Severe leptospirosis in tropical Australia: Optimising intensive care unit management to reduce mortality

Abstract

BackgroundSevere leptospirosis can have a case-fatality rate of over 50%, even with intensive care unit (ICU) support. Multiple strategies–including protective ventilation and early renal replacement therapy (RRT)–have been recommended to improve outcomes. However, management guidelines vary widely around the world and there is no consensus on the optimal approach.Methodology/Principal findingsAll cases of leptospirosis admitted to the ICU of Cairns Hospital in tropical Australia between 1998 and 2018 were retrospectively reviewed. The patients’ demographics, presentation, management and clinical course were examined. The 55 patients’ median (interquartile range (IQR)) age was 47 (32–62) years and their median (IQR) APACHE III score was 67 (48–105). All 55 received appropriate antibiotic therapy, 45 (82%) within the first 6 hours. Acute kidney injury was present in 48/55 (87%), 18/55 (33%) required RRT, although this was usually not administered until traditional criteria for initiation were met. Moderate to severe acute respiratory distress syndrome developed in 37/55 (67%), 32/55 (58%) had pulmonary haemorrhage, and mechanical ventilation was required in 27/55 (49%). Vasopressor support was necessary in 34/55 (62%). Corticosteroids were prescribed in 20/55 (36%). The median (IQR) fluid balance in the initial three days of ICU care was +1493 (175–3567) ml. Only 2/55 (4%) died, both were elderly men with multiple comorbidities.ConclusionIn patients with severe leptospirosis in tropical Australia, prompt ICU support that includes early antibiotics, protective ventilation strategies, conservative fluid resuscitation, traditional thresholds for RRT initiation and corticosteroid therapy is associated with a very low case-fatality rate. Prospective studies are required to establish the relative contributions of each of these interventions to optimal patient outcomes.

Clinical profile, management and outcome of patients with leptospirosis during the times of COVID-19 pandemic: A prospective study from a tertiary care centre in South India

“…In a study from Brazil, most leptospirosis clusters occurred after a natural disaster preceded by heavy rainfall in that area [20]. Other studies have described the increased incidence of leptospirosis during monsoon and floods [10,11,[21][22][23][24]. Due to the southwest monsoon winds from July to September 2020, heavy rainfall occurred in Udupi (Karnataka, India) and nearby districts.…”

Leptospirosis in Intensive Care Unit

“…In a study done by Smith et al in ICUs in Australia, moderate to severe ARDS developed in 37/55 (67%), 32/55 (58%) had a pulmonary hemorrhage, and mechanical ventilation was required in 27/55 (49%) cases. 6 Dyspnea and chest infiltrates are poor prognostic indicators and mortality predictors in severe leptospirosis.…”

Acute Kidney Injury and Acute Liver Failure in Leptospira Infection and Weil’s Syndrome

“…There is definite cardiac involvement in leptospirosis, which, although not symptomatically evident, may add to the morbidity and mortality or contribute to the mortality associated with the disease (37). In patients with severe leptospirosis in tropical Australia, prompt intensive care unit (ICU) support, including early antibiotic administration, protective ventilation strategies, cautious fluid resuscitation, traditional thresholds for renal replacement therapy initiation, and corticosteroid therapy, was associated with a very low case-fatality rate (38). Pulmonary involvement at admission is a strong predictor of mortality among patients with severe leptospirosis (39).…”