LEPTOSPIROSIS

Emergency Policies and Procedures Manual

Editors
Romina A. Danguilan, M.D.
Mel-Hatra I. Arakama, M.D.

National Kidney and Transplant Institute

August 2013
 Acknowledgment

The following Departments contributed to this manual:

Emergency Room Department Ma. Victoria Santos, RN

Apple Baquing, RN
Department of Adult Nephrology Ruchelle Marie Turqueza, MD
Department of Internal Medicine Nicolas Radovan, MD
Department of Pediatric Nephrology Coe Dela Seña, MD
Department of Vascular Surgery Rophel Miguel, MD
Nursing Services Department Helen Malata, RN
Glecita Erni, RN
Mercedita Jocson, RN
Hemodialysis Unit Ma. Elizabeth Espiritu, RN
Peritoneal Dialysis Unit Rita Blanco, RN
Medical Social Services Division Leonides Basada, RSW
Eufemia Chona De Jesus, RSW
Pharmacy Salvacion Munda, RPh
Purchasing and Warehouse Marichu Escober
Ma. Lourdes Tengson
Central Supply & Sterilization Unit Ferdinand Cruz, RN
Patient Business & Services Division Leticia Doblado
Milagros Tordecilla
Admitting Section Chita Thelma Llanes
Information Resource Management Farlyz Felix Villanueva
Jacob Orillanes
Housekeeping & Linen Section Ma. Theresa Argarin
Eddie Mayo

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 Table of Contents

I. Statement of Purpose and Scope

Purpose 1
Scope 1
II. Key Policies
Criteria for Activation of Leptospirosis Emergency Policy 1
Phase I - Opening of PhilHealth Ward for Leptospirosis Admissions Only 1
Phase II - Opening of Employees’ Lounge 1
Activation of Leptospirosis Emergency Policy 2
During Office Hours 2
After Office Hours 2
Critical Bed Status Procedure 4
Standards for Admission of Leptospirosis Patients 4
III. Staffing Plans, Responsibilities and Resources
Emergency Room Department 5
Department of Internal Medicine 7
Department of Adult and Pediatric Nephrology 7
Department of Vascular Surgery 8
Department of Laboratory Medicine 8
Pulmonary Medicine 8
Department of Radiology 9
Department of Nursing 9
Hemodialysis Unit 10
Peritoneal Dialysis Unit 11
Medical Social Services Division 11
Pharmacy 12
Purchasing and Warehouse 13
Central Supply and Sterilization Unit 13
Patient Business Services Division 13
Admitting Section 14
Information Resource Management 14

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 Table of Contents

IV. Antibiotic Prophylaxis for Leptospirosis

For Adults 15
For Pregnant Women 15
For Children 16

V. Appendices
Appendix I.
Emergency Room Process Flow of Patients with Leptospirosis 16
Appendix II.
Treatment Algorithm for Leptospirosis 17
Appendix III.
Treatment Algorithm for Leptospirosis (Pediatric Patients) 20
Appendix IV.
Leptospirosis Census Format for Reporting 25
Appendix V.
MSSD Patient Registry Format for Reporting 26
Appendix VI.
Estimated Quantities of Medications Needed for Leptospirosis Patients 27
Appendix VII.
Leptospirosis Prophylaxis Survey 2013 28

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 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 within the National
Kidney and Transplant Institute (NKTI). This manual provides guidance
to all the departments within NKTI, with a general concept of potential
emergency assignments before, during, and following a Leptospirosis
crisis. It also provides for the systematic integration of emergency
resources when activated including purchasing of necessary supplies
and materials for renal replacement therapy and allocation of financial
support from alternative sources such as the Department of Health
(DOH) and Philippine Health Insurance Corporation (PHIC). It also
includes activation of communications networking with relevant
government and non-government agencies.

B. Scope
This plan applies to all participating departments within NKTI.

Key Policies
A. Criteria for Activation of Leptospirosis Emergency Policy
To ensure that patients receive appropriate and timely medical care
and renal replacement if necessary, the following criteria shall guide
health care:
Phase I - Opening of PhilHealth Ward for Leptospirosis Admissions Only
Patients with a presumptive diagnosis of Leptospirosis, of more than 6 patients
per day, requiring more than simple hydration (i.e. renal replacement therapy,
blood component transfusion or requiring respiratory support).

Phase II - Opening of Employees’ Lounge

Patients with a presumptive diagnosis of Leptospirosis, of more than 10 patients
per day, requiring more than simple hydration (i.e. renal replacement therapy,
blood component transfusion or requiring respiratory support) and releasing the
PhilHealth ward for admission of regular patients.

Special Note: Other patients may also be accommodated in service beds under
any medical department.

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 Key Policies

B. Activation of Leptospirosis Emergency Policy

DURING OFFICE HOURS from Monday-Friday, 8:00AM - 5:00PM, the
Head Nurse of ER and the Head of the ER will inform the Executive
Office if the criteria for activation of the Leptospirosis Emergency
Policy has been met. Any one of the Deputy Directors or the Executive
Director will activate the Leptospirosis Emergency Policy.
Upon Activation of the Leptospirosis Emergency Policy, the Secretary
of any of the Deputy Directors or Executive Director will send out a
memorandum through Outlook, and will notify the Heads of the
following Departments:
◊ Departments of Adult and Pediatric Nephrology
◊ Department of Internal Medicine
◊ Department of Vascular Surgery
◊ Department of Nursing
- All Charge Nurses in all Clinical Wards
- IANAHP
- Operating Room
◊ Department of Laboratory Medicine
◊ Pulmonary Medicine
◊ Pharmacy, Purchasing, Warehouse, Central Supply and Sterilization Unit
(CSSU), Housekeeping, Patient Business Services Division (PBSD),
Admitting Section
◊ Medical Social Services Division (MSSD)
◊ Information Resource Management (IRM)
- Upload Hospital Memorandum regarding the activation of the
Leptospirosis Emergency Policy to all concerned Departments through
OUTLOOK.
- Inform all Heads of the concerned Departments including the Executive
Director and Deputy Directors through SMS.

AFTER OFFICE HOURS from Monday-Friday, weekends and holidays,

the ER Charge nurse will contact the Hospital Administrator (HA) who
will activate the Leptospirosis Emergency Policy. The HA will inform
the following of the activation (See Diagram I).

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 Key Policies

Diagram I: Activation of Leptospirosis Emergency Policy

◊ Executive Director and all the Deputy Directors

◊ The Senior House Officer (SHO)

SHO will then be responsible for informing the following physicians through
landline or SMS:
- Departments of Adult and Pediatric Nephrology on duty
- Department of Vascular Surgery on duty
- Department of Internal Medicine on duty
The above mentioned physicians on duty will then inform their Chief Fellow/
Chief Resident and their respective Department Chairs through landline or
SMS.

◊ Senior Nurse in charge of the Department of Nursing on duty

The Senior Nurse in charge will then be responsible for informing the
following through landline or SMS:
- All Charge Nurses in all Clinical Wards on duty
- IANAHP, Training Officer
- Operating Room Charge Nurse on duty

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 Key Policies

◊ All other concerned Departments:

- Department of Laboratory Medicine on Duty
- Pulmonary Medicine on Duty Respiratory Therapist
- Pharmacy, Purchasing, Warehouse, CSSU, Housekeeping,
Patient Business Services Division, Admitting Section on duty
- MSSD on duty

◊ IRM Staff on Duty

- Upload Hospital memorandum regarding Leptospirosis Emergency
Policy to all concerned Departments through OUTLOOK.
- Inform all Heads of the concerned Departments through SMS.

C . Critical Bed Status Procedure – NKTI Leptospirosis Emergency 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 hospital
during a Leptospirosis Outbreak. This is to ensure that patients
receive proper medical care.

Procedure:
The Hospital Administrator (HA) will report the bed status and availability, to the
post duty Senior Adult Nephrology Fellow and Chair of the Department of Adult
Nephrology or Pediatric Nephrology as the case may be, 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.

D. Standards for Admission of Leptospirosis Patients

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

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 Key Policies

All patients with a presumptive diagnosis of Leptospirosis will be

triaged under the Department of Adult Nephrology (Patients > 18 yo)
or Department of Pediatric Nephrology (Patients < 18 yo) with the
following criteria:
1. Serum Creatinine : > 3 mg/ dl
2. Presence of any ONE of the Criteria for Pulse Therapy (See Appendix II)

Staffing Plans, Responsibilities and Resources

A. Emergency Room Department
◊ Provide emergency medical treatment, triage patients or assist with triage and
ensure administrative or clinical backup for the ER Department.
(See Appendix I)

◊ All prescriptions for medications, supplies, dialysis orders and laboratories shall
be stamped 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.

◊ The presumptive diagnosis of Leptospirosis will be made with the presence of

the following:
- Fever
- Conjunctival Suffusion
- Muscle Aches
- History of Wading In Flood Waters
- +/- Icterisia
- Jaundice

◊ The following diagnostics will be done:

- CBC with platelet count
- Creatinine, Sodium, Potassium
- ABG as needed
- Baseline ECG
- Chest PA
- PT, PTT daily if necessary
- Latex Agglutination Test (LAT)
- If with negative LAT, do MAT but save serum for all for
Microscopic Agglutination Test (MAT)

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 Staffing Plans, Responsibilities and Resources

◊ Initial Management:
- Fast drip 2 liters Plain Nss (may insert 2 IV lines) then continue hydration
at 300 cc/ hour
- Start Penicillin-G at 1.5 million units IV every 6 hours OR Ceftriaxone 1gram-
IV OD, if patient fulfills the criteria for Pulse Therapy (See Appendix II)

◊ Patients who fulfill the criteria for referral to Nephrology must be referred
immediately.

◊ 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 ER Department will 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 patients will be applied.

◊ Patients requiring access placement for either hemodialysis or peritoneal

dialysis will be referred to the Department of Vascular Surgery, and access
creation or placement will be performed either in the ER Procedure Room or
Operating Room (OR) to ensure that there is no delay in dialysis access
placement. Emergency placement of HD access may also be performed by the
nephrology fellow as per Department of Adult Nephrology protocol.

◊ The ER Department will ensure that they have 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.

◊ Patients will be referred to MSSD for completion of clinical information for

inclusion as a service patient, and for possible application for the PhilHealth
Leptospirosis benefit.

◊ Patients who will require admission to the wards will be referred to the
appropriate Medical Department for facilitation of admission.

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 Staffing Plans, Responsibilities and Resources

B. Department of Internal Medicine

Assess patients and ensures that they are given adequate hydration,
appropriate antibiotics and that patients are monitored. The
Department is also responsible for following the Leptospirosis
algorithm for proper diagnosis, management and documentation. The
ER Medical Resident on duty together with Adult and Pediatric
Nephrology Fellow on duty are in charge to provide 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
for reporting to the Chair, Department of Adult Nephrology, who will
submit the same to the Executive Director and to the HEMS Operations
Center, under the Department of Health.

C. Department of Adult and Pediatric Nephrology

Assess patients, provide renal replacement therapy/hydration as
needed, and ensures that appropriate medications are administered. It
allocates and prioritizes 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.
◊ Patients who fulfill the criteria for renal replacement will be allocated to
either HD or PD according to the algorithm in Appendix II & III.

◊ 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 Department 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. Please see
Appendix IV for the format for reporting.

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 Staffing Plans, Responsibilities and Resources

◊ The post duty Senior Adult Nephrology Fellow in the ward will complete the
census every morning by 8:00AM and report the same to the Chair,
Department of Adult Nephrology. The same report will be submitted to the
Executive Director and to the HEMS Operations Center, Department of
Health, at the East Avenue Medical Center.

The Senior Adult Nephrology Fellow will be in charge of the Leptospirosis

ward and all the other Leptospirosis patients after office hours, and
endorse the patients to the PD Fellow in the morning.

◊ The Deputy Director for Medical Services and/or the Chair of the
Department of Adult Nephrology will coordinate with any of the concerned
Departments of NKTI, as needed, to ensure that patients are treated in a
timely manner, and to ensure that all the patients' needs are provided. The
Deputy Director and/or Chair of the Department of Adult Nephrology will
update the Executive Director as necessary.

◊ The Chair of the Department of Adult Nephrology together with the

Executive Director, will attend the HEMS meetings, as necessary, to provide
updates on the status of patients admitted at the NKTI and to request for
logistical support, if necessary.

D. Department of Vascular Surgery

◊ Responsible in providing timely insertion of temporary HD catheters or PD
catheters and their removal, prior to patients final discharge and other
surgical procedures if deemed necessary.

E. Department of 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.

F. Pulmonary Medicine
◊ Responsible for pulse oximetry, arterial blood gas, and providing mechanical
ventilatory support in a timely manner.

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 Staffing Plans, Responsibilities and Resources

G. Department of Radiological Sciences

◊ Should be readily available to the Emergency Department for all routine
studies utilizing the portable x-ray machine or ultrasound as necessary. The
Radiology Department will provide emergency services with designated
technicians.

H. Nursing Services Department

◊ Assures that there is adequate nursing staff, medications and supplies, and
that proper nursing care is provided.

◊ In preparation for the Leptospirosis Phase 2 activation a 1-week learning and

development intervention on HD will be facilitated and scheduled in August
each year or as necessary. A similar workshop for PD will be facilitated
effective 1st week of September each year or as necessary. 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. A Personnel Requisition Form will be forwarded to
the Management to support the additional staff required, once the
Leptospirosis ward is opened. A total of 5 new nurses will be required with
the opening of the Leptospirosis ward at the PhilHealth Ward (10-patients),
while 20-30 new nurses will be required with the conversion of the
Employees Lounge to the Leptospirosis ward (30-patients).

◊ Once the Leptospirosis wards are opened, the following should be put in
place:
PhilHealth Ward
- Conversion of each room to accommodate 2 patients
- Augment basic medical supplies
Employees Lounge Conversion
- Nurses Station (2 tables and 3 chairs)
- Computer station with access to charging of supplies, etc and
Medsys access for laboratories etc.
- Telephone unit
- Forms: laboratory requests, admitting forms, order sheets, TPR
sheet, input/output sheet etc.

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 Staffing Plans, Responsibilities and Resources

- Patient folders or clipboards

- Basic medical supplies for patients
- Inform Housekeeping for set-up of the following for 30 patients:
patient cots oxygen gauge
IV stands oxygen tank
watcher chairs oxygen mask
bed- linens
- Inform PD Unit for transfer of PD cycler machines, PD supplies, and
PD catheters
- HD access catheters and supplies
- Dressing kits and cut-down sets
◊ 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.

I. Hemodialysis (HD) Unit

◊ Once the Leptospirosis Emergency Policy is activated, the HD Unit
Supervisor will contact the Fresenius Medical Care (FMC) to augment the
number of HD machines and portable RO machines available to provide
continuous HD services.
◊ 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 nephrologists.
◊ The HD Unit Supervisor will recommend to the HD Unit Head whether there
is a need for the IMCU to be reserved to provide HD services, so as HD can
be provided in a timely manner.
◊ The HD Unit Supervisor/Assistant or Charge Nurse will contact the FMC
Facility Engineer and Biomedical Engineer on duty to assess the area for
conversion to an HD Extension Unit.
◊ HD Charge Nurse and HD technicians will prepare and set-up the HD
Extension 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.

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 Staffing Plans, Responsibilities and Resources

J. Peritoneal Dialysis (PD) Unit

◊ Once the Leptospirosis Emergency Policy is activated, the PD Unit
Supervisor will contact the Fresenius Medical Care (FMC) to augment the
number of cycler machines to accommodate the increased number of
patients who will be requiring PD and to request for additional FMC 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 wards.

◊ 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 catheter infection that occurs.

◊ 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 the nephrologist, the PD Nurse

will ensure that the patient is referred back to Vascular Surgery for removal
of the PD catheter prior to discharge. This may be done at the ER Procedure
Room or OR. The PD Nurse will ensure that the appropriate charges for PD
catheter removal are included in the patient's final bill.

K. Medical Social Service Division

◊ 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
Emergency Policy.

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 Staffing Plans, Responsibilities and Resources

◊ 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.

◊ They will complete a database on all service patients treated, the type of
dialysis provided, if any, and outcome, dates of admission and discharge.
See Appendix V for the format of reporting.

◊ 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.

L. Pharmacy
◊ 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 wards and other wards that have
admitted Leptospirosis patients are equipped with all the necessary
medications ( See Appendix VI) such as:
- IV Penicillin G 1 mg/vial
- Amoxicillin Syrup 250 mg/5 ml
- IV Ceftriaxone 1 gram/vial
- IV Hydrocortisone 100 mg/vial
- IV Methylprednisolone 500 mg/vial
- IV Cyclophosphamide 1 gram/vial

◊ The following should also be available:

- Doxycycline 200 mg/ cap
- Amoxicillin 500 mg/ tab or cap
- Omeprazole 40 mg/ amp
- IV Plain NSS 1000 cc/ bottle
- Dopamine 200 mg/5 ml vial
- Norepinephrine 1 mg/ml, 10-ml vial
- Dobutamine 250 mg/20-ml vial

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 Staffing Plans, Responsibilities and Resources

M. Purchasing and Warehouse

◊ Strategize, lead and manage logistics to ensure operational effectiveness. It
includes ensuring the hospital has sufficient inventory to manage the
Leptospirosis crisis, and that all inventory are accurately accounted for at all
times.

◊ They will manage and direct timely and cost effective supply of goods .

N. Central Supply and Sterilization Unit (CSSU)

◊ Responsible for supplying all of the Departments in 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.

◊ They will fabricate and sterilize silastic PD catheters, single-cuff, straight line
for use in the management of acute PD for Leptospirosis patients requiring
dialysis.

◊ Silastic PD catheters and HD catheters may be sold to other government

hospitals to assist them in providing dialysis to their patients.

◊ The following should be available in sufficient supply:

- Micropore - Endotracheal Tube
- Cotton balls - Nasogastric Tube
- Betadine - HD Catheters
- Foley Catheters - PD Catheters (adult and pedia)
- Alcohol - Cut down set

O. Patient Business Services 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 the total cost borne by NKTI in
subsidizing patients admitted for Leptospirosis in coordination with MSSD.

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 Staffing Plans, Responsibilities and Resources

◊ They will coordinate with IRM to ensure that patients are charged with the
appropriate room rates when they are admitted to the Leptospirosis
PhilHealth ward or at the converted Employees Lounge.

P. Admitting
◊ They will facilitate admission of patients with Leptospirosis to the
designated Leptospirosis wards or service beds, and that the appropriate
room rates are charged for service patients.

◊ They will use the special ROOM NUMBERS dedicated by IRM for
Leptospirosis since these room numbers are tagged with the appropriate
room rates.

◊ 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.

Q. Information Resource Management (IRM)

◊ Responsible for the management of data within NKTI, to ensure a seamless
coordination with the different Departments.

◊ They will designate special ROOM NUMBERS for use in the admission of
Leptospirosis patients, tagged with the appropriate recommended room
rates.

◊ 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.

◊ They will monitor all databases used for Leptospirosis patients to ensure
their accuracy.

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 Antibiotic Prophylaxis for Leptosiposis

For relatives of patients and NKTI 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

C. Recommended post-exposure prophylaxis for Leptospirosis for children

◊ More than 8 years old- Doxycycline 4 mg/kg single dose. Max Dose: 200 mg/day
◊ Less than 8 years old: Amoxicillin 50 mg/kg/day divided in 3 doses x 3-5 days

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 Appendices

Appendix I
Emergency Room Process Flow of Patients with Leptospirosis

START

Receiving of Patient

Assessment of Patient

Identifies Patient with

Leptospirosis

Carries out Initial Orders

Renal Replacement
Therapy

Access Creation
or Placement

Hemodialysis Peritoneal Dialysis

Patient Referral to MSSD

Admits Patient to Ward

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 Appendices

Appendix II
Algorithm for Leptospirosis (Revised August 2013)

Fever, Conjunctival Suffusion, Muscle Aches

History of Wading In Flood Waters
+/- Icterisia, Jaundice

DIAGNOSTICS: INITIAL MANAGEMENT:

CBC with platelet count
Creatinine, Sodium, Potassium 1. Fast drip 2 liters Plain Nss
ABG as needed (May insert 2 Iv Lines) then
Baseline ECG continue hydration at 300 cc/ hour
Chest PA
PT, PTT Daily if needed 2. Start Penicillin-G at 1.5million units IV
LAT every 6 hrs OR Ceftriaxone 1gram IV
If with negative LAT, do MAT but save serum OD, if patient fulfills criteria for Pulse
for all for Microscopic Agglutination Test (MAT) Therapy.*

*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

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 Appendices

YES NO

Give Methylprednisolone 500 mg/ IV after Patient requires dialysis**

HD OD x 3 days.
After the 3rd Methylprednisolone dose or Platelet count >100,000 but less than
after any episode of hemoptysis, give 150,000
Cyclophosphamide 1 gm IV as a single
dose after HD
Give Ceftriaxone 1 gm IV OD (instead of
Penicillin G)
Give Omeprazole 40 mg IV OD YES NO

*If the patient has been started on

Hydrocortisone IV, give the remaining ster-
oid dose to reach the target dose of MPP
500 mg/ day (see steroid conversion). Then Give hydrocortisone 100 mg IV every
give the Methyprednisolone 500 mg IV OD
6 hours
on days 2 and 3.
Continue IV Penicillin G
*Steroid conversion:
Hydrocortisone 5mg = Methyprednisolone 1mg Give Omeprazole 40 mg IV OD

PROCEED TO ALGORITHM FOR DIALYSIS THERAPY

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 Appendices

**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

FULFILLS ANY OF THE CRITERIA

FOR PULSE THERAPY

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 a NKTI Multi-Disciplinary Team composed of:
Dr. Romina Danguilan, Department of Adult Nephrology
Dr. Myrna Mendoza, Infection Control Committee
Dr. Ernesto Que, Department of Internal Medicine
Dr. Joselito Chavez, Deputy Executive Director for Medical Services, Pulmonary Medicine

Leptospirosis Policies and Procedures Manual | 19

 Appendices

Appendix III
Algorithm for Leptospirosis (Pediatric Patients)

SU SPECTED LEPTOSPIR OSIS

Fever for 2 days
PLUS
History of wading in flood water
PLUS
Non-specific signs and symptoms
(conjunctival suffusion, headache, myalgia, vomiting, diarrhea, abdominal pain, difficulty of breathing)
+
Jaundice/Icteresia

DIAGNOSTICS THERAPEUTICS

CBC Outpatient/Step down (to complete 7 days):

BUN, crea, Na, K For children more than 8 years old
SGPT Doxycycline
Urinalysis 100mg PO BID on day 1 then 100mg OD thereafter or 4mg/kg
Chest xray divided into 2 doses (for less than 50kgs)
LAT/MAT For children 8 years old or less
PT/PTT Amoxicillin 30-50mg/kg/day q6H (max:500mg QID)
ABG OR
ECG* if needed Azithromycin 1 gram initial dose the 500mg once daily OR
10mg/kg/day OD for 3 days

In patient:
Penicillin G 1.5million units q6H x 7 days OR
10,000units/kg/day in 4 divided doses
Renal Adjustment:
GFR: 10-50: decrease to 75%
GFR <10:20-50%
If on PD, give similar dose for GFR<10

Ceftriazone 1g OD OR 75-100mg/kg/day once daily dosing

Avner: Renal adjustment
GFR 10-30: decrease to 80%
GFR < 10: decrease to 50%

Drugs Prescribing in Renal Failure: 5th Ed. 2007. Aronoff et. al.
No dose adjustment if on PD: q12 dosing

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 Appendices

SU SPECTED LEPTOSPIR OSIS

Mild Leptospirosis Moderate-Severe Leptospirosis

(AKI-Risk) (AKI-Injury and Failure)
Stable vital signs and no signs of shock (Including patients with elevated creatinine,
No jaundice with or without hepatic involvement)
Urine output > 0.5cc/kg/hr
Normal creatinine
No evidence of pulmonary congestion/
Hemorrhage sepsis
Able to take oral medications
A D MI T

Close follow-up
Give fluids based on fluid status Decrease eGFR, Decrease eGFR,
increased BUN, increased BUN,
non-anuric oligo-anuric
(UO > 0.5cc/kg/hr)
MAY SEND PATIENT HOME Stable vital signs
HOME MEDICATIONS
For children more than 8 years old: see next section
Doxycycline 100mg PO BID on day 1 then
100mg OD thereafter or Close monitoring
4mg/kg divided into 2 doses Continue hydration
(for less than 50kgs) Monitoring of crea,
electrolytes* levels
For children 8 years old or less: (q12H or q24H)
Amoxicillin 30-50mg/kg/day q6H *if patient is polyuric >
(max:500mg QID) 4cc/kg/hr
OR Observe for possible
Azithromycin 1gram initial dose the complications
500mg once daily or 10mg/kg/day OD
for 3 days

Leptospirosis Policies and Procedures Manual | 21

 Appendices

DECREASE eGFR, INCREASED BUN OLIGO-ANURIA

Give plain NSS 10-20cc/kg/hr

and assess. May continue for Euvolemic ?
3 more doses until euvolemic. No
Adjust IVF rate depending on Yes
hydration status.

Start Dopamine
(dose:5-20mcg/kg/min) Stable vital signs?
OR BP Normal?
Norepinephrine No
(dose:0.05-2mcg/kg/min Yes
Titrate to maintain normal
blood pressure

Furosemide
May use either bolus
doses or drip. If
Urine output >
hypotensive or if with
No 0.5cc/kg/hr?
unstable vital signs,
use drip.
Bolus dose: Yes
1-2mg/kg/dose q6H-q12H
IV drip dose:
0.1-0.15mg/kg/hr

Optional:
Insert foley
catheter

Monitor hourly and adjust IV fluids

Urine output according to fluid status.
> 0.5cc/kg/hr Yes Reassess kidney status.

No

With any of the following: Renal Replacement Therapy

Pulmonary congestion, intractable Peritoneal Dialysis First Option
metabolic acidosis, hyperkalemia or Yes OR
No ECG changes of hyperkalemia Hemodialysis

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 Appendices

L E PT O S PIR O SI S
With Suspected Pulmonary Hemorrhage

Cough, dyspnea, hemoptysis Give Methylprednisolone

Continue Observation RR > 30 for children > 5yo 10-20mg/kg
No > 40 for children 1-5yo Yes Max: 500mg IV

Presence of the following:

Continue Observation Chest Xray-Bilateral Infiltrates
Discontinue Steroids PF ration < 250 OR
No 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

Leptospirosis Policies and Procedures Manual | 23

 Appendices

Post Exposure Prophylaxis

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 dose, Proven efficacy for preventing
Max: 200mg clinical disease.
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
Azithromycin Efficacy for prevention of lepto-
spirosis was seen in vitro and ani-
mal models.
Amoxicillin 50mg/kg/day divided into No clinical trial for prevention of
4 doses for 3-5 days leptospirosis, but amoxicillin is
Max: 500mg q6H known alternative for the treat-
ment of disease.
Dose is for 3-5 days due to the
very short half-life.
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 Department of Pediatric Nephrology:
Dr. Zenaida L. Antonio Dr. Ofelia R. De Leon
Dr. Ma. Angeles Marbella Dr. Ma. Lorna L. Simangan
Dr. Violeta M. Valderama Dr. Norma V. Zamora
Dr. Coe P. Dela Seña

Leptospirosis Policies and Procedures Manual | 24

 Appendix IV
Leptospirosis Census Format for Reporting

Date No. of New No. of New No. of Current Category Age Location Treatment
Admissions Referrals from Mortality in No. of
Other Hospitals the Last 24 hrs Patients Pay Svc Adult Pedia ER Lepto 2D 2E PD Pay HD PD Hydration
Ward Main Ward Alone
(30 beds)

Leptospirosis Policies and Procedures Manual | 25

Appendices
 Appendix V *THB- Total Hospital Bill
**QFS- Qualified Free Service
MSSD Patient Registry Format of Reporting

Date of Name Address Age Sex Class PHIC (Member, THB* QFS** PHIC Patient’s Treatment Date of Total No. of Outcome
Entry Dependent, None) Counterpart Counterpart Discharge Hospital Days (Improved,
HAMA, Died)

Leptospirosis Policies and Procedures Manual | 26

Appendices
 Appendices

Appendix VI
Estimated Quantities of Medications Needed for Leptospirosis Patients

Table I. Medications Needed for a Patient with Leptospirosis per Day

Medications Recommended Dose/Day/Person Corresponding Number of
Vials/Patient/Day
IV Penicillin G 1 mu/vial 1.5 Million Units IV q6 hours 6
Ceftriaxone 1 gram/vial 1 gram IV OD 1
IV Methylprednisolone 500 mg IV OD (3 Doses) 1
500 mg/vial
IV Cyclophosphamide 1 gram IV Single Dose 1
1 gram/vial
IV Hydrocortisone 100 mg IV q 6 4
100mg/vial
IV Omeprazole 40 mg/vial 40 mg IV OD 1
For Pediatric Patients:
Amoxicillin 250 mg/5 ml 30-50 mg/kg/day q6H 1
(max:500mg QID)

Assumptions:
1. Fifty percent (50%) of patients will be given Methylprednisolone and
Cyclophosphamide and 50% of patients will be given Hydrocortisone.
2. Ten percent (10%) of patients will be given IV Penicillin G and 90% of patients will
be given Ceftriaxone.

Table II. Medications Needed for 10 Patients with Leptospirosis per Day
Medications Recommended Corresponding Number of Patients
Dose/Day/Person Number of Vials Requiring Medications
IV Penicillin G 1 mu/vial 1.5 Million Units IV 6 1
q 6 hours
Ceftriaxone 1 gram/vial 1 gram IV OD 9 9
IV Methylprednisolone 500 mg IV OD 5 5
500 mg/vial (3 Doses)
IV Cyclophosphamide 1 gram IV 5 5
1 gram/vial Single Dose
IV Hydrocortisone 100 mg IV q 6 20 5
100mg/vial
IV Omeprazole 40 mg/vial 40 mg IV OD 10 10
Amoxicillin 250 mg/ 5 ml 30-50 mg/kg/day q6H 5 5
(max: 500mg QID)

Leptospirosis Policies and Procedures Manual | 27

 Appendices

Appendix VII
Leptospirosis Prophylaxis Survey 2013

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:

Leptospirosis Policies and Procedures Manual | 28

Notes
Notes
National Kidney and Transplant Institute
Asia’s Leading Kidney Transplant Center
East Avenue, Quezon City, Philippines 1101
Telephone Nos.: 981-0300 & 981-0400 Fax: 922-5608
Email Address: pro@nkti.gov.ph
Website: http://www.nkti.gov.ph