Leptospirosis CPG 2010 TABLE OF CONTENTS

Leptospirosis CPG 2010 TABLE OF CONTENTS free pdf ebook was written by Admin on November 20, 2010 consist of 66 page(s). The pdf file is provided by www.psmid.org.ph and available on pdfpedia since April 11, 2012.

leptospirosis cpg 2010 table of contents foreword the guideline development process .. the..and ancillary procedures may indicate severe leptospirosis? references. chapter 3 - treatment..american-european consensus conference criteria for ards .. 6.2 diagnostic studies .. references. 6.3 management...

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Leptospirosis CPG 2010 TABLE OF CONTENTS pdf




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Leptospirosis CPG 2010 TABLE OF CONTENTS - page 1
Leptospirosis CPG 2010 TABLE OF CONTENTS Foreword .......................................................................................... The Guideline Development Process ............................................... The Leptospirosis Task Force........................................................... Chapter 1 – Clinical Recognition of Leptospirosis ............................ 1.1 What clinical manifestations should alert a health practitioner to suspect leptospirosis among patients presenting with acute fever? ................................... Table 1. Clinical features of leptospirosis after a flood .......... Table 2. Clinical features of seasonal leptospirosis among patients at various hospitals in Manila compared to the 2009 outbreak ............................. 1.2 Which patient will need hospital admission? ........................ References............................................................................ Chapter 2 – Laboratory Diagnosis of Leptospirosis.......................... 2.1 What laboratory tests are available locally to confirm the diagnosis of leptospirosis? .............................................. Table 3. Summary of guidelines for specimen collection ...... Table 4. Performance characteristics of rapid diagnostic tests ........................................................................ Table 5. Local guidelines for collection and transport of specimens ........................................................... Table 6. Summary of laboratory diagnosis of leptospirosis ... 2.2 What other laboratory tests are recommended for leptospirosis? ........................................................................ 2.3 What laboratory findings and ancillary procedures may indicate severe leptospirosis? ....................................... References............................................................................ Chapter 3 - Treatment of Leptospirosis ............................................ 3.1 What antibiotics are recommended for leptospirosis? ......... Table 7. Dosage of antibiotics recommended for leptospirosis ...................................................... Table 8. Dosage of antibiotics in adults with renal impairment .............................................................. 3.2 When should antibiotic therapy be started? .......................... References............................................................................ 3 4 6 7 7 8 9 10 11 13 13 18 21 22 23 25 25 28 31 31 33 33 34 35 1
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Leptospirosis CPG 2010 TABLE OF CONTENTS - page 2
Leptospirosis CPG 2010 Chapter 4 – Antibiotic Prophylaxis for leptospirosis.......................... 4.1 What is the recommended pre-exposure prophylaxis? ........ 4.2 What is the recommended post-exposure prophylaxis? ....... Figure 1. Algorithm for post-exposure prophylaxis................ Pharmacology of Doxycycline ............................................... References............................................................................ Chapter 5 – Leptospirosis-Associated Acute Kidney Injury .............. 5.1 Diagnosis of AKI due to leptospirosis.................................... 5.2 Management of AKI .............................................................. Figure 2. Algorithm for the management of oliguria .............. References............................................................................ Chapter 6 – Pulmonary Complications of Leptospirosis .................. 6.1 Clinical diagnosis of pulmonary complications ..................... Table 9. Characteristics of patients with and without pulmonary involvement............................... Table 10. American-European consensus conference criteria for ARDS ................................ 6.2 Diagnostic studies ................................................................. References............................................................................ 6.3 Management of pulmonary complications ............................ Figure 3. Algorithm for the diagnosis and management of pulmonary complications .................................... References............................................................................ Appendix Leptospirosis Data Collection Form ...................................... 36 36 38 40 41 43 45 45 46 49 50 52 52 53 55 56 57 59 61 62 64 2
Leptospirosis CPG 2010 TABLE OF CONTENTS - page 3
Leptospirosis CPG 2010 F OREWORD Leptospirosis is an endemic zoonosis in the Philippines with an average of 680 leptospirosis cases and 40 deaths from the disease reported every year and a prevalence of 10/100,000. It is seasonal with a peak incidence during the rainy months of July to October. Clinical studies in the 60s and 70s and seroepidemiological surveys have documented the presence of leptospiral serovars in the country. Specifically, antibodies to various leptospiral serovars have been reported in urban domestic rats, rural eld rats, water buffaloes, cattle, pigs, dogs and monkeys in the Philippnes. It has been more than a year now since Typhoon Ketsana, locally known as “Ondoy” and Typhoon Parma or “Peping” ravaged the country in succession. Leptospirosis re- emerged as an aftermath of the heavy rainfall which led to massive ooding in the cities of Metro Manila and in the provinces of Luzon. Within only six hours, 455mm of rain fell on the area, an amount equivalent to a typical month’s rainfall in the monsoon season according to the Philippine Atmospheric, Geophysical and Astronomical Services Administration (PAGASA). Several communities were under water due to clogged drainage systems brought about by poor garbage disposal systems. The Center for Health Development offices of the Department of Health reported that “Ondoy” affected 12 regions in the country and afflicted more than 800,000 families. The most affected regions were the CALABARZON, the National Capital Region (NCR) and Central Luzon, putting these areas under a state of calamity. As soon as the leptospirosis outbreak was recognized in Metro Manila in October 2009, interim clinical practice guidelines were drafted by the Philippine Society for Microbiology and Infectious Diseases, the Philippine Society of Nephrology and the Council for Critical Care and Vascular Pulmonary Diseases of the Philippine College of Chest Physicians. Consensus meetings were held to formulate recommendations on the diagnosis and management of suspected leptospirosis cases and its complications. These interim guidelines were released by the Philippine College of Physicians and the Department of Health to guide the health care practitioners in the affected areas in the diagnosis, treatment and prevention of leptospirosis and its complications. As of November 2009, the National Epidemiology Center of the Department of Health reported 2,299 presumptive cases of leptospirosis with 178 deaths in 15 hospitals in Metro Manila over a period of two months. In the Luzon region, 1090 cases and 71 deaths in Regions I, III, IV-A and Cordillera Autonomous Region were recorded. Overall case fatality rate was 7.4%. This was way beyond the yearly endemic threshold of leptospirosis cases in the country. It is anticipated that leptospirosis will continue to re-emerge in the country as a result of rapid urbanization, deforestation, poor sanitation and increased incidence of typhoons brought about by climate changes. Thus, the Leptospirosis Task Force composed of members of the PSMID, PSN and PCCP have decided to update and nalize the 2009 interim guidelines released during the outbreak. This updated guideline is intended to guide health care practitioners in the early recognition, prompt management and prevention of leptospirosis and its complications in primary, secondary and tertiary health facilities. The guideline also aims to heighten the awareness and index of suspicion of clinicians not just during an outbreak but also during the rainy months and in cases associated with travel, recreational sports and occupational exposures. 3
Leptospirosis CPG 2010 TABLE OF CONTENTS - page 4
Leptospirosis CPG 2010 The Guideline Development Process Phase 1: Preparation of the evidence-based draft The members of the Leptospirosis Task Force agreed to review the evidence on the following topics: 1. 2. 3. 4. 5. Clinical diagnosis of leptospirosis Laboratory diagnosis of leptospirosis Treatment of Leptospirosis Prevention of leptospirosis Diagnosis and management of complications a. Acute kidney injury b. Pulmonary hemorrhage The task force members then searched the MEDLINE database up to September 2010 and the Cochrane Library Issue 2010 for relevant literature. The group also searched the websites of the Philippine College of Physician and Philippine Society for Microbiology and Infectious Diseases for local literature. The HERDIN database was also searched and experts in the eld were contacted for published and unpublished local literature. Phase 2: Preparation of the intermediate and penultimate drafts The PSMID was assigned to prepare the summaries of evidence on the diagnosis, treatment and prevention of leptospirosis. The PSN was assigned to prepare the draft for the diagnosis and management of leptospirosis-associated acute kidney injury, while the PCCP Council on Critical Care and Pulmonary Vascular diseases prepared the draft for the diagnosis and management of pulmonary complications associated with leptospirosis. These evidence-based drafts were then presented and discussed in subsequent meetings of the task force. The task force formulated recommendations on diagnosis, treatment and prevention based on the level of quality of the evidence, applicability and availability of health resources. We used the following system for grading the recommendations and quality of the evidence: 4
Leptospirosis CPG 2010 TABLE OF CONTENTS - page 5
Leptospirosis CPG 2010 Grading System for the Strength of the Recommendations and Quality of Evidence GRADE Strength of recommendation A B C Quality of evidence Level 1 Level 2 DEFINITION Good evidence to support a recommendation for or against use Moderate evidence to support a recommendation for or against use Poor evidence to support a recommendation for or against use Evidence from at least one properly randomized trial or a well-conducted systematic review Evidence from at least one well-designed trial, without randomization; from cohort or case-control analytic studies (preferably from >1 center); from multiple time series; or from dramatic results of uncontrolled experiments Evidence from opinions of experts, based on clinical experience, descriptive studies, or reports from expert committees, clinical trials or systematic reviewswith high risk for bias based on methodologic quality Level 3 In grading the recommendations, the task force considered not just the overall quality of the evidence but also the consistency of the evidence as well as issues on applicability and availability of the diagnostic, therapeutic or preventive intervention at different levels of health care facilities. The tradeoffs between benefit and harm were also weighed, e.g. risk of progression to severity, risk exposure assessment, development of complications, and severity of adverse effects versus the benefits of treatment or prophylaxis, including cost-effectiveness. 5
Leptospirosis CPG 2010 TABLE OF CONTENTS - page 6
Leptospirosis CPG 2010 The Leptospirosis Task Force Philippine Society for Microbiology and Infectious Diseases Chair: Co-Chair: Members: Manolito L. Chua, MD Marissa M. Alejandria, MD Rhona G. Bergantin, MD Raul P. Destura, MD Mario M. Panaligan, MD Cecilia S. Montalban, MD Minette O. Rosario, MD Paul P. Salandanan, MD Rontgene M. Solante, MD Maria Fe R. Tayzon, MD Dionisio M. Tiu, MD Philippine Society of Nephrology Irmingarda Gueco, MD Susan Anonuevo, MD Roberto Tanchanco, MD Jose Marcia, MD Melvin Marcial, MD Philippine College of Chest Physicians Council on Critical Care and Pulmonary Vascular Diseases Aileen Guzman-Banzon, MD, FPCCP Joseph Hope G. Cal, MD, FPCCP Teresita S. de Guia, MD, FPCCP 6
Leptospirosis CPG 2010 TABLE OF CONTENTS - page 7
Leptospirosis CPG 2010 1. C LINICAL R ECOGNITION OF L EPTOSPIROSIS 1.1 What clinical manifestations should alert a health practitioner to suspect leptospirosis among patients presenting with acute fever? Any individual presenting with acute febrile illness of at least 2 days AND either residing in a flooded area or has high-risk exposure (defined as wading in floods and contaminated water, contact with animal fluids, swimming in flood water or ingestion of contaminated water with or without cuts or wounds) AND presenting with at least two of the following symptoms: myalgia, calf tenderness, conjunctival suffusion, chills, abdominal pain, headache, jaundice, or oliguria should be considered a suspected leptospirosis case. [Grade A] Leptospirosis occurs throughout the world but is highest in the tropics. It is one of the most common zoonoses with human infection occurring commonly through superficial cuts and open wounds after exposure to a contaminated environment (e.g. flood), direct contact with infected animals or following rodent bites. 1,2 The spectrum of presentation of leptospirosis is protean and varies from a mild and inapparent form to a severe one involving multiorgan system. 1 Clinicians should therefore have a high index of suspicion among patients with febrile illness and high risk exposures because mortality may be as high as 15%. 1,3 A review of the clinical presentation of 353 cases of laboratory confirmed leptospirosis in Hawaii from 1974 to 1998 showed that the most common presentation included fever, myalgia and headache. 4 Leptospirosis is endemic in the Philippines and the number of cases peak during the rainy months of June to August. Outbreaks have been associated with wading in flood waters. A review of patients hospitalized for suspected leptospirosis in the 70’s showed abrupt fever, myalgia, headache, abdominal pain, meningismus, conjunctival suffusion and gastrocnemius or calf tenderness to be the common symptoms. 5,6,7 In the eighties and nineties, other symptoms observed included oliguria/anuria, diarrhea, thrombocytopenia and bleeding diatheses. 8-13 Usually, an average of 680 leptospirosis cases and 40 deaths from the disease are reported every year in the Philippines. However, in October 2009 a leptospirosis outbreak was declared by the Department of Health two weeks after the heavy rainfall typhoon Ketsana last September 26, 2009. As of 13 November 2009 a total of 2,292 suspected cases of leptospirosis were recorded with 178 deaths (8%) in 15 hospitals in Metro Manila. 14 The clinical features of 257 confirmed 7
Leptospirosis CPG 2010 TABLE OF CONTENTS - page 8
Leptospirosis CPG 2010 cases (Philippine General Hospital = 90, National Kidney and Transplant Institute =77, The Medical City = 52, University of Santo Tomas Hospital = 11, Manila Doctors Hospital = 7, Ospital ng Maynila = 6, Cardinal Santos Medical Center = 5, East Avenue Medical Center = 5, Makati Medical Center = 4) diagnosed during the outbreak are compared in Table 1 with reports of leptospirosis outbreaks in Brazil, 15 India 16 and Korea 17 ; and in Table 2 with seasonal leptospirosis in the Philippines. No significant differences were seen in the clinical features of leptospirosis after an outbreak with that of seasonal leptospirosis. 18 Table 1. Clinical features of leptospirosis after a flood 18 Signs & symptoms (%) Number of patients Korea 1987 Salvador, Brazil 1996 Mumbai, India 2005 Philippines 2009 Fever Myalgia Headache Conjunctival suffusion Abdominal pain Diarrhea Jaundice Oliguria NR Renal failure Respiratory symptoms (pulmonary hemorrhage) Thrombocytopenia CNS manifestations - altered sensorium, meningitis/ meningismus NR-not reported 93 confirmed 193 confirmed 237 probable 257 confirmed cases & probable cases cases 97 93.8 100 98.4 88 93.8 39.7 78.6 70 74.6 NR 55.6 58 28.5 24.5 59.1 40 NR 4.2 52.1 36 NR 7.6 39.3 16 92.7 81.4 38.1 33.2 37.6 56.8 15 23.9 NR 75.1 40 15.0 7.6 (8.6) 18 6 NR 24.9 14.3 2.1 14.8 5.1 8
Leptospirosis CPG 2010 TABLE OF CONTENTS - page 9
Table 2. Clinical features of seasonal leptospirosis admitted at various hospitals in Metro Manila compared with the 2009 outbreak. 18 Symptoms & signs (%) 104 clinical & probable 97.1 82.9 64.4 79.8 69.2 33.6 70.2 43.3 74 5 NR 12.5 50 20.9 61 17 NR 77 68 - 2.1 61 68 83 93 18.6 NR 56.5 37.9 89.8 13.0 NR 2.7 NR 61 NR 42 30.7 73 69.0 30.7 NR NR 7.6 100 95.3 88.5 95.8 100 68 81.3 76 95.2 92.5 74.1 85 100 19.2 50.0 61.5 99 87 NR 99 26.5 NR 61 66 89.1 2.4 30 NR 98.4 78.6 55.6 59.1 52.1 39.3 38.1 56.8 75.1 8.6 14.8 5.1 191 presumptive cases 59 confirmed cases 147 presumptive cases 26 presumptive cases 83 presumptive cases 257 confirmed cases UST 1967-71 5 PGH 1978 6 UST 1974-78 7 UST 1979-93 8 PGH 1985-91 9 PGH 1995-96 10 PGH 1990-97 11 QMMC 1999 12 JRRMH 2000-01 13 2009 outbreak 14 Number of cases 17 confirmed 34 Confirmed 13 confirmed 16 clinical 100 71 58.8 41 92 92 NR 62 100 40 65.5 60 71 91 70 6 29 29 17.6 5.9 NR 74 NR 80 NR 20 60 60 NR 3.4 NR 35 NR 24 NR 18 Leptospirosis CPG 2010 9 Fever Myalgia Headache Conjunctival Suffusion Abdominal pain Diarrhea Jaundice Oliguria/anuria Renal failure Pulmonary Hemorrhage Thrombocytopenia CNS manifestations NR=not reported
Leptospirosis CPG 2010 TABLE OF CONTENTS - page 10
Leptospirosis CPG 2010 1.2 Which patient will need hospital admission? Any suspected case of leptospirosis presenting with acute febrile illness and various manifestations BUT with stable vital signs, anicteric sclerae, with good urine output, and no evidence of meningismus / meningeal irritation, sepsis / septic shock, difficulty of breathing nor jaundice and can take oral medications is considered MILD LEPTOSPIROSIS and can be managed on an OUT-PATIENT SETTING. [Grad e A] Any suspected case of leptospirosis presenting with acute febrile illness associated with unstable vital signs, jaundice/icteric sclerae, abdominal pain, nausea, vomiting and diarrhea, oliguria/anuria, meningismus / meningeal irritation, sepsis / septic shock, altered mental states or difficulty of breathing and hemoptysis is considered MODERATE – SEVERE LEPTOSPIROSIS and BEST managed in a HEALTHCARE / HOSPITAL SETTING. [Grade A] The incubation period of leptospirosis may range from 2 to 28 days. Signs and symptoms are highly variable. Asymptomatic seroconversion is the most common result of infection. The mildest presentation of leptospirosis is fever, headache, and myalgia, accompanied by other nonspecific findings such as nausea and vomiting, diarrhea, nonproductive cough, and maculopapular rash. Conjunctival suffusion (red eyes without exudate) and severe calf pain may be characteristic of acute leptospirosis, but are not specific. Mild leptospirosis may resolve spontaneously without requiring antimicrobial therapy. Severe manifestations of leptospirosis include any combination of jaundice, renal failure, hemorrhage (most commonly pulmonary), myocarditis, and hypotension refractory to fluid resuscitation. Other complications include aseptic meningitis and ocular involvement including uveitis. As originally described in the 19th century, Weil’s disease is characterized by a triad of fever, jaundice, and splenomegaly. Current usage of the term “Weil’s disease” refers to fever, jaundice, and renal failure and is often considered synonymous with severe leptospirosis. 19 Clinical features associated with increased risk for mortality include altered mental status, respiratory insufficiency (rales, infiltrates), hemoptysis, oliguric hyperkalemic acute renal failure, and cardiac involvement (myocarditis, complete or incomplete heart block, atrial fibrillation). In a retrospective study of 68 patients with leptospirosis in a teaching hospital of Pointe-a-Pitre in French West Indies, prognostic factors independently associated with mortality were: dyspnea (OR 10
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