DOH GUIDELINES for LEPTOSPIROSIS for HOSPITALS

DOH GUIDELINES for LEPTOSPIROSIS for HOSPITALS 2019 Edition DOH GUIDELINES for LEPTOSPIROSIS for HOSPITALS 2019 Edition DOH Guidelines for Leptospirosis for Hospitals i DOH Guidelines for Leptospirosis for Hospitals F O R E W O R D ii DOH Guidelines for Leptospirosis for Hospitals iii DOH Guidelines for Leptospirosis for Hospitals 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. iii DOH Guidelines for Leptospirosis for Hospitals iv DOH Guidelines for Leptospirosis for Hospitals 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 iv DOH Guidelines for Leptospirosis for Hospitals 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 v DOH Guidelines for Leptospirosis for Hospitals 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 vi DOH Guidelines for Leptospirosis for Hospitals 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 1 DOH Guidelines for Leptospirosis for Hospitals 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

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