
 platelet count <100
 MAP <65 mmHg
 Prolonged PT/PTT
 Need for inotropes
If there is a decision to use steroids for such patients, it should be initiated as

soon as the first signs and symptoms of pulmonary leptospirosis is detected (e.g.
tachypnea, hemoptysis, dyspnea). The following regimens have been used:
a. Methylprednisolone at a dose of 500 mg IV/day for 3 days, with the first dose
given as bolus within the first 12 hours of onset of respiratory involvement.
b. For those with renal failure, methylprednisolone 500mg IV after HD OD x 3 days.
After 3rd MP dose or after any episode of hemoptysis, give Cyclophosphamide
1g IV as a single dose after HD.
VIII. PULMONARY COMPLICATIONS OF LEPTOSPIROSIS
Pulmonary hemorrhage and Acute Respiratory Distress Syndrome (ARDS) are

the two most common pulmonary complications of leptospirosis. They are usually
associated with worse prognosis and high mortality.
A. Diagnosis of pulmonary complications of leptospirosis

Pulmonary symptoms usually appear between the 4th and 6th day of
disease. Significant risk factors for pulmonary complications are delayed
antibiotic treatment and thrombocytopenia at the onset of the disease.
Pulmonary involvement should be suspected in a leptospirosis patient with the
following:
 Tachypnea (RR > 30 breaths/minue)  Hemoptysis
 Cough  Dyspnea
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On top of the clinical factors, findings from important laboratory tests aid in the
diagnosis of ARDS. The severity of pulmonary involvement can be assessed by
abnormalities on chest radiograph and arterial blood gas.
1. Radiographic findings commonly accompany pulmonary symptoms. All
patients have bilateral pulmonary infiltration and maybe seen as early as the
first 24 hours of the systemic stage of leptospirosis.
2. Hypoxemia and hypocarbia are common blood gas abnormalities. Elevated
PCO2 is seen in severe cases. Continuous monitoring of oxygen saturation is
recommended in the presence of pulmonary complications.
The table below are parameters that can be used for the diagnosis of ARDS
and for risk stratification to identify site-of-care, particularly the level of oxygenation.
Table 6. American-European Consensus Conference Criteria for ARDS11

Timing Within 1 week of a known clinical insult or new/worsening respiratory
symptoms
Origin of Edema Respiratory failure not fully explained by cardiac failure or fluid
overload; Need objective assessment (e.g., echocardiography) to
exclude hydrostatic edema if no risk factor present
Mild Moderate Severe
Oxygenation 200<PaO2/FiO2<300 100<PaO2/FiO2<200 PaO2/FiO2 < 100
with PEEP or CPAP≥ 5 with PEEP≥ 5 with PEEP ≥ 10cmH2O
cmH2O cmH2O
Chest Imaging Bilateral opacities-not fully explained by effusions, lobar collapse,
masses
Table adapted from: ARDS Definition Task Force, Ranieri, V. M., Rubenfeld, G. D., Thompson,
B. T., Ferguson, N. D., Caldwell, E., Slutsky, A. S. (2012). Acute Respiratory Distress Syndrome.
JAMA, 307(23), 2526–2533. https://doi.org/10.1001/jama.2012.5669
B. Management of pulmonary complications of leptospirosis

 Initiate steroid therapy as soon as pulmonary involvement is recognized
 Initiate either invasive (mechanical ventilation) or noninvasive ventilation
(bipap) if there are bilateral infiltrates on chest radiograph and PaO2/FiO2 is
<300 or SaO2 is less than 90% (Refer to Figure 1).
 Referral to a pulmonologist is recommended.
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Figure 1. Algorithm for the Diagnosis and Management of Leptospirosis with Pulmonary
Complications
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Non-invasive ventilation (NIV) vs. Invasive ventilation
A trial of NIV can be done in most patients who do not require emergent
intubation. The presence of the following conditions, however, are contrainidication
to NIV and therefore warrant invasive ventilation:
Table 7. Contraindications To Non-Invasive Positive Pressure Ventilation12

Non-respiratory organ failure that is acutely life-threatening
Severe encephalopathy (eg, GCS <10)
Severe upper gastrointestinal bleeding
Hemodynamic instability or unstable cardiac arrhythmia
Facial or neurological surgery, trauma, or deformity
Upper airway obstruction
Inability to cooperate/protect airway
Inability to clear secretions
High risk for aspiration
Table adapted from: International Consensus Conferences in Intensive Care Medicine:
Noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med
2001; 163:283.
Recommended initial non-invasive ventilator setting are as follow: inspiratory

positive airway pressure (IPAP) of 10cmH20, and expiratory positive airway
pressure (EPAP) of 4-5cmH20 = Pressure support level 5 – 6 cmH20. Target tidal
volume of 6-8 mls/Kg (ideal body weight) is aimed for all adult patient. Optimal
noninvasive positive pressure ventilation (NPPV) is the lowest pressure and lowest
Fio2 that achieved SaO2 of 90% or PaO2 of 60mmHg without further clinical
deterioration.
Recommended initial mechanical ventilator settings are as follows:

assist/control mode, utilizing low tidal volume at 6ml/kg body weight, positive end
expiratory pressure (PEEP) of 5cmH2O, FiO2 of 100% and respiratory rate of
25/min. FiO2 and PEEP should be adjusted accordingly to maintain SaO2 ≥90%. If
there are facilities available to measure plateau pressure, it should be maintained at
≤ 30cmH2O. Respiratory rate should also be adjusted according to the patient’s rate
to avoid asynchrony.
Prone positioning is recommended in patient with moderate to severe form of

hypoxemia (PaO2/FiO2 < 150 mm Hg) ideally within the first 48 hrs of ARDS
recognition.
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This maneuver requires 3-5 people, paying close attention to endotracheal

tube (ETT) and central lines. Make sure that patient has an empty stomach. Steps
in prone positioning:
1. Pre-oxygenation
2. Suction endotracheal tube and oral cavity
3. Remove ECG leads and reattach to back after shifting position.
4. Turn over the patient to the prone position.
5. Do repeated zeroing of hemodynamic transducers
6. Support and frequently reposition pressure points: face, shoulder, anterior
pelvis
Successful trials evaluating prone positioning in ARDS used at least 16 hours

of daily proning. When PaO2/FiO2 remained > 150 mm Hg 4 h after supinating
(with PEEP < 10 cm H2O and FiO2 < 0.6), stop prone positioning.
C. Extracorporeal Membrane Oxygenation (ECMO) in leptospirosis

 The benefits of ECMO use in severe pulmonary form of leptospirosis and
associated ARDS are still under evaluation.
 ECMO has been used more extensively as a potential bridge therapy in
patients with severe ARDS and/or massive hemoptysis.
 The best outcome in ECMO for adult respiratory failure occurs when ECMO is
instituted early after the onset (1-2 days).
 ECMO is done in a highly specialized center with a trained multi-disciplinary
team. Should ECMO be considered, prompt referral and close coordination
should be done to such centers who can perform the procedure.
IX. RENAL COMPLICATIONS OF LEPTOSPIROSIS

Renal complications of leptospirosis may present in a spectrum which may
span from sterile pyuria , tea colored urine, mild proteinuria to severe anuric acute
renal failure.
Commonly it may present as non-oliguric renal failure with mild hypokalemia.

Oliguria with hyperkalemia may reflect the severity of AKI and may connote poor
prognosis. Oliguria is defined as urine output < 0.5 mL/kg/hr or <400mL/day or
a self-report of decreased or no urine output within the last 12 hours.
15
The following are the list of diagnostic tests that should be performed when
AKI is suspected:
 CBC with platelet count
 BUN, creatinine, sodium, potassium, AST, ALT, bilirubins
 Urinalysis
 Chest x-ray – check for congestion and/or signs of pulmonary hemorrhage
The algorithm below (Figure 2) is a guide in the management of leptospirosis

patients that present with oliguria.
The recommended initial fluid resuscitation for Leptospirosis patient is

Balanced crystalloids. If potassium is in the high normal value or with hyperkalemia,
Isotonic saline is recommended. Hydroxyethyl starch should be NOT be given
because it is associated with increased risk of Acute Kidney Injury, need for Renal
Replacement and mortality.
The recommended initial fluid resuscitation rate is 20ml/kg/h or 500ml of crystalloids

within 15- 30mins Patients with Leptospirosis are prone to ARDS due to
downregulation of the Na transport via Epithelial Sodium Channel (ENaC),
NaKATPase as well as decrease in Aquaporin P5.
Any one of the following are indications for dialysis:

 Uremic symptoms- nausea, vomiting, altered mental status, seizure, coma
 pH 3 mg/dl in ABG
 Serum K >5 meq in an oliguric patient
 ARDS, pulmonary hemorrhage (GRADE: moderate)
Hemodialysis is preferred over peritoneal dialysis in patients with AKI secondary to

Leptospirosis. The latter is a valid option if hemodialysis machine is not readily
available.
Daily dialysis is suggested to maintain strict control of azotemia and fluid volume
which can improve survival for those patients with severe Leptospirosis especially if
with pulmonary hemorrhage.
16
Figure 2. Algorithm for leptospirosis patients with oliguria
17
X. PREVENTION AND CONTROL
A. Hygienic conditions should be encouraged in slaughterhouses, farmyard

buildings and bathing pools
B. Avoidance of exposure to urine and tissues from infected animals such as
wading in flooded areas. Likewise, activities in possible contaminated bodies
of water should be prevented.
C. Vaccination of animals against leptospirosis
D. Rodent control
E. When a potential exposure to contaminated water is anticipated, individuals
should wear protective clothing (boots, gloves, spectacles), cover skin
lesions with waterproof dressings, wash or shower after exposure to
contaminated water, and wash and clean wounds.
F. Avoid drinking water from possible contaminated water sources.
G. Chemoprophylaxis (see next section)
XI. CHEMOPROPHYLAXIS
The use of chemoprophylaxis requires prior consult with a physician. It should

not be taken unless prescribed and fully explained by a physician, including
common side-effects and contraindications. Since antibiotic prophylaxis is not 100%
effective, individuals should continue to monitor themselves for fever and other flu-
like symptoms and should continue to wear personal protective measures when
contact with contaminated water is anticipated.
A. Pre-exposure Prophylaxis
Pre-exposure antibiotic prophylaxis is NOT ROUTINELY RECOMMENDED.
However, this may be considered for short-term exposures in those individuals who
intend to visit highly endemic areas AND are likely to get exposed, including but not
limited to:
 Travelers
 Soldiers
 People who engage in water-related recreational and occupational
activities
 Disaster relief workers deployed to flooded or post-typhoon areas
Doxycycline 200mg orally once a week, to begin 1 to 2 days before exposure

and continued throughout the period of exposure.
18
B. Post-exposure prophylaxis
Post-exposure prophylaxis is given following contact with contaminated
sources such as flood water, animal carcasses, infected body fluids, etc. The post-
exposure prophylactic regimens depends on the risk for leptospirosis following the
exposure (see Table 7).
Table 8. Post-exposure prophylaxis for leptospirosis in adults and children

ADULTS
MILD MODERATE HIGH RISK
single exposure, non-mucosal, no mucosal exposure, presence or When there is repeated or
breaks in the skin wound continuous exposure
Doxycycline 200mg single dose, Doxycycline 200 mg once daily Doxycycline 200 mg once
immediately within 24 to 72 hours for 3-5 days to be started weekly until the end of
from exposure immediately within 24 to 72 hours exposure
from exposure
CHILDREN13
First-line: Doxycycline 4 mg/kg single dose, max dose: 200 mg
Alternative:
Azithromycin 10 mg/kg single dose, max dose: 500 mg*
Amoxicillin 50 mg/kg/day q 6 hrs for 3-5days, max dose: 500 mg q6 hrs**
Note: * Efficacy for prevention of leptospirosis was seen in vitro and animal models
** No clinical trial for prevention of leptospirosis, but amoxicillin is a known alternative for the treatment of disease
Doxycycline has been known to cause permanent discoloration or enamel

hypoplasia in developing teeth (among fetuses and children). There are currently no
good quality evidence on pre- or post-exposure prophylaxis among children and
pregnant patients. However, the American Academy of Pediatrics recently released
a new statement saying that short course doxycycline therapy (i.e. <21 days) is not
expected to cause teeth discoloration in children <8 years.14 As such, the Pediatric
Infectious Disease Society has come up with chemoprophylactic recommendations
for children. For pregnant patients, the use of azithromycin or amoxicillin post-
exposure may be justifiable based on the reasons stated in Table 7 (note).
19
XII. REFERENCES
1. Marquez A, Djelouadji Z, Lattard V, Kodjo A. Overview of laboratory methods to diagnose
Leptospirosis and to identify and to type leptospires. Int Microbiol. 2017;20(4):184-193.
doi:10.2436/20.1501.01.302
2. World Health Organization Southeast Asia Regional Office. Leptospirosis - Fact Sheet.
http://www.searo.who.int/about/administration_structure/cds/CDS_leptospirosis-
Fact_Sheet.pdf. Accessed July 4, 2019.
3. Yanagihara Y, Villanueva S, Yoshida S, Okamoto Y, Masuzawa T. Current status of
leptospirosis in Japan and Philippines. Comp Immunol Microbiol Infect Dis. 2007;30:399-413.
4. United Nations Office for the Coordination of Humanitarian Affairs. Philippines Typhoon
Season 2009 Situation Report#14 (30 October 2009).; 2009.
5. Republic of the Philippines Department of Health. Leptospirosis Quarterly Surveillance Report
No. 4 (2018).; 2018.https://portal2.doh.gov.ph/sites/default/files/statistics/
2018_Leptospirosis_QSR_N4.pdf. Accessed July 4, 2019.
6. Roxas EA, Alejandria MM, Mendoza MT, Roman ADE, Leyritana KT, Ginete-Garcia JKB.
Leptospirosis Outbreak after a Heavy Rainfall Typhoon in the Philippines: Clinical Features,
Outcome and Prognostic Factors for Mortality. Acta Med Philipp. 2016;50(3):121-128.
https://www.actamedicaphilippina.org/article/6866-leptospirosis-outbreak-after-a-heavy-
rainfall-typhoon-in-the-philippines-clinical-features-outcome-and-prognostic-factors-for-
mortality. Accessed July 4, 2019.
7. Amilasan A-ST, Ujiie M, Suzuki M, et al. Outbreak of leptospirosis after flood, the Philippines,
2009. Emerg Infect Dis. 2012;18(1):91-94. doi:10.3201/eid1801.101892
8. Collaborative Statement of the Philippine Society for Microbiology and Infectious Diseases,
Philippine Society of Nephrology and the Philippine College of Chest Physicians Council on
Critical Care and Pulmonary Vascular Diseases. The Philippine Clinical Practice Guidelines
on the Diagnosis, Treatment and Prevention of Leptospirosis in Adults 2010. 2010.
9. Brato D, Mendoza M, Cordero C, et al. Validation of the World Health Organization (WHO)
Criteria Using the Microscopic Agglutination Test (MAT) as the Gold Standard in the
Diagnosis of Leptospirosis. PJMID. 27(4):125-128.
10. Brett-Major DM, Coldren R. Antibiotics for leptospirosis. Cochrane Database Syst Rev.
2012;(2):CD008264. doi:10.1002/14651858.CD008264.pub2
11. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al. Acute Respiratory Distress
Syndrome. JAMA. 2012;307(23):2526-2533. doi:10.1001/jama.2012.5669
12. Organized jointly by the American Thoracic Society, the European Respiratory Society, the
European Society of Intensive Care Medicine, and the Société de Réanimation de Langue
Française, and approved by ATS Board of Directors, December 2000. International
Consensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure
Ventilation in Acute Respiratory Failure. Am J Respir Crit Care Med. 2001;163(1):283-291.
doi:10.1164/ajrccm.163.1.ats1000
13. Pediatric Infectious Disease Society of the Philippines. POST DISASTER INTERIM ADVICE
ON THE PREVENTION OF LEPTOSPIROSIS IN CHILDREN. 2012.
14. American Academy of Pediatrics Committee on Infectious Diseases, Kimberlin D, Brady M,
Jackson M, Long S. Red Book 2018-2021 Report of TheCommittee on Infectious Diseases.
31st ed.; 2018. https://redbook.solutions.aap.org/book.aspx?bookid=2205. Accessed July 4,
2019.
20
APPENDICES
Appendix A. Modified Faine’s Criteria (2012)
This check-list is designed for those who deal directly with the patient. It may
be used even before results of leptospiral diagnostic tests are available. To use the
this, give the appropriate score if the parameter is present for the patient and
compute for the sum.
MODIFIED FAINE’S CRITERIA (2012)

Clinical data Epidemiological Bacteriological and laboratory
(Part A) factors (Part B) findings (Part C)
Headache 2 Rainfall 5 Isolation of leptospira in

culture - Diagnosis certain
Fever 2 Contact with 4 PCR 25
contaminated
Environment
Temperature >39°C 2 Animal contact 1 Serology
Conjunctival suffusion 4 ELISA IgM positive* 15
Meningism 4 SAT positive* 15
Conjunctival suffusion 10 Other rapid tests** 15
+ Meningism
+ Myalgia
Jaundice 1 MAT – single positive in 15
high titer
Albuminuria/Nitrogen retention 2 MAT – rising 25
titer/seroconversion
Hemoptysis/Dyspnea 2 * Any one of the tests only
should be scored
** Latex agglutination
test/Lepto dipstick/Lepto
Tek lateral flow/Lepto Tek
Dri-Dot test
Presumptive diagnosis of leptospirosis is made if:
Part A or Part A and Part B score: 26 or more
Parts A, B, C (Total): 25 or more
A score between 20 and 25 suggests leptospirosis as a possible diagnosis.
Table adapted from: Shiva Kumar, S. Indian Guidelines for the Diagnosis and Management of
Human Leptospirosis (2013), p. 26. Accessed on 4 July 2019 from
http://www.apiindia.org/medicine_update_2013/chap07.pdf
21
Appendix B: Guidelines in Specimen Collection, Storage, Transport and Submission
22
23
24
Chapter 2: UPSURGE POLICIES AND PROCEDURES
I. STATEMENT OF PURPOSE AND SCOPE
A. Purpose
It is the purpose of this manual to define the actions and roles necessary to
provide a coordinated response during an upsurge in leptospirosis cases in the
HEALTHCARE FACILITY. This manual provides guidance to all the Departments
within the HEALTHCARE FACILITY, with a general concept of potential Upsurge
assignments before, during, and following a Leptospirosis Upsurge. It also
provides for the systematic integration of Upsurge resources when activated
including purchasing of necessary supplies and materials for renal replacement
therapy, supporting the provision of necessary services, and even upgrading the
facilities of the areas assigned to become temporary “leptospirosis wards.”
Important as well is the allocation of financial support or resources from
government agencies such as the Department of Health (DOH), specifically the
Health Emergency Management Bureau (HEMB) and the Field Implementation
and Coordination Team for NCR. It also includes activation of communications
networking with relevant government, non-government agencies and media
focusing on the prophylaxis, prevention and early treatment of leptospirosis.
B. Scope
This plan applies to all participating Divisions/Departments within the
HEALTHCARE FACILITY.
II. KEY POLICIES
A. Criteria for Activation of the Leptospirosis Upsurge Policy

The Leptospirosis Upsurge Policy will be activated when there is a surge in the
number of leptospirosis patients requring admission to the HEALTHCARE
FACILITY to ensure that patients receive appropriate and timely medical care,
renal replacement and respiratory support using the HEALTHCARE FACILITY
criteria to guide health care:
Opening of a Leptospirosis Ward

The HEALTHCARE FACILITY will identify the CRITICAL NUMBER OF
PATIENTS BEING ADMITTED FOR LEPTOSPIROSIS PER DAY that will
activate the policies and procedures in this handbook. When this critical number
of patients who require more than simple hydration (i.e. renal replacement
25
therapy, blood component transfusion or requiring respiratory support) is

reached, a Leptospirosis Ward will be identified and opened for these patients.
Stable patients who do not require ventilatory support will be placed in the
Leptospirosis Ward, while toxic patients who are unstable, requiring inotropic
support, ventilatory support or who require intensive monitoring as they are likely
to need intubation, will be admitted to the regular wards. Unstable patients will be
placed in a special identified ward with a higher nurse to patient ratio.
B. Person Responsible for Activation of the Leptospirosis Upsurge Policy

DURING OFFICE HOURS from Monday-Friday, 8:00AM - 5:00PM, the
Head Nurse and Head Consultant of the Emergency Room (ER) will inform the
Executive Office if the criteria for activation of the Leptospirosis Upsurge Policy
has been met. Any one of the Deputy Executive Directors or the Chief of Hospital
will activate the Leptospirosis Upsurge Policy.
Upon Activation of the Leptospirosis Upsurge Policy, the Secretary of any of

the Deputy Executive Directors or Chief of Hospital will send out a memorandum
through Outlook, and will notify the Heads of the following Departments /
Divisions:
 Divisions of Adult and Pediatric Nephrology
 Division of Internal Medicine
 Division of Organ Transplantation and Vascular Surgery
 Nursing Services
- All Head Nurses or Charge Nurses in all Clinical Wards
- Operating Room (OR)
 Department of Pathology and Laboratory Medicine
 Section of Pulmonary Medicine
 Pharmacy, Procurement, Supply, Central Supply and Sterilization Unit
(CSSU), Housekeeping, Billing and Claims, Admitting and Discharge
 Medical Social Services Division (MSSD)
 Information Resource Management Division (IRM)
- Upload Hospital Memorandum regarding the activation of the
Leptospirosis Upsurge Policy to all concerned departments through
OUTLOOK
- Inform all Heads of the concerned Department/Division including the
Chief of Hospital and Deputy Executive Directors through SMS
 HEALTHCARE FACILITY-HEMB
26
AFTER OFFICE HOURS from Monday-Friday, weekends and holidays, the

ER Charge Nurse will contact the Senior House Officer (SHO) who will activate
the Leptospirosis Upsurge Policy and inform IRM to disseminate the information.
(See Diagram I)
ER
Chief of Hospital and Senior House All Other

Deputy Executive Directors Officers (SHO) Departments
IRM All Medical Nursing

Depts/Divisions
Deploy Memo through All Nursing

OUTLOOK to all those Departments
on Duty and all the their
Heads by SMS
Diagram I: Activation of Leptospirosis Upsurge Policy

after Office Hours
C. Activation of the Leptospirosis Upsurge Management Team

Once the Leptospirosis Upsurge Policy is activated, the Chief of Hospital or
any of the Deputy Executive Directors will call on a meeting of the Leptospirosis
Upsurge Management Team, to coordinate efforts on ensuring adequate
provisions of necessary services for the leptospirosis patients. Meetings can be
called on daily to update the entire team of the needs of the Leptospirosis ward
and other areas. A Leptospirosis Upsurge Management Team Head will be
assigned by the Chief of Hospital.
This team is composed of the following:
 Chief of Hospital/Deputy Executive Director/s – Head
 Chair, Departments/Divisions of Adult and Pediatric Nephrology, Internal
Medicine, Vascular, Laboratory Medicine
 Deputy Executive Director for Nursing Services
 ER Head
 Head Nurse of ER, Clinical Wards, HD Unit, PD Unit, Operating Room
 Head of Housekeeping, Purchasing, Warehouse, Pharmacy, CSSU,
PBSD, MSSD, IRM, HEALTHCARE FACILITY-HEMB
27
D. Critical Bed Status Procedure – HEALTHCARE FACILITY Leptospirosis Upsurge

Policy
It is the goal of this Policy to provide a systematic method for identifying the
available hospital beds, to unload the ER, to ensure that beds are being
appropriately used during critical bed status, and to prevent the denial of
transfers from other government hospitals during a Leptospirosis Upsurge. This is
to ensure that patients receive proper medical care.
Procedure:
The post duty Senior Adult Nephrology Fellow will report on the total bed
status and availability, to the Head of the Leptospirosis Upsurge Management
Team by 8:00AM every morning.
The Chief Fellow / Resident will prioritize admissions of the Leptospirosis

patients especially those who need RRT or require ventilator support.
E. Standards for Admission of Leptospirosis Patients

All patients with a presumptive diagnosis of Leptospirosis will be triaged
under the Division of Internal Medicine with the following criteria:
1. Serum Creatinine: < 3 mg/ dl
2. Absence of Criteria for Pulse Therapy
All patients with a presumptive diagnosis of Leptospirosis will be triaged

under the Division of Adult Nephrology (Patients > 19 yo) or Pediatric
Nephrology (Patients < 18 yo and 364 days) with the following criteria:
1. Serum Creatinine: > 3 mg/ dl
2. Presence of any ONE of the Criteria for Pulse Therapy (See Appendix A)
28
III. ROLES AND RESPONSIBILITIES OF THE VARIOUS DEPARTMENTS /

DIVISIONS / SECTIONS IN THE MANAGEMENT OF A LEPTOSPIROSIS
UPSURGE
A. Emergency Room (ER)

 Provide emergency medical treatment, triage patients and ensure
administrative or clinical backup for the ER.
 Stamp clinical charts with “LEPTOSPIROSIS” so that the Pharmacy, CSSU
and other concerned areas will be alerted that the requests should be
provided, without pre-approval by MSSD.
 Refer patients who fulfill the criteria for Leptospirosis immediately to
Nephrology or Internal Medicine. Patients developing acute kidney injury, who
fulfill the criteria for renal replacement will be treated without delay. This
should be provided to all patients and will not require MSSD pre-approval.
 The Head of the ER should ensure that the Leptospirosis Prophylaxis Survey
2013 is completed for all patients and placed in the clinical chart of the patient.
The Chief Fellow of the Division of Adult Nephrology should collect the survey
forms including forms from Pediatric Nephrology and Internal Medicine. (See
Appendix B)
 The Head Nurse of the ER shall ensure that the ER Procedure Room is
adequately prepared for use and will maintain adequate sterility for dialysis
access procedures. The appropriate measures to maintain sterility of the area
especially between procedures will be applied.
 ER Nephrology fellows shall refer patients requiring access placement for
either hemodialysis (HD) or peritoneal dialysis (PD) to the Department of
Vascular Surgery / General Surgery. Placement of a temporary HD catheter
will be done either in the ER Procedure Room or Operating Room (OR) to
ensure that there is no delay in dialysis access placement. Placement of HD
access may also be performed by the Nephrology Fellow as per Division of
Adult Nephrology protocol. Placement of a temporary PD catheter will be done
in the OR only.
 The Head Nurse of the ER shall ensure that there are enough supplies for
either HD or PD access placement, sufficient number of cut-down sets and
other supplies necessary at the ER. These should be provided to all patients
and will not require MSSD pre-approval. Any problems with supplies should be
communicated immediately to the Head of the Leptospirosis Upsurge
Management Team, Head of Warehouse, CSSU, and Purchasing.
- For HD access – use triple lumen catheters
- For intubation – use ET tube with subglottic suction
29
 Residents and fellows shall refer patients to MSSD for completion of clinical
information for inclusion as a service patient, and for possible application for
the PhilHealth Leptospirosis benefit or other funding agencies to assist the
HEALTHCARE FACILITY in sourcing funds for these patients.
 Residents and fellows shall refer patients who will require admission to the
clinical wards (for patients on inotropes, require ventilator support, or who are
clinically unstable) to the appropriate Medical Department/Division for
facilitation of admission, while all other patients will be admitted to the
Leptospirosis Ward.
B. Division of Internal Medicine

Assess patients and ensure that they are given adequate hydration,
appropriate antibiotics and that patients are monitored. The Division is also
responsible for following the Leptospirosis algorithm for proper diagnosis,
management and documentation. The ER Medical Residents on duty are in
charge of providing an efficient patient flow, consultation, and disposition at the
ER.
◊ Patients will be admitted to the appropriate pay or service beds as necessary.
 The total daily number of patients admitted under the IM Service will be
reported to the post duty Senior Adult Nephrology Fellow who will be
responsible for consolidating the DAILY CENSUS of patients with
Leptospirosis.
 Medical service residents will manage, monitor and provide proper medical
disposition of patients admitted under IM service. If necessary, the service
resident will transfer patients to nephrology service once the patient requires
intravenous methylprednisolone pulse therapy and renal replacement therapy.
 Subspecialty service rotators will work in conjunction with nephrology fellows
to manage difficult and complicated Leptospirosis cases. Rotators are also
responsible for referring cases to the subspecialty consultant of the month.
 Medical service residents assigned to the Leptospirosis Ward will be
responsible for answering urgent calls for patients admitted under IM service
in the Leptospirosis Ward, in the absence of a nephrology fellow, and promptly
refer to the service consultant.
 Medical Staffing of the Leptospirosis Ward is seen in Section V.
30
C. Divisions of Adult and Pediatric Nephrology

Assess patients, provide renal replacement therapy / hydration as needed,
and ensure that appropriate medications are administered. Nephrology fellows
prioritize admissions based on the medical needs of patients. The NKTI is the
tertiary referral center for renal disease for all DOH hospitals and will accept
referrals from these hospitals for renal replacement. DOH hospitals with RRT
services referring patients to NKTI will be reported to the Head of the
Leptospirosis Upsurge Management Team and to DOH.
 Patients who fulfill the criteria for renal replacement will be allocated to either
HD or PD according to the algorithm in Appendix A and C.
 Since the patients are diagnosed with acute kidney injury, this illness is
reversible and all the needs for dialytic therapy, antibiotics and other
therapeutics will be provided.
 The Division of Adult Nephrology will serve as the lead Department in
consolidating the census for all patients seen at the ER and admitted,
including basic demographics, treatment and outcome. (See Appendix D)
 The post duty Senior Adult Nephrology Fellow will be responsible for
consolidating the 24-hour daily census of patients with Leptospirosis from all
Departments at 12:00AM using the appropriate form (See Appendix D). This
will be emailed to the Chief of Hospital, the Head of the Leptospirosis Upsurge
Management Team, the Chair of the Division of Adult Nephrology, and to the
Epidemiology Bureau and HEMB Operations Center, under the Department of
Health.
 The PD Fellow 1 will be in charge of the Leptospirosis Ward and all the other
Leptospirosis patients during office hours. After office hours, the PD Fellow 2
will take over and endorse the patients back to PD Fellow 1 in the morning.
Nephrology Staffing of the Leptospirosis Ward is seen in Section V.
 The Head of the Leptospirosis Upsurge Management Team will coordinate
with any of the concerned Departments/Divisions/Sections of HEALTHCARE
FACILITY, as needed, to ensure that patients are treated in a timely manner,
and to ensure that all the patients' needs are provided. The Head of the
Leptospirosis Upsurge Management Team will update the Chief of Hospital /
Deputy Executive Directors as necessary.
 The Head of the Leptospirosis Upsurge Management Team and/or the Chief
of Hospital / Deputy Executive Directors, will attend the DOH-HEMB meetings,
as necessary, to provide updates on the status of patients admitted at the
HEALTHCARE FACILITY and to request for logistical support, if necessary.
 Nephrology Staffing of the Leptospirosis Ward is seen in Section V.
31
D. HEALTHCARE FACILITY-Health Emergency Management Bureau (HEMB)

Team
The HEALTHCARE FACILITY-HEMB Team will be included in the
Leptospirosis Management Team. They will facilitate requests for augmentation
of staffing and resources as necessary from the DOH-HEMB Office or the Field
Implementation Coordination Team DOH-NCR. They will coordinate with the
Head of the Leptospirosis Upsurge Management Team for any other needs.
E. Division of Organ Transplantation and Vascular Surgery

Responsible in providing timely insertion of temporary HD catheters or PD
catheters and their removal, prior to patient’s final discharge and other surgical
procedures if deemed necessary.
F. Department of Pathology and Laboratory Medicine

 Responsible for processing of blood chemistry, hematology, transfusion
requirements, microbiology, coagulation, and urinalysis available 24/7 for
patients with Leptospirosis.
 Responsible for storage of blood for MAT, and to find out where these tests
can be done at the lowest possible price. Shall ensure that the required clinical
information is completed for the MAT tests.
G. Section of Pulmonary Medicine

 Responsible for pulse oximetry, nebulization, arterial blood gas, and providing
mechanical ventilatory support in a timely manner.
 The ECMO TEAM, headed by a Pulmonary consultant will decide whether or
not referred leptospirosis patients fulfill the criteria for ECMO therapy. Once a
patient is identified then the ECMO Team Head will activate the
HEALTHCARE FACILITY multi-disciplinary ECMO Team to provide the
necessary services for the patient. The ECMO Team head ensures the
availability of ECMO supplies such as oxygenator, cannulaes and various
tubings.
 Medical criteria for assisted ventilation and ECMO therapy is seen in
Appendix E.
H. Department of Medical Imaging and Therapeutic Radiology

 All radiologic services should be readily available to the ER, Leptospirosis and
medical wards for all diagnostic studies and services utilizing the portable x-
ray machine, ultrasound or CT scan as necessary.
32
I. Nursing Services
 Assures that there is adequate nursing staffing complement, equipment,
medications and supplies, and that proper nursing care is provided.
 In preparation for the activation of the Leptospirosis Upsurge Policy a 1-week
learning and development intervention on HD will be facilitated and scheduled
at least once a year or as necessary. A similar workshop for PD will be
facilitated at least once a year or as necessary to ensure that there are
sufficient nurses in the ward adept at PD. This comprises 8-hours of a lecture
workshop program and 40 hours of practicum.
 Senior staff nurses will be identified from each ward to undergo the HD and/or
PD training as above. These nurses will be assigned to the Leptospirosis
Ward once opened, and new staff nurses will be assigned to replace them in
their respective units.
 Nurse Staffing of the Leptospirosis Ward is seen in Section V.
J. Hemodialysis (HD) Unit

 The HD Unit Head will determine whether HD machines will be placed in the
Leptospirosis Ward to facilitate HD treatments, so as not to disrupt the in-
patients and ER patients requiring urgent HD. The guideline is when there are
at least 16 patients requiring HD from the Leptospirosis Ward, 4-HD machine
stations will be set-up in the Ward with portable reverse osmosis machines.
 Once a decision is made to set-up an HD Unit in the Leptospirosis Ward, the
HD Unit Supervisor will contact the HEALTHCARE FACILITY’s HD provider to
augment the number of HD machines and portable RO machines to be placed
in the Leptospirosis Ward, and contact the Provider’s Facility. Engineer and
Biomedical Engineer on duty to assess the area for setting up an HD Unit,
such as the water and power source.
 The HD Unit Supervisor or Assistant will coordinate with all the wards where
there are Leptospirosis patients to determine how many patients need HD and
to schedule their treatments according to the prioritization level given by the
Division of Adult Nephrology, and where the patients will have their HD
treatments, ie. in the Leptospirosis Ward or in the HD Main Unit.
 If an HD Unit will be set-up in the Leptospirosis Ward, the following will be put
in place:
- 1 Computer Station
- 1 Telephone Line
- Sufficient HD supplies and on and off dressing kits
33
 The HD Charge Nurse and HD technicians will prepare and set-up the HD
Unit. The HD Unit Supervisor or Assistant will arrange for additional HD staff if
necessary, to ensure that the provision of HD is not disrupted.
 An HD fellow should be present at all times when there are patients
undergoing HD in the Leptospirosis Ward.
 All prescriptions for medications, supplies, dialysis orders and laboratories
shall be stamped with “LEPTOSPIROSIS” so that the Pharmacy and CSSU
will be alerted that the requests should be provided, without pre-approval by
MSSD.
K. Peritoneal Dialysis (PD) Unit

 Once the Leptospirosis Upsurge Policy is activated, the PD Unit Supervisor
will contact the HEALTHCARE FACILITY’s PD Provider to augment the
number of PD cycler machines as needed, to accommodate the increased
number of patients who will be requiring PD and to request for additional PD
Nurses to assist the PD Unit in providing PD services.
 The PD Unit Supervisor will ensure that there are sufficient supplies of PD
catheters, solutions and accessories at all times, in coordination with
Warehouse and Purchasing in all areas where Leptospirosis patients are
admitted, especially in the Leptospirosis Ward.
 The PD Nurses will monitor all Leptospirosis patients who are started on PD
therapy, whether manual or cycler-assisted.
 Patients will not be allowed to do their own PD exchanges while admitted in
the wards.
 The PD nurses will ensure that PD is performed in a sterile manner and that
there is no PD-related infection.
 The PD nurses will ensure that PD is done as prescribed, according to the
prescription of the Nephrologist.
 The PD Nursing Attendant will assist the PD nurses in all activities related to
PD.
 Once the patient is ordered discharged by Nephrology, the PD Nurse will
ensure that the patient is referred back to Vascular Surgery for removal of the
PD catheter prior to discharge. This should be performed in the OR. The PD
Nurse will ensure that the appropriate charges for PD catheter removal are
made.
34
L. Infection Prevention and Control Committee

 Tasked to monitor cases of Leptospirosis and to submit the cases to the DOH-
Philippine Integrated Disease Surveillance and Response through master
database system.
 The post duty Senior Adult Nephrology fellow will email to the IPCC Office the
daily leptospirosis tally and census.
M. Medical Social Services Division (MSSD)

 Facilitate care regarding the psychological and social needs of patients.
 The MSSD will provide staff that will be available 24 hours a day, 7 days a
week with on-call coverage at all times during activation of the Leptospirosis
Upsurge Policy.
 They are responsible for determining if patients are already members of
PhilHealth, or are dependents of PhilHealth members, and if not, for
completing all the information necessary for patients to enroll in PhilHealth at
point-of-care.
 They will complete a database on all patients treated, demographics, the type
of dialysis provided, if any, and outcome, dates of admission and discharge,
referring hospital, financial assistance, PHIC membership and running
charges.
 Since patients may develop reversible acute kidney or liver injury, all the
medical needs should be provided without the need for pre-approval from
MSSD.
 They will prepare the running balance of expenses related to Leptospirosis
and submit regular reports to the Chief of Hospital and to the Head of the
Leptospirosis Upsurge Management Team and other Executives.
N. Pharmacy Division
 Responsible for making sure that patients receive the most appropriate
medicines in the most effective and timely way. They prepare and dispense
medications.
 All the Pharmacy requirements should be provided without the need for pre-
approval from MSSD.
 They will ensure that the Leptospirosis Ward and other wards that have
admitted Leptospirosis patients are provided with all the necessary
medications (See Appendix A and C) such as:
- Amoxicillin suspension 250mg/5ml
- IV Penicillin G 1.5M units/vial
35
- IV Ceftriaxone 1 gram/vial
- IV Hydrocortisone 100mg/ampule
- IV Methylprednisolone 500mg/vial
- IV Cyclophosphamide 1gram/vial
- IV Potassium chloride 2meq/ml, 5ml/vial
- IV Calcium gluconate 10%/vial
- IV Magnesium sulfate 50%/vial
 The following should also be available in sufficient quantities:

- Doxycycline 200mg/cap
- Amoxicillin 500mg/cap
- Omeprazole 40mg/amp
- IV Plain NSS 1liter/ bottle
- Dopamine 200mg/5ml vial
- Norepinephrine 1mg/ml, 10ml vial
- Dobutamine 250mg/25ml vial
O. Housekeeping Section
 Tasked to set up the Leptospirosis Ward once ordered by the Head of the
Leptospirosis Upsurge Management Team for a maximum of 50-cot beds.

(See Part IV)
P. Procurement and Supply Management Divisions

 Strategize, lead and manage logistics to ensure operational effectiveness. It
includes ensuring the hospital has sufficient inventory to manage the
Leptospirosis Upsurge, and that all inventory are accurately accounted for at
all times.
 They will manage and direct the timely and cost effective supply of goods.
 All purchases in relation to the treatment of Leptospirosis patients or in
augmenting supplies or equipment for the Leptospirosis Ward shall be
reported on a weekly basis and submitted to the Head of the Leptospirosis
Upsurge Management Team, the Chief of Hospital and to the Deputy
Executive Director for Hospital Support Services.
 The Head of Procurement and Supply Management Divisions must inform the
Head of the Leptospirosis Upsurge Management Team immediately if there
are problems with stocks required to support the services for the Leptospirosis
Ward.
36
Q. Central Supply and Sterilization Unit (CSSU)

 Responsible for supplying all of the wards of the hospital with all of the
supplies necessary to complete daily operations.
 They are in charge of keeping the hospital's storage facilities stocked with
adequate supplies for HD, PD, dialysis access, cut down sets etc.
 The following should be available in sufficient supply:
- Paper tape - Endotracheal tube standard
- Hand sanitizer - Endotracheal Tube with subglottic
- Cotton balls suction
- Povidone-iodine - Nasogastric tube
- Alcohol - HD triple lumen catheters for right
- Foley catheters and left internal jugular vein
- Cut down set - PD catheters (Adult and Pediatric)
R. Billing and Claims Division

 They are responsible for the preparation of hospital bills for Leptospirosis
patients.
 They are responsible for submitting claims to PhilHealth for point-of-care
benefit, as well as the routine claims for PhilHealth members.
 They will provide reports to Management on a weekly basis on the total
subsidy by the HEALTHCARE FACILITY for Leptospirosis patients in
coordination with MSSD.
 They will coordinate with IRM to ensure that patients are charged with the
appropriate room rates when they are admitted to the Leptospirosis Ward.
S. Admitting and Discharge Section

 They will facilitate admission of patients with Leptospirosis to the designated
Leptospirosis Ward or service beds, and ensure that the appropriate room
rates are charged for service patients.
 The Admitting “face sheet” shall be stamped with “LEPTOSPIROSIS” so that
the Wards, Pharmacy, CSSU and other concerned areas will be alerted that
the medical diagnostics and treatments should be provided, without pre-
approval by MSSD.
37
T. Information Resource Management Division (IRM)

 Responsible for the management of data within HEALTHCARE FACILITY, to
ensure a seamless coordination with the different Departments.
 They will set-up the computer stations in the Leptospirosis Ward Nurses
Station with connectivity to the Medsys and radiology system and for the HD
unit set-up in the Leptospirosis Ward.
 They will ensure that charges for use of the ER-OR for removal of either HD or
PD catheters are included in the patient's final hospital bill, even if the patient
is admitted in the wards.
U. Nutrition and Dietetics Division (NDD)

 They will provide meals for all patients in the Leptospirosis Ward.
 They will provide meals for the HEALTHCARE FACILITY staff and augmented
staff from other hospitals assigned to the Leptospirosis Ward.
 Once there are more than 100 patients admitted for Leptospirosis, in excess of
the total number of in-patient beds, they will do emergency purchase of food
items and other supplies to ensure the continuous supply of meals.
38
IV. SETTING UP A LEPTOSPIROSIS WARD
Once the Leptospirosis Ward is opened, the following should be put in

place for a 30 to 50 bed ward by the Housekeeping Unit:
 Patient cots  Oxygen gauge
 IV stands  Oxygen tank
 1 watcher chair per patient  Oxygen mask
 Bed linens  1 Disposable thermometer per patient
 BP Apparatus  Infusion pumps
 Wheel chairs with IV stand
The following may be placed in the Leptospirosis Ward if needed:

 Extension wires for the infusion pumps, coolers, PD cyclers, HD machines
etc.
 Air Coolers or industrial fans
 Freezers or ice chests
 Water dispenser
A Nurses Station will be put in place in a strategic area in the Leptospirosis

Ward to ensure accessibility to communications. The Nurses Station will be
equipped with the following:
 3 Computer stations with access to charging of supplies etc., access to the
HEALTHCARE FACILITY COMMUNICATIONS MODULE for laboratories
etc. and 1 printer
 2 Telephone units
 Forms: laboratory requests, admitting forms, order sheets, TPR sheet,
input/output sheet etc.
 Patient folders or clipboards
 Basic medical supplies for patients
 HD access catheters, PD catheters and supplies
 Dressing kits and cut-down sets
 Other logistics such as industrial electric fans, ice for the fans etc. may be
requested from the Housekeeping Section
The PD Unit will be informed for transfer of PD cycler machines as needed.

All prescriptions for medications, supplies, dialysis orders and laboratories shall
be stamped with “LEPTOSPIROSIS” so that the Pharmacy and CSSU will be
alerted that the requests should be provided, without pre-approval by MSSD.
39
V. STAFFING REQUIREMENTS IN THE LEPTOSPIROSIS WARD
A. Medical Staffing in the Leptospirosis Ward

 The goal for medical staffing is to maintain a doctor-patient ratio of 1:20. The
Adult Nephrology PD fellow 1 is assigned to cover the Leptospirosis Ward until
a maximum of 20 patients. The PD fellow 2 goes on night duty at the
Leptospirosis Ward.
 Pediatric Nephrology fellows make rounds on their patients only, but do not go
on duty at the Leptospirosis Ward. Once there are more than 10 pediatric
patients at the Leptospirosis Ward then a Pediatric Nephrology fellow will go
on duty in the area.
 One Internal Medicine resident is also assigned to the Leptospirosis Ward
once it opens.
 Once there are >20 to 40 patients, the PD senior and GN senior fellows are
called to augment staffing on rotation to maintain at least 2 Nephrology fellows
at any time. At this point, fellows from outside rotations and elective rotations
will be recalled to assist in going on duty in the Leptospirosis Ward.
 A Nephrology fellow must be at the Leptospirosis Ward while there are
patients undergoing HD in the area.
 Seriously ill patients are admitted to the regular hospital wards (ie. require
inotropes, active bleeding, require oxygen support). Thus, relatively stable
patients, dialysis-dependent, hydration requiring alone, are confined in the
Leptospirosis Ward.
 Once the Leptospirosis Ward reaches a capacity of 40 patients or more, the
Senior Nephrology Fellow will inform the Head of the Leptospirosis Upsurge
Management Team and the Chief of Hospital to request for external staff
augmentation from other Institutions to help in monitoring of patients. The
HEALTHCARE FACILITY Chief of Hospital will inform the DOH-Field
Implementation and Coordination Team-NCR, of the need for medical staff
augmentation. Physicians with experience in attending to general medical
patients will be preferred. They will report to the Chief Adult Nephrology Fellow
for assignment.
40
B. Nurses Staffing in the Leptospirosis Ward

 Once the HEALTHCARE FACILITY has 30 patients admitted, they will be
placed in the identified “Leptospirosis Ward” and the Leptospirosis Critical
Extension Ward (for Patient Classification System (PCS) Level IV).
 12 nurses, 6 nursing attendants and 1 clerk from the different units of
HEALTHCARE FACILITY will be identified and pulled-out and assigned to the
Leptospirosis Ward. Three nurses and 1 nursing attendant will be assigned
per shift with the nurse-patient ratio of 1:8-10.
 For leptospirosis patients on PD, a PD Unit Roving nurse will do the rounds on
a regular basis to facilitate PD.
 Once the number of patients exceeds 30, the Deputy Executive Director for
Nursing Services will inform the Head of the Leptospirosis Upsurge
Management Team and the Chief of Hospital to request for external staff
augmentation from other Institutions to help in monitoring of patients. The
Head of the Leptospirosis Upsurge Management Team and/or Chief of
Hospital will inform DOH-Field Implementation and Coordination Team-NCR,
of the need for staff augmentation (physicians, nurses, nursing attendants etc.)
The Assistant Coordinator of the Health Emergency Management Bureau
(HEMB) of HEALTHCARE FACILITY will likewise be informed of the need for
staff augmentation to coordinate with HEMB.
 Nurses staffing augmentation will be composed of 12 nurses and 6 nursing
attendants to be assigned to either of the two identified units or to the ER.
They will report to the Deputy Executive Director for Nursing Services or
his/her representative for the assigned area of deployment.
 The Chief of Hospital and other Deputy Executive Directors may also call other
Department of Health Hospitals, Army Hospitals or LGU Hospitals for
assistance in augmenting the staffing needs.
 Once the number of leptospirosis cases decreases to thirty (30) and below,
the augmentation team shall return to their respective hospitals.
41
VI. HEALTH CARE PROVIDER NETWORK (previously called as SDN)
To guarantee access of patient with Leptospirosis to quality and affordable health

services, without causing any financial burden it is important that a Health Care
Provider Network be established.
Under the Universal Health Care Law, RA 11223, Sec. 4.i. Health Care Provider
Network refers to a group of primary to tertiary care providers, whether public or
private, offering people-centered and comprehensive care in an integrated and
coordinated manner with the primary care provider acting as the navigator and
coordinator of health care within the network.
An important key feature of a Health Care Provider Network is a functional Two-way

Referral System which will help ensure the continuity of care from one health service
facility to another. It Includes:
1. Transport system to move the patient from one facility to another
2. Establishment of two-way communication system
3. Interoperable information system
4. Clearly defined referral manual
The NKTI is one of four specialty hospitals strategically situated in Metro Manila. As
an end referral hospital for patients suffering from severe form of Leptospirosis with
pulmonary and/or renal complication, maximization of its service capability utilization
for targeted patient population can be achieved efficiently thru a functional service
provider network currently being organized by DOH-FICT Team (NCR and MM).
42
VII. ANTIBIOTIC PROPHYLAXIS FOR LEPTOSPIROSIS
For relatives of patients and HEALTHCARE FACILITY employees with a

history of flooding in flooded waters, the following prophylaxis should be given:
A. Recommended post-exposure prophylaxis for Leptospirosis for adults

(San Lazaro Hospital’s Guideline on Prophylaxis for Leptospirosis 2009)
LOW-RISK EXPOSURE is defined as those individuals with a single history of
wading in flood or contaminated water without wounds, cuts or open
lesions of the skin.
 Doxycycline 200 mg single dose within 24 to 72 hours from exposure
[Grade B]
MODERATE-RISK EXPOSURE is defined as those individuals with a single

history of wading in flood or contaminated water and the presence of wounds,
cuts, or open lesions of the skin, OR accidental ingestion of contaminated
water.
 Doxycycline 200 mg once daily for 3-5 days to be started immediately
within 24 to 72 hours from exposure [Grade C]
HIGH-RISK EXPOSURE is defined as those individuals with continuous

exposure (those having more than a single exposure or several days such as
those residing in flooded areas, rescuers and relief workers) of wading in flood
or contaminated water with or without wounds, cuts or open lesions of the
skin. Swimming in flooded waters especially in urban areas infested with
domestic/ sewer rats and ingestion of contaminated water are also considered
high risk exposures.
 Doxycycline 200 mg once weekly until the end of exposure [Grade B]
B. Recommended post-exposure prophylaxis for Leptospirosis for pregnant

women
 Amoxicillin 500 mg/tab 1 tab BID x 3 days
 If allergic to amoxicillin, may give erythromycin 250 mg BID x 3 days
43
C. Recommended post-exposure prophylaxis for Leptospirosis for children
From the Post Disaster Interim Advice on the Prevention of Leptospirosis in

Children. August 10, 2012. Pediatric Infectious Disease Society of the
Philippines, Inc.
Drug Dose Comments
Doxycycline 4mg/kg single Proven efficacy for preventing clinical
dose, disease.
Max: 200mg Adverse effects are similar to other
tetracyclines; in children below 8 years of
age, doxycycline is unlikely to cause
dental staining at the dose and duration
recommended to treat serious infections.
Avoid milk, dairy products, iron and
antacids 1 hour before and 2 hours after
administration; may be given with food to
avoid stomach upset.
Alternative
Drugs Efficacy for prevention of leptospirosis
Azithromycin was seen in vitro and animal models.
Amoxicillin 50mg/kg/day No clinical trial for prevention of
divided into 4 leptospirosis, but amoxicillin is known
doses for 3-5 alternative for the treatment of disease.
days Dose is for 3-5 days due to the very short
Max: 500mg half-life.
q6H
If children are exposed for more than 7 days, the dose should be repeated
after 1 week.
*This algorithm for Leptospirosis was made by the NKTI-Department of Pediatric Nephrology:
Dr. Zenaida Antonio Dr. Ofelia De Leon
Dr. Ma. Angeles Marbella Dr. Ma. Lorna Lourdes Simangan
Dr. Violeta Valderama Dr. Norma Zamora
Dr. Coe Dela Seña
44
APPENDICES
Appendix A. Algorithm for Leptospirosis (Revised August 2013)
Fever, Conjunctival Suffusion, Muscle Aches

History of Wading In Flood Waters
+/- Icterisia, Jaundice
DIAGNOSTICS:
INITIAL MANAGEMENT:
1. CBC with platelet count
1. Fast drip 2 liters Plain NSS
2. Creatinine, Sodium, Potassium Calcium,
(May insert 2 IV Lines) then continue hydration at
Albumin, Lipase
300 cc/ hour
3. ABG as needed
2. Start Penicillin-G at 1.5million units IV every 6 hrs
4. Baseline ECG
OR Ceftriaxone 1gram IV OD, if patient fulfills
5. Chest PA
criteria for Pulse Therapy.*
6. PT, PTT Daily if needed
7. LAT IgG and IgM
8. If negative for both, send serum for IgM and
IgG after 7 days
9. Send out specimen for Microscopic
Agglutination Test (MAT) care of Laboratory
Medicine Department
*CRITERIA FOR PULSE THERAPY

(any one)
1. Platelet count less than 100,000
2. SBP less than 90mm Hg after isotonic fluid resuscitation of 2L
3. Requires inotropes
4. Lung infiltrates on Chest Xray
5. Prolonged PT, PTT
YES NO
 Give Methylprednisolone 500 mg/ IV after HD OD  Patient requires dialysis**

x 3 days.  Platelet count >100,000 but less than
 After the 3rd Methylprednisolone dose or after 150,000
any episode of hemoptysis, give
Cyclophosphamide 1 gm IV as a single dose
after HD YES NO
 Give Ceftriaxone 1 gm IV OD (instead of
Penicillin G)
 Give Omeprazole 40 mg IV OD  Give hydrocortisone 100 mg IV every 6
*If the patient has been started on Hydrocortisone IV, hours
give the remaining steroid dose to reach the target  Continue IV Penicillin G
dose of MPP 500 mg/ day (see steroid conversion).  Give Omeprazole 40 mg IV OD
Then give the Methyprednisolone 500 mg IV OD on
days 2 and 3.
*Steroid conversion:
Hydrocortisone 5mg = Methyprednisolone 1mg
PROCEED TO ALGORITHM FOR DIALYSIS THERAPY
45
ALGORITHM FOR DIALYSIS THERAPY
Urine output: <500cc/day

AND/OR Creatinine: >3 mg/dl
YES NO
FULFILLS ANY OF THE CRITERIA Continue hydration

FOR PULSE THERAPY Do serial laboratory monitoring
YES NO
Do Acute Do acute PERITONEAL DIALYSIS (APD)

HEMODIALYSIS 1. APD 1.5%, 1.5L per exchange, dwell time 30 min x 40 exchanges.
May use hypertonic exchange if patient needs fluid removal.
2. Hydrocortisone 100mg IV q6 hrs x 3 days
3. Omeprazole 40 mg 1 tab OD
If with improving creatinine, urine output and better well-being,

step down antibiotic to Doxycycline 100mg BID on day 1,
then 100mg OD thereafter OR Amoxicillin 500mg QID, to complete 7 days.
* This algorithm for Leptospirosis was made by NKTI Multi-Disciplinary Team composed of:
Dr. Romina Danguilan, Department of Adult Nephrology
Dr. Myrna Mendoza, Internal Medicine, Section of Infectious Disease
Dr. Ernesto Que, Internal Medicine, Section of Gastroenterology
Dr. Joselito Chavez, Internal Medicine, Section of Pulmonary Medicine
46
Appendix B. Leptospirosis Prophylaxis Survey

For Patient
Name: Date of Admission:
Address:
Age/Sex: Chief Complaint:
Exposure to Flood: Yes No Date of Exposure:
Duration in Days: Number of Times Exposed:
Wounds on Exposed Area to the Flood: Yes No

Ingestion of Flood Water: Yes No Prophylaxis Taken: Yes No
Drugs Used and Dosage:  Doxycycline 100mg 2x/day for days
 Amoxicillin 500mg 2x/day for days
Initial Sign/Symptom:
Signs and Symptoms Began:
Total number of household members including patient:
How many were EXPOSED to flood?
Fill-in for Each Household Member EXPOSED

Type of Household Member:
Family (state relation to patient):

Non-family (state role in household):
Name:
Age/Sex: Date of Exposure:
Duration in Days: Number of Times Exposed:
Wounds on Exposed Area to the Flood: Yes No

Ingestion of Flood Water:  Yes No
Prophylaxis Taken: Yes No
If Yes, Drugs Used and Dosage:
  Doxycycline 100mg 2x/day for days
 Amoxicillin 500mg 2x/day for days
Sign and Symptom:
47
Appendix C. Algorithm for Leptospirosis (Pediatric Patients)
SUSPECTED LEPTOSPIROSIS
Fever for 2 days plus

History of wading in flood water plus
Nonspecific signs and symptoms
(conjunctival suffusion, headache, myalgia, vomiting, diarrhea,
abdominal pain, difficulty of breathing)
+ jaundice/icterisia
DIAGNOSTICS
CBC;
BUN creatinine, serum Na, K, Ca, SGPT
Urinalysis
Chest xray
Leptospirosis LAT/MAT
PT PTT
ABGs
MILD LEPTOSPIROSIS MODERATE-SEVERE LEPTOSPIROSIS

(AKI-Risk) (AKI-Injury and Failure)
Elevated serum creatinine, with or without hepatic involvement
Stable vital signs, no jaundice Urine output < 0.5cc/kg/hr with pulmonary congestion/
Urine output > 0.5cc/kg/hr hemorrhage/ sepsis able to take oral medications
Normal serum creatinine
No evidence of pulmonary congestion/
hemorrhage/ sepsis ADMIT
able to take oral medications
CRITERIA FOR PULSE THERAPY

Close follow-up Any one
Give fluids based in fluid status 1. Platelet count <100,000
2. SBP < 90mm Hg after isotonic
fluid resuscitation of 2L
MAY SEND PATIENT HOME 3. Requires inotropes
For children >8 years old, 4. Lung infiltrates on chest xray
DOXYCYCLINE 100 mg PO BID on 5. Prolonged PT, PTT
Day1 then 100 mg OD thereafter or
4mg/kg divided into 2 doses for less
than 50kg
For children 8 years old or less, YES NO

Amoxicillin 30-50mg/kg/day q6
(max 500mg QID)
or
Azithromycin 1g initial dose then Give methylprednisolone 500mg
500mg OD or 10mg/kg/day OD for 3 IV after HD OD x 3 days
days Give ceftriaxone 1g IV OD
Low eGFR, high BUN,
(instead of Penicillin G)
UO > 0.5cc/kh/hr
Give omeprazole 40mg IV OD
stable vital signs (1)
Low eGFR, high

BUN,
UO > 0.5cc/kg/hr
stable vital signs (2)
48
Low eGFR, High BUN,

(1) (Pediatric Patients) UO decrease 0.5cc/kh/hr
stable vital signs
CXR
NO CONGESTION WITH CONGESTION

Step A IV hydration 3- Step B Start furosemide 2-6mg/kg as IV
5cc/kg/hr bolus q6 or drip IVF M x 0.3 + UO
Monitor UO Monitor UO
Increase UO, stable vital No improvement, with

signs, increase eGFR signs of congestion
Continue hydration Proceed to step B
Increase UO, stable vital No improvement, with

signs, increase eGFR progression of congestion
Continue step B Step C: Do RRT
Decreased eGFR, increased

BUN, UO increase 0.5cc/kh/hr
(2) (Pediatric Patients)
stable vital signs
HYPOVOLEMIA EUVOLEMIA HYPERVOLEMIA
PNSS 20cc/kg/hr IV fast

drip upto 3 doses or until PNSS 20cc/kg IV fast drip + signs of congestion
euvolemic upto 2 doses With crackles
Continue IVF depending Proceed to Step C
on hydration status
(mild/moderate/severe)
No improvement, with Increase UO, stable vital

signs of congestion signs, increase eGFR
Increase UO, stable vital Proceed to Step C Continue Step A
signs, increase eGFR
Continue Step A
No improvement, with signs of With signs of Increase UO, stable vital

congestion congestion signs, increase eGFR
Proceed to step B Proceed to Step C Continue step B
If hypotensive, start inotropes:
Dopamine drip if in cold shock,
norepinephrine drip if in warm shock
49
Step C (Pediatric Patients)

No improvement, with signs
of congestion
Proceed to Step C
MILD CONGESTION MODERATE-SEVERE CONGESTION
No acidosis, normal RR Intractable acidosis, increased RR

+ crackles BLF, no desaturation Crackles BLF, oxygen-requiring
CAPD HEMODIALYSIS
LEPTOSPIROSIS
With Suspected Pulmonary Hemorrhage
Cough, dyspnea, hemoptysis Give Methylprednisolone

Continue Observation RR > 30 for children > 5yo 10-20mg/kg
> 40 for children 1-5yo Max: 500mg IV
Continue Observation Presence of the following:

Discontinue Steroids Chest Xray-Bilateral Infiltrates
No PF ratio < 250 OR
SaO2< 90% at 6L/min via face
Yes
Intubate patient* and hook to

mechanical ventilator
Continue methylprednisolone
10-20mg/kg, max 500mg IV for 2 more days
then Prednisone 1mg/kg/day x 7 days
50
Appendix D.Leptospirosis Census Format for Reporting
51
Appendix E. Criteria for Assisted Ventilation for Leptospirosis Patients
Indications for BIPAP:

Establish need for Ventilatory Assistance in an alert and cooperative patient:
 Moderate to severe respiratory distress
 Tachypnea (RR>24 breaths/min)
 Accessory muscle use or abdominal paradox
 pH <7.35, arterial PCO2>45mmHg or arterial PO2/FIO2<200
Exclude patients with contraindications to Non-invasive ventilation:

 Respiratory arrest
 Medically unstable (septic or cardiogenic shock, uncontrolled upper
gastrointestinal bleeding, uncontrolled arrhythmias)
 Unable to protect airway
 Excessive secretions
 Uncooperative or agitated
 Unable to fit mask
 Recent upper airway or gastrointestinal surgery
Indications for Intubation:

 Hypoxic respiratory failure: PaO2/FiO2 <200 (moderate ARDS) or O2
saturation <90% at 10 L/min face mask with rebreathing bag
 Hypercapneic respiratory failure: pH <7.2, PCO2 > 45mmHg
 Deterioration of sensorium
 Failure of noninvasive ventilation
*Once intubated, co-manage with anesthesiologists for adequate sedation
Indications for ECMO in Leptospirosis patients with pulmonary hemorrhage resulting

in ARDS;
Use of SOFA/ Murray Score to initially evaluate patient
 PaO2/FiO2 < 100 on FiO2> 90% and/or Murray score 3-4 despite optimal care
for 6 hours or less. The best outcome in ECMO for adult respiratory failure
occurs when ECMO is instituted early after onset (1-2 days).
 CO2 retention on mechanical ventilation despite high Pplat (>30 cm H2O)
52
Contraindications for ECMO:

There are no absolute contraindications to ECMO. Each patient is considered
individually with respect to benefits and risks. However, the following may be
considered contraindications if present (based on HEALTHCARE FACILITY
Protocol).
 Cardiac arrest
 Mechanical ventilation for more than 3 days
 CNS hemorrhage
 Nonrecoverable comorbidity such as major CNS damage or terminal
malignancy
 Age: no specific age contraindication but consider increasing risk with
increasing age
 Pancreatic enzymes: Lipase > 2x upper limit of normal
References:
Murray and Nadel’s Textbook of Respiratory Medicine
ELSO Adult Respiratory Failure Guideline
Murray Score
53
DEFINITION OF TERMS
Upsurge An increase or an upward surge in the number of leptospirosis patients

requiring hospital admission, wherein the hospital must augment
bedspace availability to accommodate all of the patients
GLOSSARY
ER – Emergency Room
HD – Hemodialysis
MSSD – Medical Social Services Division
OR – Operating Room
PD – Peritoneal Dialysis
RRT – Renal Replacement Therapy
SHO – Senior House Officer
54
NOTES DOH Guidelines for Leptospirosis for Hospitals
55
NOTES DOH Guidelines for Leptospirosis for Hospitals
56
57

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DOH

TECHNICAL WORKING GROUP

Research Institute for Tropical Medicine

National Kidney and Transplant Institute

Chapter 1: MANAGEMENT PROTOCOL FOR LEPTOSPIROSIS

II. Criteria for Diagnosis 5

III. Indications for Admission and Guidelines on

IV. Laboratory Work Up

V. General Guidelines in the Management of Leptospirosis 9

VI. Antibiotic Management 9

VII. Steroid Therapy 11

VIII. Pulmonary Complications of Leptospirosis

IX. Renal Complications of Leptospirosis 15

X. Prevention and Control 18

Chapter 2: UPSURGE POLICIES AND PROCEDURES

I. Statement of Purpose and Scope

II. Key Policies

III. Roles and Responsibilities of the Various Departments/ Divisions/Sections

IV. Setting up a Leptospirosis Ward 39

V. Staffing Requirements in the Leptospirosis Ward

VI. Health Care Provider Network 42

VII. Antibiotic Prophylaxis for Leptospirosis

Chapter 1: MANAGEMENT PROTOCOL FOR LEPTOSPIROSIS

Leptospirosis is a zoonotic infection caused by pathogenic spirochetes of the

In Philippines, leptospirosis tends to occur frequently in urban flood-prone

Leptospirosis is primarily a disease of domesticated and wild animals. Humans

Leptospirosis presents in two (2) forms: anicteric (mild) or icteric (severe)

The clinical course of leptospirosis varies but it is generally predictable. Both

2. The IMMUNE PHASE (sometimes LEPTOSPIRURIC PHASE,

In the Philippines, majority of the symptoms of Leptospirosis is non-specific,

II. CRITERIA FOR DIAGNOSIS

Leptospirosis should be suspected in an individual with:

A checklist for diagnosing leptospirosis for frontliners have been developed

III. INDICATIONS FOR ADMISSION AND GUIDELINES ON

Patients with suspected leptospirosis presenting with MILD symptoms can be

On the other hand, patients with suspected MODERATE to SEVERE

Patients with leptospirosis who are suspected to have pulmonary

Moderate hypoxemia: 100<PaO2/FiO2<200 with PEEP≥ 5 cmH2O

Patients with moderate to severe hypoxemia need to be admitted to the

IV. LABORATORY WORK UP

The DEFINITIVE diagnosis depends on laboratory findings. Criteria for definite

PRESUMPTIVE diagnosis of Leptospirosis may be based on the following

2. Microbiologic Test: Non-culture Method

b. Rapid leptospiral diagnostic kits (i.e. immunochromatographic tests or

Table 3. Appropriate timing of Specimen collection for specific leptospiral tests

Refer to Annex B: Guidelines on Specimen collection, storage and transport

b. MODERATE to SEVERE (request each test if clinically indicated)

V. GENERAL GUIDELINES IN THE MANAGEMENT OF LEPTOSPIROSIS

Most cases of leptospirosis will be mild and self-limited. A suspicion of

The subsequent chapters will discuss the specific recommendations in the

VI. ANTIBIOTIC MANAGEMENT

All patients with suspected leptospirosis should be started on antimicrobial

Treatment with effective antibiotics should be initiated as soon as the

Doxycycline 5 mg/kg/day PO in 2 divided doses (max 200mg/day) x 1 week.

Table 4. Recommended Antibiotic Regimens for Leptospirosis

Doxycycline 100 mg BID PO for 10 days Amoxicillin 30-50 mg/kg/day in 3 divided

Amoxicillin 500mg QID or 1g q8h

hrs for 7 days in 6 divided doses for 1 week

 Ampicillin 0.5-1.0 gm q6h  Tetracycline 25-50 mg/kg/day orally in four

 Doxycycline 5 mg/kg/day PO in 2 divided