DOH GUIDELINES for 2019 Edition

Page created by Corey Daniels
 
CONTINUE READING
DOH GUIDELINES for 2019 Edition
DOH
GUIDELINES for
LEPTOSPIROSIS
for HOSPITALS
2019 Edition
DOH GUIDELINES for 2019 Edition
DOH GUIDELINES for
LEPTOSPIROSIS for HOSPITALS
                  2019 Edition
DOH Guidelines for Leptospirosis for Hospitals

                                                 i
DOH Guidelines for Leptospirosis for Hospitals

FOREWORD

                                                            ii
DOH Guidelines for Leptospirosis for Hospitals

                                                 iii
DOH Guidelines for Leptospirosis for Hospitals

TECHNICAL WORKING GROUP

Research Institute for Tropical Medicine
    Celia C. Carlos, MD
    Arthur Dessi E. Roman, MD

National Kidney and Transplant Institute
     Romina A. Danguilan, MD
     Mel-Hatra I. Arakama, MD

CONTRIBUTORS
     Amang Rodriguez Memorial Medical Center      Imelda M. Mateo, MD
     Dr.Jose Fabella Memorial Hospital            Esmeraldo T. Ilem, MD
     East Avenue Medical Center                   Alfonso G. Nuñez III, MD
     Jose R. Reyes Memorial Medical Center        Emmanuel F. Montaña Jr., MD
     National Center for Mental Health            Alan Baquir, MD
     National Children’s Hospital                 Epifania S. Simbul, MD
     National Kidney and Transplant Institute     Rose Marie R. Liquete, MD
                                                  Joselito R. Chavez, MD
     Philippine Orthopedic Center                 Jose Brittanio S. Pujalte Jr., MD
     Quirino Memorial Medical Center              Evelyn Victoria E. Reside, MD
     Rizal Medical Center                         Relito M. Saquilayan, MD
     San Lazaro Hospital                          Edmundo B. Lopez, MD
                                                  Benjamin D. Estrella Jr., MD
                                                  Rontgene M. Solante, MD
     Tondo Medical Center                         Maria Isabelita M. Estrella, MD
     Dr. Jose N. Rodriguez Memorial Hospital      Alfonso Victorino H. Famaran, MD
     Las Piñas General Hospital and               Rodrigo H. Hao, MD
            Satellite Trauma Center
     San Lorenzo Ruiz Women’s Hospital            Marilou T. Nery, MD
     Valenzuela Medical Center                    Maria Estrella B. Litam, MD
     DOH-TRC Bicutan                              Alfonso A. Villaroman, MD
     DOH-NCR                                      Corazon I. Flores, MD
                                                  Ma. Paz P. Corrales, MD
     DOH-FICT NCR                                 Emmanuel A. Tiongson, MD
                                                  Ruben C. Flores, MD
                                                  Francisco A. Valdez, MD

A Project of FICT Team NCR in cooperation with NKTI under the supervision of
Asec. Elmer G. Punzalan.

                                                                                                  iii
DOH Guidelines for Leptospirosis for Hospitals

                                                 iv
DOH Guidelines for Leptospirosis for Hospitals

TABLE OF CONTENTS

Chapter 1: MANAGEMENT PROTOCOL FOR LEPTOSPIROSIS

I.    Introduction                                                                       1

II.   Criteria for Diagnosis                                                             5

III. Indications for Admission and Guidelines on
     Site-of-Care Decisions                                                               5

IV. Laboratory Work Up
     Leptospiral Tests                                                                   7
     Non-Leptospiral Tests                                                               8

V. General Guidelines in the Management of Leptospirosis                                 9

VI. Antibiotic Management                                                                9

VII. Steroid Therapy                                                                     11

VIII. Pulmonary Complications of Leptospirosis
       Diagnosis of Pulmonary Complications of Leptospirosis                             11
       Management of Pulmonary Complications of Leptospirosis                            12
       Extracorporeal Membrane Oxygenation in leptospirosis                              15

IX. Renal Complications of Leptospirosis                                                 15

X. Prevention and Control                                                                18

XI. Chemoprophylaxis
     Pre-exposure Prophylaxis                                                            18
     Post-exposure Prophylaxis                                                           19

XII. References                                                                          20

Appendices
    Appendix A. Modified Faine’s Criteria (2012)                                         21
    Appendix B. Guidelines in Specimen Collection, Storage,
                Transport and Submission                                                 22

                                                                                                 iv
DOH Guidelines for Leptospirosis for Hospitals

Chapter 2: UPSURGE POLICIES AND PROCEDURES

I. Statement of Purpose and Scope
       Purpose                                                                             25
       Scope                                                                               25

II. Key Policies
      Criteria for Activation of Leptospirosis Emergency Policy                            25
      Person Responsible for Activation of the Leptospirosis Upsurge Policy                26
      During Office Hours                                                                  26
       After Office Hours                                                                  27
      Activation of the Leptospirosis Upsurge Management Team                              27
      Critical Bed Status Procedure                                                        28
      Standards for Admission of Leptospirosis Patients                                    28

III. Roles and Responsibilities of the Various Departments/ Divisions/Sections
     in the Management of a Leptospirosis Upsurge
        Emergency Room                                                      29
        Division of Internal Medicine                                       30
        Divisions of Adult and Pediatric Nephrology                         31
        HEMB Team                                                           32
        Division of Organ Transplantation and Vascular Surgery              32
        Department of Pathology and Laboratory Medicine                     32
        Section of Pulmonary Medicine                                       32
        Department of Medical Imaging and Therapeutic Radiology             32
        Nursing Services                                                    33
        Hemodialysis Unit                                                   33
        Peritoneal Dialysis Unit                                            34
        Infection Prevention and Control Committee                          35
        Medical Social Services Division                                    35
        Pharmacy Division                                                   35
        Housekeeping Section                                                36
        Procurement and Supply Management Divisions                         36
        Central Supply and Sterilization Unit                               37
        Billing and Claims Division                                         37
        Admitting and Discharge Section                                     37
        Information Resource Management Division                            38
        Nutrition and Dietetics Division                                    38

                                                                                                   v
DOH Guidelines for Leptospirosis for Hospitals

IV. Setting up a Leptospirosis Ward                                                         39

V. Staffing Requirements in the Leptospirosis Ward
      Medical Staffing                                                                      40
      Nurses Staffing                                                                       41

VI. Health Care Provider Network                                                            42

VII. Antibiotic Prophylaxis for Leptospirosis
      For Adults                                                                            43
      For Pregnant Women                                                                    43
      For Children                                                                          43

Appendices
    Appendix A. Treatment Algorithm for Leptospirosis                                       45
    Appendix B. Leptospirosis Prophylaxis Survey                                            47
    Appendix C. Treatment Algorithm for Leptospirosis (Pediatric Patients)                  48
    Appendix D. Leptospirosis Census Format for Reporting                                   51
    Appendix E. Criteria for Assisted Ventilation for Leptospirosis Patients                52

                                                                                                    vi
DOH Guidelines for Leptospirosis for Hospitals

Chapter 1: MANAGEMENT PROTOCOL FOR LEPTOSPIROSIS

I. INTRODUCTION

      Leptospirosis is a zoonotic infection caused by pathogenic spirochetes of the
genus Leptospira. Ten (10) out of the 22 identified species under this genus are
considered pathogenic, while the remaining 7 and 5 are non-pathogenic, free-living
saprophytes (e.g. Leptospira biflexa) or of unclear pathogenicity, respectively.1 An
older system has been used to classify them into serovars (based on serology) so
isolates are currently identified using two systems, e.g. Leptospira
icterohemorrhagiae serovar manilae. Over 250 serotypes of pathogenic leptospires
have been recognized and the severe form of leptospirosis have been reported to
be caused by all of these.2 Leptospira icterohaemorrhagiae, by far, has been
commonly associated with severe disease. In the Philippines, earlier studies
reported that the major serovars affecting humans in Metro Manila and neighboring
provinces were Manilae, Losbanos, Tarassovi, and Poi.3

      In Philippines, leptospirosis tends to occur frequently in urban flood-prone
areas such as Metro Manila. This disease gained much attention after an outbreak
following typhoon Ondoy in October of 2009. About two weeks following this heavy
rainfall typhoon that left many areas of Metro Manila flooded, the Department of
Health reported 2,894 probable and confirmed cases of leptospirosis with 210
deaths.4

      From January 1, 2018 to December 31, 2018, a total of 5,232 cases were
reported to the Department of Health with a case fatality rate of 9.65%. This is a
71% increase in the total number of cases compared to 2017.5 In fact, in July of
2018, the Department of Health has declared an outbreak of leptospirosis in certain
areas of Metro Manila. Outbreaks of leptospirosis in the Philippines are expected to
occur with increasing incidents of heavy rainfall, rapid urbanization (dramatic
increase in populations), deforestation, increasing number of flood-prone areas,
poor infrastructures, among many other factors.

       Leptospirosis is primarily a disease of domesticated and wild animals. Humans
are infected through direct and indirect contact with these animals. The source of
infection is water or soil contaminated with infected urine, infected urine or tissues
from infected animals. The leptospires enter through cuts and abrasions in the skin
or mucosal surfaces, the conjunctiva, or by inhalation (into the lungs) of droplets or
aerosols of fluid containing leptospires. After penetrating intact mucous membranes
or abraded skin, leptospires enter the blood stream and are rapidly carried to all

                                                                                                     1
DOH Guidelines for Leptospirosis for Hospitals

parts of the body (including the cerebrospinal fluid [CSF] and the eyes) presenting
as an acute, systemic disease is characterized by extensive vasculitis.

     The incubation generally is 5-14 days but a range of 2 to 30 days has been
noted. The incubation period does not vary significantly among serotypes. It may
present as influenza-like illness with headache and myalgia in its mild form and may
present with jaundice, renal dysfunction and hemorrhage (Weil’s Syndrome) when it
presents as severe form.

      Leptospirosis presents in two (2) forms: anicteric (mild) or icteric (severe)
leptospirosis. Anicteric (mild) leptospirosis is often characterized by abrupt onset
of fever, headache, severe muscle aches, malaise and prostration. High intermittent
fever, chills, persistent headache, severe myalgias, abdominal pain and nausea and
vomiting persist for 4-7 days. Death almost NEVER occurs during this stage. In
anicteric infections, the second stage may not occur. On the other hand, icteric
(severe) leptospirosis or Weil Syndrome may present with impaired renal and
hepatic function, hemorrhage, vascular collapse, and even severe alterations in
consciousness. This form has a high mortality rate.

     The clinical course of leptospirosis varies but it is generally predictable. Both
forms of leptospirosis follow a biphasic course:
     1. The LEPTOSPIREMIC PHASE (or ACUTE stage) is characterized by an
         acute systemic infection. The onset of symptoms is abrupt and resolves
         after 4-7 days. Symptomatic improvement and lysis of the fever coincide
         with the disappearance of leptospires from the blood, cerebrospinal fluid
         and all other tissue with the EXCEPTION of the aqueous humor (resolves
         in 4-30 days) and renal parenchyma (persists for 1-4 weeks in the urine).
         Antibody titers to leptospires develop rapidly. This immune response
         heralds the second or immune stage of the illness.

     2. The IMMUNE PHASE (sometimes LEPTOSPIRURIC PHASE,
        CONVALESCENT STAGE) is the second stage and lasts 4-30 days.
        Occasionally, there is a brief asymptomatic period of 2-3 days between the
        two stages. Leptospiruria continues for 1 week to 1 month. Generally, this
        phase is not affected by antibiotic therapy. This phase is characterized by
        the presence of circulating antibody and development of meningitis, uveitis,
        rash, and (in severe cases) hepatic and renal involvement. In icteric cases,
        leptospires can sometimes be isolated from the blood for 24-48 hours after
        the appearance of jaundice.1

                                                                                                     2
DOH Guidelines for Leptospirosis for Hospitals

       In the Philippines, majority of the symptoms of Leptospirosis is non-specific,
which indicates that the initial impression could be viral rather than bacterial. Table 1
lists down the percentage frequencies of signs and symptoms of leptospirosis seen
in our local setting. A comparison of two studies from the Philippine 2009 outbreak
reported that the most common clinical features include fever, myalgia, conjunctival
suffusion, malaise, headache, abdominal pain, oliguria, and jaundice.

Table 1. Clinical Features of Leptospirosis after a flood, National Capital Region, 2009
 Sign or Symptom                     9 Manila Hospitals, 20096     San Lazaro Hospital, 20097
 Number of patients              259 confirmed leptospirosis cases         471 cases
 Fever                                         98.5                          100*
 Myalgia/calf-tenderness                       78.1                          76.7
 Malaise                                       74.9                          44.2
 Headache                                      55.6                          52.2
 Chills                                        44.8                           NR
 Conjunctival suffusion                        59.3                          78.1
 Hypotension                                   23.6                           NR
 Abdominal pain                                52.7                          61.2
 Nausea/vomiting                               52.0                          57.8
 Diarrhea                                      39.0                          40.8
 Jaundice                                      38.0                          47.8
 GI bleeding                                   16.1                           NR
 Oliguria                                      56.6                          60.7
 Hematuria                                     22.3                          33.1
 Cough                                         30.5                          17.6
 Dyspnea                                       21.6                           NR
 Crackles/rales                                23.3                           NR
 Hemoptysis                                    14.9                           3.2
 Hemorrhagic signs                             14.6                           0.4
*part of inclusion criteria; NR – no report

     These clinical findings are consistent with prior local studies done in Metro
Manila since the 1970s (Table 2).

                                                                                                          3
Table 2. Clinical features of seasonal leptospirosis admitted at various hospitals in Metro Manila compared with the 2009 outbreak 8
                                                                                                                                           DOH Guidelines for Leptospirosis for Hospitals

4
DOH Guidelines for Leptospirosis for Hospitals

II. CRITERIA FOR DIAGNOSIS

     Leptospirosis should be suspected in an individual with:
      An acute febrile illness of at least 2 days AND
      Two or more of the following symptoms: myalgia, calf tenderness,
       conjunctival suffusion, chills, abdominal pain, headache, jaundice, or
       oliguria AND
      Any risk factor for acquiring the disease which includes:
           - residing in a flooded area
           - wading or swimming in floods and contaminated water, with or
              without cuts or wounds
           - contact with animal fluids especially carcass
           - ingestion of contaminated water

     A checklist for diagnosing leptospirosis for frontliners have been developed
(See Appendix A). The checklist consists of three parts: Clinical data,
Epidemiologic factors and Bacteriologic and laboratory findings. Using paired MAT
as the gold standard, the estimated sensitivity and specificity of the WHO criteria
were 33% and 66% respectively.9 Studies on the clinical utility of this criteria are
were probably limited by the small sample size.

III. INDICATIONS FOR ADMISSION AND GUIDELINES ON
     SITE-OF-CARE DECISIONS

      Patients with suspected leptospirosis presenting with MILD symptoms can be
managed on an OUT-PATIENT SETTING. These include patients with stable vital
signs, anicteric sclerae, no jaundice, with good urine output, no evidence of
meningismus/ meningeal irritation, no dyspnea, no tachypnea, no hemoptysis, no
bleeding, not in sepsis / septic shock, and can take oral medications.

       On the other hand, patients with suspected MODERATE to SEVERE
LEPTOSPIROSIS should be admitted in a healthcare facility for proper diagnosis
and appropriate monitoring and management. The presence of the following signs
and symptoms will classify a patient to have moderate to severe leptospirosis and
will require admission:
        Unstable vital signs
        Jaundice / Icteric sclerae
        Abdominal pain
        Nausea, vomiting and diarrhea

                                                                                                   5
DOH Guidelines for Leptospirosis for Hospitals

         Oliguria or anuria
         Bleeding
         Meningismus / meningeal irritation
         Sepsis / septic shock
         Altered mental status
         Difficulty of breathing or hemoptysis

      Patients with leptospirosis who are suspected to have pulmonary
complications such as pulmonary hemorrhage or acute respiratory distress
syndrome (ARDS) require special attention because these conditions have been
consistently associated with increased mortality. These patients present with
dyspnea, tachypnea, chest x-ray findings of localized or multilobar infiltrates or
pleural effusion. The decision to admit a leptospirosis patient with pulmonary
complications will depend on the level of hypoxemia (see Table 6).

      Moderate hypoxemia: 100
DOH Guidelines for Leptospirosis for Hospitals

    PRESUMPTIVE diagnosis of Leptospirosis may be based on the following
    findings:
   positive dark field examination;
   presentation of clinical symptoms that are compatible with leptospirosis and a
    microscopic agglutination titer of 1:100 or greater;
   a positive macroscopic agglutination slide test reaction on a single specimen
    obtained after the onset of symptoms; and
   stable microscopic agglutination titer of 1:100 or greater in two or more serum
    specimens obtained after the onset of symptoms

A. LEPTOSPIRAL TESTS
   1. Microbiologic Test: Culture Method (definitive)
      Culture of leptospires can be done using blood or cerebrospinal fluid (CSF)
      obtained during the septicemic stage of illness or urine during the immune
      and convalescent stage. Additionally, tissue sections obtained by biopsy or
      at necropsy, can be submitted for culture of Leptospira. The media used
      for culture are Fletcher semisolid medium or Ellinghausen-McCullough -
      Johnson-Harris (EMJH) semisolid medium or Tween 80 - albumin medium
      (OAC) or Korthoff medium. Cultures are incubated at 28-30oC in the dark
      for 6 weeks or longer.

    2. Microbiologic Test: Non-culture Method
       a. Dark field microscopy – recommended as an aid that may suggest BUT
          NOT establish the diagnosis of Leptospirosis
       b. PCR for detection of leptospiral nucleic acid in blood or urine (definitive)

    3. Serologic Tests
       a. Microscopic Agglutination Test (MAT) – detects agglutinating antibodies
          against live leptospires using darkfield microscopy. The 21-serovar MAT
          is considered the "reference standard" or cornerstone of serodiagnosis
          of leptospirosis.     However, a genus-specific MAT using a non-
          pathogenic Leptospira patoc I strain are being performed by some
          centers.

          Interpretation:
          Single specimen: Titer > 1:800 (probable)
          Paired specimen (using acute and convalescent sera): four-fold increase
                       (definitive)

                                                                                                    7
DOH Guidelines for Leptospirosis for Hospitals

         b. Rapid leptospiral diagnostic kits (i.e. immunochromatographic tests or
            ICTs) - useful rapid tests in the early diagnosis of leptospirosis among
            patients with compatible signs and symptoms. There is an increasing
            number of tertiary healthcare facilities that are offering these rapid tests
            already.
         c. IgM ELISA- simple, with acceptable sensitivity that is quite variable
            depending on the method of ELISA performed

Table 3. Appropriate timing of Specimen collection for specific leptospiral tests
          Timing                      0-7 days                7-14 days               14-28 days
   (from onset of illness)
  Specimen and leptospiral   CSF for culture or darkfield
           test              microscopy
                             Dialysate for leptospiral
                             culture
                             Heparinized blood for
                             culture and or PCR
                             Serum (acute specimen)         Serum for serologic tests (rapid ICTs, IgM
                             for MAT                        ELISA) and MAT (convalescent specimen)
                                                            Urine for culture

Refer to Annex B: Guidelines on Specimen collection, storage and transport
for leptospiral tests.

   B. NON-LEPTOSPIRA TEST
        a. MILD
           1. CBC with quantitative platelet count
           2. Urinalysis
           3. BUN and Creatinine
           4. Liver function tests (SGPT, SGOT)

         b. MODERATE to SEVERE (request each test if clinically indicated)
            1. Serum sodium and potassium
            2. Bilirubins (Total Bilirubin, direct and indirect bilirubin)
            3. PT/PTT
            4. Total protein with A/G, Alkaline phosphatase
            5. Chest X-ray
            6. 12-Lead ECG
            7. Arterial blood gas (ABG) - severe metabolic acidosis (ph< 7.2,
               HCO3
DOH Guidelines for Leptospirosis for Hospitals

V. GENERAL GUIDELINES IN THE MANAGEMENT OF LEPTOSPIROSIS

      Most cases of leptospirosis will be mild and self-limited. A suspicion of
leptospirosis should warrant management as such even without evidence from
leptospiral diagnostics.
    Supportive management with hydration and analgesic/antipyretic therapy with
      paracetamol are recommended.
    Correct electrolyte derangements.
    Knowledge on the clinical indicators of progression from an undifferentiated
      fever to severe leptospiral disease is very limited. Thus, it is recommended
      that any illness [regardless of severity, duration or phase of the disease] that
      prompts a patient to seek medical consult and leptospirosis is suspected,
      antibiotic therapy should be administered to shorten the duration of illness
      and reduce shedding of organisms in the urine.
    When the disease is classified as severe, the management is generally the
      same as in the management of organ failure from sepsis. Supportive care
      with renal replacement therapy, ventilatory support, and blood products may
      be required. Consequently, timely referrals to specialists and facilities who
      can provide such services are also recommended to prevent delays and
      progression of anticipated complications.

   The subsequent chapters will discuss the specific recommendations in the
various aspects of leptospirosis management.

VI. ANTIBIOTIC MANAGEMENT

      All patients with suspected leptospirosis should be started on antimicrobial
therapy regardless of the phase of the disease of duration of symptoms to shorten
the duration of illness. While there is insufficient evidence on the use of antibiotics
in preventing death from leptospirosis, its use has been shown to have beneficial
effects on several clinically relevant and important outcomes (e.g. decreased the
duration of clinical illness by 2-4 days).10

     Treatment with effective antibiotics should be initiated as soon as the
diagnosis of leptospirosis is suspected. Antibiotic administration should not be
delayed regardless of the need for renal replacement therapy.

     Doxycycline 5 mg/kg/day PO in 2 divided doses (max 200mg/day) x 1 week.

                                                                                                     9
DOH Guidelines for Leptospirosis for Hospitals

Table 4. Recommended Antibiotic Regimens for Leptospirosis
                               MILD LEPTOSPIROSIS
                 ADULT                                     CHILDREN
 First line

               Doxycycline 100 mg BID PO for 10 days Amoxicillin 30-50 mg/kg/day in 3 divided
                                                     doses. Maximum of 2 grams per day

               
 Alternative

                   Amoxicillin 500mg QID or 1g q8h
                  Azithromycin dihydrate 1 g initially,   Erythromycin 10 mg/kg/day orally in four
                   followed by 500 mg OD for 2 more        divided doses for 1 week
                   days
                                SEVERE LEPTOSPIROSIS (WEIL SYNDROME)
                            ADULT                                           CHILDREN
                Penicillin G 1.5 million units IV q 6      Aqueous penicillin G 6-8 million U/m2/day
 regimen
 Primary

                 hrs for 7 days                              in 6 divided doses for 1 week
                Ceftriaxone 1gm q24h for 7 days            Ampicillin 100 mg/kg/day IV every 6 hours

                Ampicillin 0.5-1.0 gm q6h                  Tetracycline 25-50 mg/kg/day orally in four
                Azithromycin dihydrate 500 mg OD            divided doses or IV tetracycline 10-
                 for 5 days                                  20mg/kg/day IV in four divided doses, max
                Cefotaxime 1 gm q6h                         3 g/day, avoid in children < 9 years
 Alternative

                                                            Doxycycline 5 mg/kg/day PO in 2 divided
                                                             doses (max 200mg/day) x 1 week
                                                            Ampicillin 100 mg/kg/day IV every 6 hours
                                                             or
                                                            Erythromycin 10 mg/kg/day orally in four
                                                             divided doses for 1 week
Note: Step-down therapy can be instituted once patient is clinically stable and able to tolerate oral
medication. Any oral antibiotic can be selected.

Table 5. Dosage of Antibiotics in Adults with Renal Impairment
      Antibiotic              Dose for                    Adjustment for renal failure
                      Normal Renal Function Estimated creatinine clearance (CrCl), ml/min
                                                    50-90         10-50
DOH Guidelines for Leptospirosis for Hospitals

VII. STEROID THERAPY

      Steroids have been reported to reduce or delay the need for ventilator support,
improve PTT or mortality among patients with leptospirosis. While the evidence for
its use is not overwhelming, steroid therapy has found relevance in clinical practice
given the devastating complications of severe leptospirosis, particularly pulmonary
hemorrhage. Thus, steroid therapy is suggested for:
          (1) patients at high-risk of pulmonary hemorrhage, and
          (2) AKI PLUS any of the following:
                    platelet count
DOH Guidelines for Leptospirosis for Hospitals

      On top of the clinical factors, findings from important laboratory tests aid in the
diagnosis of ARDS. The severity of pulmonary involvement can be assessed by
abnormalities on chest radiograph and arterial blood gas.
   1. Radiographic findings commonly accompany pulmonary symptoms. All
      patients have bilateral pulmonary infiltration and maybe seen as early as the
      first 24 hours of the systemic stage of leptospirosis.
   2. Hypoxemia and hypocarbia are common blood gas abnormalities. Elevated
      PCO2 is seen in severe cases. Continuous monitoring of oxygen saturation is
      recommended in the presence of pulmonary complications.

      The table below are parameters that can be used for the diagnosis of ARDS
and for risk stratification to identify site-of-care, particularly the level of oxygenation.

Table 6. American-European Consensus Conference Criteria for ARDS11
       Timing         Within 1 week of a known clinical insult or new/worsening respiratory
                                                       symptoms
 Origin of Edema          Respiratory failure not fully explained by cardiac failure or fluid
                         overload; Need objective assessment (e.g., echocardiography) to
                                exclude hydrostatic edema if no risk factor present
                                Mild                     Moderate                   Severe
   Oxygenation          200
DOH Guidelines for Leptospirosis for Hospitals

Figure 1. Algorithm for the Diagnosis and Management of Leptospirosis with Pulmonary
Complications

                                                                                                     13
DOH Guidelines for Leptospirosis for Hospitals

Non-invasive ventilation (NIV) vs. Invasive ventilation

      A trial of NIV can be done in most patients who do not require emergent
intubation. The presence of the following conditions, however, are contrainidication
to NIV and therefore warrant invasive ventilation:

Table 7. Contraindications To Non-Invasive Positive Pressure Ventilation12
 Non-respiratory organ failure that is acutely life-threatening
 Severe encephalopathy (eg, GCS
DOH Guidelines for Leptospirosis for Hospitals

      This maneuver requires 3-5 people, paying close attention to endotracheal
tube (ETT) and central lines. Make sure that patient has an empty stomach. Steps
in prone positioning:
      1. Pre-oxygenation
      2. Suction endotracheal tube and oral cavity
      3. Remove ECG leads and reattach to back after shifting position.
      4. Turn over the patient to the prone position.
      5. Do repeated zeroing of hemodynamic transducers
      6. Support and frequently reposition pressure points: face, shoulder, anterior
         pelvis

      Successful trials evaluating prone positioning in ARDS used at least 16 hours
of daily proning. When PaO2/FiO2 remained > 150 mm Hg 4 h after supinating
(with PEEP < 10 cm H2O and FiO2 < 0.6), stop prone positioning.

C. Extracorporeal Membrane Oxygenation (ECMO) in leptospirosis
    The benefits of ECMO use in severe pulmonary form of leptospirosis and
     associated ARDS are still under evaluation.
    ECMO has been used more extensively as a potential bridge therapy in
     patients with severe ARDS and/or massive hemoptysis.
    The best outcome in ECMO for adult respiratory failure occurs when ECMO is
     instituted early after the onset (1-2 days).
    ECMO is done in a highly specialized center with a trained multi-disciplinary
     team. Should ECMO be considered, prompt referral and close coordination
     should be done to such centers who can perform the procedure.

IX. RENAL COMPLICATIONS OF LEPTOSPIROSIS
      Renal complications of leptospirosis may present in a spectrum which may
span from sterile pyuria , tea colored urine, mild proteinuria to severe anuric acute
renal failure.

      Commonly it may present as non-oliguric renal failure with mild hypokalemia.
Oliguria with hyperkalemia may reflect the severity of AKI and may connote poor
prognosis. Oliguria is defined as urine output < 0.5 mL/kg/hr or
DOH Guidelines for Leptospirosis for Hospitals

      The following are the list of diagnostic tests that should be performed when
AKI is suspected:
   CBC with platelet count
   BUN, creatinine, sodium, potassium, AST, ALT, bilirubins
   Urinalysis
   Chest x-ray – check for congestion and/or signs of pulmonary hemorrhage

      The algorithm below (Figure 2) is a guide in the management of leptospirosis
patients that present with oliguria.

      The recommended initial fluid resuscitation for Leptospirosis patient is
Balanced crystalloids. If potassium is in the high normal value or with hyperkalemia,
Isotonic saline is recommended. Hydroxyethyl starch should be NOT be given
because it is associated with increased risk of Acute Kidney Injury, need for Renal
Replacement and mortality.

The recommended initial fluid resuscitation rate is 20ml/kg/h or 500ml of crystalloids
within 15- 30mins Patients with Leptospirosis are prone to ARDS due to
downregulation of the Na transport via Epithelial Sodium Channel (ENaC),
NaKATPase as well as decrease in Aquaporin P5.

Any one of the following are indications for dialysis:
   Uremic symptoms- nausea, vomiting, altered mental status, seizure, coma
   pH 3 mg/dl in ABG
   Serum K >5 meq in an oliguric patient
   ARDS, pulmonary hemorrhage (GRADE: moderate)

Hemodialysis is preferred over peritoneal dialysis in patients with AKI secondary to
Leptospirosis. The latter is a valid option if hemodialysis machine is not readily
available.

Daily dialysis is suggested to maintain strict control of azotemia and fluid volume
which can improve survival for those patients with severe Leptospirosis especially if
with pulmonary hemorrhage.

                                                                                                     16
Figure 2. Algorithm for leptospirosis patients with oliguria
                                                                    DOH Guidelines for Leptospirosis for Hospitals

17
DOH Guidelines for Leptospirosis for Hospitals

X. PREVENTION AND CONTROL

  A. Hygienic conditions should be encouraged in slaughterhouses, farmyard
     buildings and bathing pools
  B. Avoidance of exposure to urine and tissues from infected animals such as
     wading in flooded areas. Likewise, activities in possible contaminated bodies
     of water should be prevented.
  C. Vaccination of animals against leptospirosis
  D. Rodent control
  E. When a potential exposure to contaminated water is anticipated, individuals
     should wear protective clothing (boots, gloves, spectacles), cover skin
     lesions with waterproof dressings, wash or shower after exposure to
     contaminated water, and wash and clean wounds.
  F. Avoid drinking water from possible contaminated water sources.
  G. Chemoprophylaxis (see next section)

XI. CHEMOPROPHYLAXIS

       The use of chemoprophylaxis requires prior consult with a physician. It should
not be taken unless prescribed and fully explained by a physician, including
common side-effects and contraindications. Since antibiotic prophylaxis is not 100%
effective, individuals should continue to monitor themselves for fever and other flu-
like symptoms and should continue to wear personal protective measures when
contact with contaminated water is anticipated.

A. Pre-exposure Prophylaxis
      Pre-exposure antibiotic prophylaxis is NOT ROUTINELY RECOMMENDED.
However, this may be considered for short-term exposures in those individuals who
intend to visit highly endemic areas AND are likely to get exposed, including but not
limited to:
             Travelers
             Soldiers
             People who engage in water-related recreational and occupational
                activities
             Disaster relief workers deployed to flooded or post-typhoon areas

     Doxycycline 200mg orally once a week, to begin 1 to 2 days before exposure
and continued throughout the period of exposure.

                                                                                                    18
DOH Guidelines for Leptospirosis for Hospitals

B. Post-exposure prophylaxis
     Post-exposure prophylaxis is given following contact with contaminated
sources such as flood water, animal carcasses, infected body fluids, etc. The post-
exposure prophylactic regimens depends on the risk for leptospirosis following the
exposure (see Table 7).

Table 8. Post-exposure prophylaxis for leptospirosis in adults and children
                                                      ADULTS
                MILD                                MODERATE                          HIGH RISK
  single exposure, non-mucosal, no        mucosal exposure, presence or        When there is repeated or
          breaks in the skin                            wound                    continuous exposure
   Doxycycline 200mg single dose,         Doxycycline 200 mg once daily        Doxycycline 200 mg once
  immediately within 24 to 72 hours          for 3-5 days to be started         weekly until the end of
            from exposure                immediately within 24 to 72 hours             exposure
                                                   from exposure
                                                  CHILDREN13
                       First-line: Doxycycline 4 mg/kg single dose, max dose: 200 mg
                                                   Alternative:
                            Azithromycin 10 mg/kg single dose, max dose: 500 mg*
                    Amoxicillin 50 mg/kg/day q 6 hrs for 3-5days, max dose: 500 mg q6 hrs**
Note: * Efficacy for prevention of leptospirosis was seen in vitro and animal models
   ** No clinical trial for prevention of leptospirosis, but amoxicillin is a known alternative for the treatment of disease

       Doxycycline has been known to cause permanent discoloration or enamel
hypoplasia in developing teeth (among fetuses and children). There are currently no
good quality evidence on pre- or post-exposure prophylaxis among children and
pregnant patients. However, the American Academy of Pediatrics recently released
a new statement saying that short course doxycycline therapy (i.e.
DOH Guidelines for Leptospirosis for Hospitals

XII. REFERENCES
1.    Marquez A, Djelouadji Z, Lattard V, Kodjo A. Overview of laboratory methods to diagnose
      Leptospirosis and to identify and to type leptospires. Int Microbiol. 2017;20(4):184-193.
      doi:10.2436/20.1501.01.302
2.    World Health Organization Southeast Asia Regional Office. Leptospirosis - Fact Sheet.
      http://www.searo.who.int/about/administration_structure/cds/CDS_leptospirosis-
      Fact_Sheet.pdf. Accessed July 4, 2019.
3.    Yanagihara Y, Villanueva S, Yoshida S, Okamoto Y, Masuzawa T. Current status of
      leptospirosis in Japan and Philippines. Comp Immunol Microbiol Infect Dis. 2007;30:399-413.
4.    United Nations Office for the Coordination of Humanitarian Affairs. Philippines Typhoon
      Season 2009 Situation Report#14 (30 October 2009).; 2009.
5.    Republic of the Philippines Department of Health. Leptospirosis Quarterly Surveillance Report
      No. 4 (2018).; 2018.https://portal2.doh.gov.ph/sites/default/files/statistics/
      2018_Leptospirosis_QSR_N4.pdf. Accessed July 4, 2019.
6.    Roxas EA, Alejandria MM, Mendoza MT, Roman ADE, Leyritana KT, Ginete-Garcia JKB.
      Leptospirosis Outbreak after a Heavy Rainfall Typhoon in the Philippines: Clinical Features,
      Outcome and Prognostic Factors for Mortality. Acta Med Philipp. 2016;50(3):121-128.
      https://www.actamedicaphilippina.org/article/6866-leptospirosis-outbreak-after-a-heavy-
      rainfall-typhoon-in-the-philippines-clinical-features-outcome-and-prognostic-factors-for-
      mortality. Accessed July 4, 2019.
7.    Amilasan A-ST, Ujiie M, Suzuki M, et al. Outbreak of leptospirosis after flood, the Philippines,
      2009. Emerg Infect Dis. 2012;18(1):91-94. doi:10.3201/eid1801.101892
8.    Collaborative Statement of the Philippine Society for Microbiology and Infectious Diseases,
      Philippine Society of Nephrology and the Philippine College of Chest Physicians Council on
      Critical Care and Pulmonary Vascular Diseases. The Philippine Clinical Practice Guidelines
      on the Diagnosis, Treatment and Prevention of Leptospirosis in Adults 2010. 2010.
9.    Brato D, Mendoza M, Cordero C, et al. Validation of the World Health Organization (WHO)
      Criteria Using the Microscopic Agglutination Test (MAT) as the Gold Standard in the
      Diagnosis of Leptospirosis. PJMID. 27(4):125-128.
10.   Brett-Major DM, Coldren R. Antibiotics for leptospirosis. Cochrane Database Syst Rev.
      2012;(2):CD008264. doi:10.1002/14651858.CD008264.pub2
11.   ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al. Acute Respiratory Distress
      Syndrome. JAMA. 2012;307(23):2526-2533. doi:10.1001/jama.2012.5669
12.   Organized jointly by the American Thoracic Society, the European Respiratory Society, the
      European Society of Intensive Care Medicine, and the Société de Réanimation de Langue
      Française, and approved by ATS Board of Directors, December 2000. International
      Consensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure
      Ventilation in Acute Respiratory Failure. Am J Respir Crit Care Med. 2001;163(1):283-291.
      doi:10.1164/ajrccm.163.1.ats1000
13.   Pediatric Infectious Disease Society of the Philippines. POST DISASTER INTERIM ADVICE
      ON THE PREVENTION OF LEPTOSPIROSIS IN CHILDREN. 2012.
14.   American Academy of Pediatrics Committee on Infectious Diseases, Kimberlin D, Brady M,
      Jackson M, Long S. Red Book 2018-2021 Report of TheCommittee on Infectious Diseases.
      31st ed.; 2018. https://redbook.solutions.aap.org/book.aspx?bookid=2205. Accessed July 4,
      2019.

                                                                                                               20
DOH Guidelines for Leptospirosis for Hospitals

APPENDICES
Appendix A. Modified Faine’s Criteria (2012)

      This check-list is designed for those who deal directly with the patient. It may
be used even before results of leptospiral diagnostic tests are available. To use the
this, give the appropriate score if the parameter is present for the patient and
compute for the sum.

                              MODIFIED FAINE’S CRITERIA (2012)
              Clinical data               Epidemiological   Bacteriological and laboratory
                (Part A)                   factors (Part B)       findings (Part C)

 Headache                            2    Rainfall            5    Isolation of leptospira in
                                                                   culture - Diagnosis certain
 Fever                               2    Contact with        4    PCR                         25
                                          contaminated
                                          Environment
 Temperature >39°C                   2    Animal contact      1    Serology
 Conjunctival suffusion              4                             ELISA IgM positive*             15
 Meningism                           4                             SAT positive*                   15
 Conjunctival suffusion              10                            Other rapid tests**             15
 + Meningism
 + Myalgia
 Jaundice                            1                             MAT – single positive in 15
                                                                   high titer
 Albuminuria/Nitrogen retention      2                             MAT – rising              25
                                                                   titer/seroconversion
 Hemoptysis/Dyspnea                  2                             * Any one of the tests only
                                                                   should be scored
                                                                   ** Latex agglutination
                                                                   test/Lepto dipstick/Lepto
                                                                   Tek lateral flow/Lepto Tek
                                                                   Dri-Dot test
 Presumptive diagnosis of leptospirosis is made if:
        Part A or Part A and Part B score: 26 or more
        Parts A, B, C (Total): 25 or more
 A score between 20 and 25 suggests leptospirosis as a possible diagnosis.
Table adapted from: Shiva Kumar, S. Indian Guidelines for the Diagnosis and Management of
Human Leptospirosis (2013), p. 26. Accessed on 4 July 2019 from
http://www.apiindia.org/medicine_update_2013/chap07.pdf

                                                                                                            21
Appendix B: Guidelines in Specimen Collection, Storage, Transport and Submission
                                                                                        DOH Guidelines for Leptospirosis for Hospitals

22
DOH Guidelines for Leptospirosis for Hospitals

                                                 23
DOH Guidelines for Leptospirosis for Hospitals

                                                 24
DOH Guidelines for Leptospirosis for Hospitals

Chapter 2: UPSURGE POLICIES AND PROCEDURES

I. 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 during an upsurge in leptospirosis cases in the
  HEALTHCARE FACILITY. This manual provides guidance to all the Departments
  within the HEALTHCARE FACILITY, 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 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 Divisions/Departments within the
  HEALTHCARE FACILITY.

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

   Opening of a Leptospirosis Ward
         The HEALTHCARE FACILITY will identify the CRITICAL NUMBER OF
   PATIENTS BEING ADMITTED FOR LEPTOSPIROSIS PER DAY that 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

                                                                                                      25
DOH Guidelines for Leptospirosis for Hospitals

   therapy, blood component transfusion or requiring respiratory support) is
   reached, a Leptospirosis Ward will be identified and opened for these patients.

        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 if the criteria for activation of the Leptospirosis Upsurge Policy
   has been met. Any one of the Deputy Executive Directors or the Chief of Hospital
   will activate the Leptospirosis Upsurge Policy.

         Upon Activation of the Leptospirosis Upsurge Policy, the Secretary of any of
   the Deputy Executive Directors or Chief of Hospital will send out a memorandum
   through Outlook, and will notify the Heads of the following Departments /
   Divisions:
       Divisions of Adult and Pediatric Nephrology
       Division of Internal Medicine
       Division of Organ Transplantation and Vascular Surgery
       Nursing Services
           - All Head Nurses or Charge Nurses in all Clinical Wards
           - Operating Room (OR)
       Department of Pathology and Laboratory Medicine
       Section of Pulmonary Medicine
       Pharmacy, Procurement, Supply, Central Supply and Sterilization Unit
         (CSSU), Housekeeping, Billing and Claims, Admitting and Discharge
       Medical Social Services Division (MSSD)
       Information Resource Management Division (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
              Chief of Hospital and Deputy Executive Directors through SMS
       HEALTHCARE FACILITY-HEMB

                                                                                                     26
DOH Guidelines for Leptospirosis for Hospitals

        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

          Chief of Hospital 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 Chief of Hospital or
   any of the Deputy Executive Directors 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 Chief of Hospital.
        This team is composed of the following:
         Chief of Hospital/Deputy Executive Director/s – Head
         Chair, Departments/Divisions of Adult and Pediatric Nephrology, Internal
            Medicine, Vascular, Laboratory Medicine
         Deputy Executive Director for Nursing Services
         ER Head
         Head Nurse of ER, Clinical Wards, HD Unit, PD Unit, Operating Room
         Head of Housekeeping, Purchasing, Warehouse, Pharmacy, CSSU,
            PBSD, MSSD, IRM, HEALTHCARE FACILITY-HEMB

                                                                                                           27
DOH Guidelines for Leptospirosis for Hospitals

D. Critical Bed Status Procedure – HEALTHCARE FACILITY 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, 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 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 A)

                                                                                                       28
DOH Guidelines for Leptospirosis for Hospitals

III. ROLES AND RESPONSIBILITIES OF THE VARIOUS DEPARTMENTS /
   DIVISIONS / SECTIONS IN THE MANAGEMENT OF A LEPTOSPIROSIS
   UPSURGE

A. Emergency Room (ER)
    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
     2013 is completed for all patients and placed in the clinical chart of the patient.
     The Chief Fellow of the Division of Adult Nephrology should collect the survey
     forms including forms from Pediatric Nephrology and Internal Medicine. (See
     Appendix B)
    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 hemodialysis (HD) or peritoneal dialysis (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 Operating Room (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 Warehouse, CSSU, and Purchasing.
         - For HD access – use triple lumen catheters
         - For intubation – use ET tube with subglottic suction

                                                                                                      29
DOH Guidelines for Leptospirosis for Hospitals

   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
    HEALTHCARE FACILITY 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.

                                                                                                     30
DOH Guidelines for Leptospirosis for Hospitals

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. 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 A and C.
     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 D)
     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 D). This
      will be emailed to the Chief of Hospital, 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 HEALTHCARE
      FACILITY, 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 Chief of Hospital /
      Deputy Executive Directors as necessary.
     The Head of the Leptospirosis Upsurge Management Team and/or the Chief
      of Hospital / Deputy Executive Directors, will attend the DOH-HEMB meetings,
      as necessary, to provide updates on the status of patients admitted at the
      HEALTHCARE FACILITY and to request for logistical support, if necessary.
     Nephrology Staffing of the Leptospirosis Ward is seen in Section V.

                                                                                                      31
DOH Guidelines for Leptospirosis for Hospitals

D. HEALTHCARE FACILITY-Health Emergency Management Bureau (HEMB)
   Team
         The HEALTHCARE FACILITY-HEMB 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 Field
   Implementation Coordination Team DOH-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. 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
     HEALTHCARE FACILITY 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 E.

H. 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.

                                                                                                     32
DOH Guidelines for Leptospirosis for Hospitals

I. 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.

J. 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 in-
     patients 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.
    Once a decision is made to set-up an HD Unit in the Leptospirosis Ward, the
     HD Unit Supervisor will contact the HEALTHCARE FACILITY’s HD provider to
     augment the number of HD machines and portable RO machines to be placed
     in the Leptospirosis Ward, and contact the Provider’s 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.
    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

                                                                                                     33
DOH Guidelines for Leptospirosis for Hospitals

    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.

K. Peritoneal Dialysis (PD) Unit
    Once the Leptospirosis Upsurge Policy is activated, the PD Unit Supervisor
     will contact the HEALTHCARE FACILITY’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 Vascular 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.

                                                                                                    34
You can also read