LEPTOSPIROSIS

Upsurge Policies and Procedures Handbook

Editors
Romina A. Danguilan, MD
Mel-Hatra I. Arakama, MD
2019 Edition

National Kidney and Transplant Institute

Quezon City, Philippines
 LEPTOSPIROSIS
UPSURGE POLICIES
AND PROCEDURES
HANDBOOK
2019 Edition

Editors
Romina A. Danguilan, MD
Mel-Hatra I. Arakama, MD
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook i

Leptospirosis Upsurge Policies and Procedures Handbook

© Copyright 2019
First Edition was published in 2013.

All rights reserved. No part of this handbook may be translated into other languages, reproduced or utilized
in any form or by any means electronic or mechanical, including photocopying, recording, microcopying, or
by any information storage and retrieval system, without permission in writing from the editors.

Romina A. Danguilan, MD
Deputy Executive Director
Education, Training and Research Services
National Kidney and Transplant Institute
radanguilan@gmail.com

Mel-Hatra I. Arakama, MD
Department of Adult Nephrology
National Kidney and Transplant Institute
melhatraarakama@gmail.com

Printed in the Philippines.

 NKTI Leptospirosis Upsurge Policies and Procedures Handbook ii

FOREWORD

In the past years, the National Kidney and Transplant

Institute’s capability has been put to test by natural
calamities and disasters arising from it. The recent upsurge
in June-July-August 2018 was an awakening, the force
which ignited the interest for NKTI to revisit the guidelines in
the management of Leptospirosis.

To cope with the need for 458 admissions in 2018, we had to convert the
Gymnasium into a Leptospirosis ward with 50-60 cot beds. Three hemodialysis
machines were installed at the gym. In severe cases with pulmonary hemorrhage,
they had to be put on ECMO machines (Extracorporeal Membrane Oxygenator). It
was providential that the first ECMO machine requested as a congressional
insertion and procured thru the Health Facility Enhancement Program arrived
sometime in May of 2018. The Department of Health felt the continuing need for it
that Sec. Francisco T. Duque III authorized purchase of 2 more ECMO machines.
With the help of ASEC Elmer G. Punzalan, Head of the Field Implementation and
Coordination Team of NCR, human resource augmentation for doctors, nurses and
aides came from National Childrens Hospital, Quirino Memorial Medical Center,
Amang Rodriguez Medical Center, Jose Fabella Memorial Medical Center,
Batangas Medical Center and other hospitals.

The remarkable innovations at NKTI earned the hospitals two awards from the
Healthcare Asia Awards 2019: Service Innovation of the Year-Philippines and
facilities Improvement Initiative of the Year-Philippines. The NKTI has made its
niche in the history of the medical field. This updated Manual on Leptospirosis is a
testimony of the team effort of the NKTI family. Now we are much more ready and
equipped to face any crisis!

ROSE MARIE O. ROSETE-LIQUETE, MD, FPCS, FACS

Executive Director
NKTI Leptospirosis Upsurge Policies and Procedures Handbook iii
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook iii

ACKNOWLEDGMENT

The following Departments, Divisions and Sections contributed to this handbook:

Emergency Room Services

Adult Nephrology Division
Pediatric Nephrology Division
Internal Medicine Division
Pulmonary Medicine Section
Organ Transplantation and Vascular Surgery Department
Pathology and Laboratory Medicine Department
Blood Donor Recruitment Section
Medical Imaging and Therapeutic Radiology Department
Nursing Services
Hemodialysis Unit
Peritoneal Dialysis Unit
Medical Social Services Division
Pharmacy Division
Procurement Division
Supply Management Division
Central Supply and Sterilization Unit
Billing and Claims Division
Admitting and Discharge Section
Information Resource Management Division
Housekeeping Section
Nutrition and Dietetics Division
Infection Prevention and Control Committee
NKTI-HEM Team
NKTI Leptospirosis Upsurge Policies and Procedures Handbook iv
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook iv

TABLE OF CONTENTS

I. Statement of Purpose and Scope

Purpose 1
Scope 1

II. Key Policies

Criteria for Activation of Leptospirosis Emergency Policy 1
Person Responsible for Activation of the Leptospirosis Upsurge Policy 2
During Office Hours 2
After Office Hours 3
Activation of the Leptospirosis Upsurge Management Team 3
Critical Bed Status Procedure 4
Standards for Admission of Leptospirosis Patients 4
Guidelines for Blood Component Transfusion
for Treatment of Leptospirosis 4
Communication during Activation of the Leptospirosis Upsurge Policy 4

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

in the Management of a Leptospirosis Upsurge
Emergency Room 5
Internal Medicine Division 6
Adult and Pediatric Nephrology Divisions 6
NKTI-HEM Team 8
Organ Transplantation and Vascular Surgery Department 8
Pathology and Laboratory Medicine Department 8
Blood Donor Recruitment Section 8
Pulmonary Medicine Section 8
Medical Imaging and Therapeutic Radiology Department 9
Nursing Services 9
Hemodialysis Unit 9
Peritoneal Dialysis Unit 10
Infection Prevention and Control Committee 11
Medical Social Services Division 11
Pharmacy Division 11
Housekeeping Section 12
Procurement and Supply Management Divisions 13
Central Supply and Sterilization Unit 13
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook v

Billing and Claims Division 14

Admitting and Discharge Section 14
Information Resource Management Division 14
Nutrition and Dietetics Division 14

IV. Setting up a Leptospirosis Ward 15

V. Staffing Requirements in the Leptospirosis Ward

Medical Staffing 16
Nurses Staffing 17

VI. Antibiotic Prophylaxis for Leptospirosis

For Adults 18
For Pregnant Women 18
For Children 19

VII. Appendices
Appendix I.
Treatment Algorithm for Leptospirosis 20
Appendix II.
Leptospirosis Prophylaxis Survey 22
Appendix III.
Treatment Algorithm for Leptospirosis (Pediatric Patients) 23
Appendix IV.
Leptospirosis Census Format for Reporting 26
Appendix V.
Criteria for Assisted Ventilation for Leptospirosis Patients 27
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 1

I. STATEMENT OF PURPOSE AND SCOPE

A. Purpose
It is the purpose of this handbook to define the actions and roles necessary
to provide a coordinated response during an upsurge in Leptospirosis cases in the
National Kidney and Transplant Institute (NKTI). This handbook provides
guidance to all the Departments/Divisions/Sections within the NKTI, 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 (FICT) 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 Departments/Divisions/Sections within
the NKTI.

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 NKTI, to ensure that
patients receive appropriate and timely medical care, renal replacement and
respiratory support using the NKTI criteria to guide health care:

Opening of a Leptospirosis Ward

Patients who are admitted with a presumptive diagnosis of
Leptospirosis, of more than 10 per day, 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 therapy, blood component
transfusion or requiring respiratory support) is reached, a Leptospirosis Ward will
be identified and opened for these patients.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 2

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 (EO) if the criteria for activation of the Leptospirosis Upsurge
Policy has been met. Any one of the Deputy Executive Directors (DED) or the
Executive Director will activate the Leptospirosis Upsurge Policy.

Upon Activation of the Leptospirosis Upsurge Policy, the Secretary of any of

the DEDs or the Executive Director will send out a memorandum through
Outlook, and will notify the Heads of the following Departments/
Divisions/Sections:
 Adult and Pediatric Nephrology
 Hemodialysis (HD) and Peritoneal Dialysis (PD) Units
 Internal Medicine
 General Surgery
 Organ Transplantation and Vascular Surgery
 Pathology and Laboratory Medicine
 Blood Donor Recruitment
 Medical Imaging and Therapeutic Radiology
 Nursing Services
- All Head Nurses or Charge Nurses in all Clinical Wards
- Operating Room (OR)
 Pulmonary Medicine
 Pharmacy, Procurement, Supply Management, Central Supply and
Sterilization Unit, Housekeeping, Billing and Claims, Admitting and Discharge
 Medical Social Services
 Information Resource Management (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
Executive Director and DEDs through SMS
 NKTI-HEM Team
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 3

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

Executive Director 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 Executive Director
or any of the DEDs 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 Executive Director.
This team is composed of the following:
 Executive Director or any of DEDs – Head
 Chair, Departments/Divisions of Adult and Pediatric Nephrology, Internal
Medicine, Vascular, Laboratory Medicine, Medical Imaging and
Therapeutic Radiology
 DED for Nursing Services
 ER Head
 PD Unit Head
 Head Nurse of ER, Clinical Wards, HD Unit, PD Unit, OR
 Head of Housekeeping, Procurement, Pharmacy, SMD, CSSU, PBSD,
MSSD, IRM, NKTI-HEM Team
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 4

D. Critical Bed Status Procedure – NKTI 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 (>10 patients per day), 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 Division of 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 I)

F. Guidelines for Blood Component Transfusion for Treatment of Leptospirosis

1. With clinical bleeding, do CBC and PT/PTT, and blood typing first.
2. Platelet level is 100 and below with prolonged PT/PTT, proceed with checking
serum fibrinogen. (Highly suspicious for DIC)
3. If platelets at least 101 and above, even with abnormal PT/PTT, less likely DIC.
4. Use the platelet filter for patients hooked to ECMO already/patients for
possible ECMO (Hemoptysis, chest X-ray worsening, low P02, high Pc02)

G. Communication during Activation of the Leptospirosis Upsurge Policy

In case of the unavailability of the Executive Director or the Head of the
Leptospirosis Upsurge Management Team, the Division of Adult Nephrology will
assign at least 3 Consultants for media interviews (radio/TV). Assigned
Consultants will be provided with the daily/latest census by the Chief Nephrology
Fellow.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 5

III. ROLES AND RESPONSIBILITIES OF THE VARIOUS DEPARTMENTS /

DIVISIONS / SECTIONS IN THE MANAGEMENT OF A LEPTOSPIROSIS
UPSURGE

A. Emergency Room
 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
Form is completed for all patients and are kept in ER for documentation. The
Chief Fellow of the Division of Adult Nephrology should collect the survey
forms including forms from Pediatric Nephrology and Internal Medicine. (See
Appendix II)
 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 HD or 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 in the 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 Supply Management/Warehouse, CSSU, and
Procurement.
- For HD access – use triple lumen catheters
- For intubation – use ET tube with subglottic suction
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 6

 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
NKTI 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.

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.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 7

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 I and 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 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 IV)
 In compliance with the Data Privacy Act, the Chief Fellow shall ensure that all
patients have signed a Consent Form before any radio or TV interview as well
as being photographed by any media personnel.
 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 IV). This
will be emailed to the Executive Director, 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 NKTI, 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 Executive Director/DEDs as
necessary.
 The Head of the Leptospirosis Upsurge Management Team and/or the
Executive Director/DEDs, will attend the DOH-HEMB meetings, as necessary,
to provide updates on the status of patients admitted at the NKTI and to
request for logistical support, if necessary.
 Nephrology Staffing of the Leptospirosis Ward is seen in Section V.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 8

D. NKTI-Health Emergency Management (HEM) Team

The NKTI-HEM 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 DOH-FICT 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. Blood Donor Recruitment Section

Ensure blood availability for Leptospirosis patients who need blood
transfusion. They will coordinate with Philippine National Red Cross (PNRC) and
other government agencies for blood supplies.

H. 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 NKTI 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 V.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 9

I. 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.

J. 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.

K. 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
inpatients 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. Alternatively, an additional 4 HD machines may be set up at the HD
Annex to accommodate the additional patients.
 Once a decision is made to set-up an HD Unit in the Leptospirosis Ward, the
HD Unit Supervisor will contact the NKTI’s HD provider to augment the
number of HD machines and portable RO machines to be placed in the
Leptospirosis Ward, and contact the NKTI’s HD Provider 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.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 10

 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
 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.

L. Peritoneal Dialysis (PD) Unit

 Once the Leptospirosis Upsurge Policy is activated, the PD Unit Supervisor
will contact the NKTI’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 General 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.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 11

M. Infection Prevention and Control Committee (IPCC)

 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.

N. 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.
 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.
 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.
 Prepare the running balance of expenses related to Leptospirosis and submit
regular reports to the Executive Director and to the Head of the Leptospirosis
Upsurge Management Team and other Executives.

O. Pharmacy Division
 Strategize, lead and manage logistics to ensure operational effectiveness. It
includes ensuring the hospital has sufficient inventory of medicines and
pharmaceutical supplies to manage the Leptospirosis Upsurge, and that all
inventory are accurately accounted for at all times.
 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.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 12

 Ensure that the Leptospirosis Ward and other wards that have admitted
Leptospirosis patients are provided with all the necessary medications (See
Appendix I and III) such as:
- Amoxicillin suspension 250mg/5ml
- IV Penicillin G 1.5M units/vial
- 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
- IV Sodium Bicarbonate 1meq/ml, 50ml/vial

 The following should also be available in sufficient quantities:

- Doxycycline 200mg/cap
- Amoxicillin 500mg/cap
- Omeprazole 40mg/amp
- IV Plain NSS 1liter/ bottle, D50-50 vial, D5W250cc, D5LR 1L/bottle,
Plain LR 1L/bottle
- Dopamine 200mg/5ml vial
- Norepinephrine 1mg/ml, 10ml vial
- Dobutamine 250mg/25ml vial

P. Housekeeping Section
 Strategize, lead and manage logistics to ensure operational effectiveness. It
includes ensuring the hospital has sufficient inventory of housekeeping
supplies to manage the Leptospirosis Upsurge, and that all inventory of
donated supplies, equipments etc. from DOH and other government agencies
are accurately accounted for at all times.
 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)
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 13

Q. Procurement and Supply Management Divisions

 Strategize, lead and manage logistics to ensure operational effectiveness. It
includes ensuring the hospital has sufficient inventory of all supplies to
manage the Leptospirosis Upsurge, and that all inventory are accurately
accounted for at all times.
 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 Executive Director and to the DED 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.

R. 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.
 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
- Hand sanitizer
- Cotton balls
- Povidone-iodine
- Alcohol
- Foley catheters
- Cut down set
- Endotracheal tube standard
- Endotracheal tube with subglottic suction
- Nasogastric tube
- HD triple lumen catheters for right and left internal jugular vein
- PD catheters (Adult and Pediatric)
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 14

S. Billing and Claims Division

 Responsible for the preparation of hospital bills for Leptospirosis patients.
 Responsible for submitting claims to PhilHealth for point-of-care benefit, as
well as the routine claims for PhilHealth members.
 Provide reports to Management on a weekly basis on the total subsidy by the
NKTI for Leptospirosis patients in coordination with MSSD.
 Coordinate with IRM to ensure that patients are charged with the appropriate
room rates when they are admitted to the Leptospirosis Ward.

T. Admitting and Discharge Section

 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.

U. Information Resource Management Division (IRM)

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

V. Nutrition and Dietetics Division (NDD)

 Provide meals for all patients in the Leptospirosis Ward.
 Provide meals for the NKTI 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.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 15

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:
 (50) Cot Bed + Bed linen  (10) Oxygen tank
 (50) IV stand  (30) Oxygen mask
 (50) Watcher chair  (50) Disposable thermometer
 (10) Wheelchair with IV stand  (50) Infusion pump
 (10) Curtain divider  (50) Nasal cannula
 (2) Emergency stretcher  (20) Extension cord
 (20) BP Apparatus  (10) Air Coolers or industrial fans
 (4) Medicine cart  (1) Freezer or ice chest
 (1) Linen cart  (2) Water dispenser
 (10) Oxygen gauge
 (50 boxes) Clear gloves, M and L sizes
 (50 boxes) Sterile gloves, 6.5 and 7 sizes
 (5) Short stool chair for blood extraction

The following may be placed in the Leptospirosis Ward if needed:

 PD Cyclers  HD machines

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 NKTI Communications Module for laboratory and radiology results etc.
 (1) Printer
 (2) Telephone units
 (50) Patient folders/clipboards
 Forms (ie. laboratory requests, admitting forms, order sheets, TPR sheet,
input/output sheet etc.)
 Basic medical supplies for patients
 Dressing kits and cut-down sets

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.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 16

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 2 is assigned to cover the Leptospirosis Ward until
a maximum of 20 patients.
 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 Executive Director to request for external staff
augmentation (physicians, nurses, nursing attendants etc.) from other
Institutions to help in monitoring of patients. The Executive Director will inform
the DOH-FICT 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.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 17

B. Nurses Staffing in the Leptospirosis Ward

 Once the NKTI 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 NKTI 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 DED for Nursing Services will
inform the Head of the Leptospirosis Upsurge Management Team and the
Executive Director 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 Executive Director will inform DOH-FICT
NCR, of the need for staff augmentation. The Assistant Coordinator of the
NKTI-HEM Team will likewise be informed of the need for staff augmentation
to coordinate with DOH-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 DED for Nursing Services or his/her representative for
the assigned area of deployment.
 The Executive Director and other DEDs may also call other DOH, Army 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.
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 18

VI. ANTIBIOTIC PROPHYLAXIS FOR LEPTOSPIROSIS

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
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 19

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 Division 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
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 20

VII. APPENDICES
Appendix I
Algorithm for Leptospirosis (Adult Patients)

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, Amylase
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

 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 21

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 a Multi-Disciplinary Team composed of:
Dr. Romina Danguilan, Adult Nephrologist
Dr. Myrna Mendoza, Infectious Disease Specialist
Dr. Ernesto Que, Gastroenterologist
Dr. Joselito Chavez, Pulmonologist
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 22

Appendix II
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:

 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 23

Appendix III
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
500mg OD or 10mg/kg/day OD for 3
days
Give methylprednisolone 500mg
IV after HD OD x 3 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)
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 24

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
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 25

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
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 26

Leptospirosis Census Format for Reporting

Appendix IV
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 27

Appendix V
Criteria for Assisted Ventilation for Leptospirosis Patients

A. 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

B. 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

C. Indications for ECMO in Leptospirosis patients with pulmonary hemorrhage

resulting in ARDS
Use of 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)
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 28

D. 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

Murray Score

References:
Murray and Nadel’s Textbook of Respiratory Medicine
ELSO Adult Respiratory Failure Guideline
 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 29

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

 NKTI Leptospirosis Upsurge Policies and Procedures Handbook 30

LEPTOSPIROSIS
Upsurge Policies and Procedures Handbook
2019 Edition

National Kidney and Transplant Institute

East Avenue, Quezon City, Philippines
www.nkti.gov.ph
Tel. Nos. (632) 8981-0300 / 8981-0400