A simple score to predict severe leptospirosis.

Melissa J Caimano,Simon Smith,Josh Hanson,Brendan J Kennedy,Alexis Dermedgoglou,Yu-Hsuan Liu,Suzanne S Poulgrain,Tarryn L Minto,Michael Luc,Matthew P Paavola

doi:10.1371/journal.pntd.0007205

Melissa J Caimano, Simon Smith + Show 8 more

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https://doi.org/10.1371/journal.pntd.0007205

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Abstract

BackgroundThe case-fatality rate of severe leptospirosis can exceed 50%. While prompt supportive care can improve survival, predicting those at risk of developing severe disease is challenging, particularly in settings with limited diagnostic support.Methodology/Principal findingsWe retrospectively identified all adults with laboratory-confirmed leptospirosis in Far North Queensland, Australia, between January 1998 and May 2016. Clinical, laboratory and radiological findings at presentation were correlated with the patients’ subsequent clinical course. Medical records were available in 402 patients; 50 (12%) had severe disease. The presence of oliguria (urine output ≤500 mL/24 hours, odds ratio (OR): 16.4, 95% confidence interval (CI): 6.9–38.8, p<0.001), abnormal auscultatory findings on respiratory examination (OR 11.2 (95% CI: 4.7–26.5, p<0.001) and hypotension (systolic blood pressure ≤100 mmHg, OR 4.3 (95% CI 1.7–10.7, p = 0.002) at presentation independently predicted severe disease. A three-point score (the SPiRO score) was devised using these three clinical variables, with one point awarded for each. A score could be calculated in 392 (98%) patients; the likelihood of severe disease rose incrementally: 8/287 (3%), 14/70 (20%), 18/26 (69%) and 9/9 (100%) for a score of 0, 1, 2 and 3 respectively (p = 0.0001). A SPiRO score <1 had a negative predictive value for severe disease of 97% (95% CI: 95–99%).Conclusions/SignificanceA simple, three-point clinical score can help clinicians rapidly identify patients at risk of developing severe leptospirosis, prompting early transfer to referral centres for advanced supportive care. This inexpensive, bedside assessment requires minimal training and may have significant utility in the resource-limited settings which bear the greatest burden of disease.

Highlights

Leptospirosis is a zoonotic infection with a global distribution [1, 2]
This review of 402 adult patients with leptospirosis in tropical Australia determined that three clinical variables identified at presentation independently predicted severe disease
These three variables were used to generate a simple, three-point clinical score which can be determined rapidly and reliably at the bedside by health care workers with minimal training. This simple score may help the clinical management of patients with leptospirosis, in lower and middle-income countries that bear the greatest burden of disease

Summary

Introduction

Leptospirosis is a zoonotic infection with a global distribution [1, 2]. most infections are mild and self-limiting, the disease is believed to kill almost 60,000 people every year [1]. The case-fatality rate of severe leptospirosis is as low as 6% if there is prompt access to vasopressors, renal replacement therapy (RRT) and mechanical ventilation [3], but it can rise to greater than 50% if the delivery of this supportive care is delayed [4]. Different studies have suggested that the presence of a variety of clinical features, laboratory investigations and imaging and electrocardiography findings can help [5,6,7,8,9,10] While these approaches may be helpful in well-resourced settings where there is access to advanced laboratory and radiology support, they may have less utility in low and middle-income countries (LMIC), which bear a disproportionate burden of the disease [1]. While prompt supportive care can improve survival, predicting those at risk of developing severe disease is challenging, in settings with limited diagnostic support

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