How to quickly identify patients who should be treated for leptospirosis is a challenge. The interest of polymerase chain reaction (PCR) assays is currently being evaluated and rapid tests which can be used outside of the specialised laboratory, have recently been developed. Leptospires are sensitive to many antibiotics and few clinical studies have been made to compare different treatment options. Doxycycline is standard therapy in early leptospirosis treatment and chemoprophylaxis. Intravenous penicillin has been considered the drug of choice in late and severe disease, although it is now challenged by ceftriaxone, which use is easier. Ciprofloxacin may be combined with standard therapy in uveitis. Adjunctive therapies proposed in the management of severe forms of leptospirosis and Jarisch-Herxheimer reactions, are reviewed.