23]. Aeromonas species are sensitive to second- and third-generation cephalosporins, fluoroquinolones, sulfamethoxazole-trimethoprim, tetracycline, and aminoglycosides, while Aeromonas is resistant to penicillin, ampicillin, first-generation cephalosporins, and erythromycin [16, 24–27]. Patients should be treated each day of leech therapy with anti-Aeromonas antibiotics such as 500 mg of ciprofloxacin [22]. However, out of 21 isolates of Aeromonas species isolated from the water collected from the leech tanks, 71.4% were ciprofloxacin susceptible. All isolates were sulfamethoxazole-trimethoprim susceptible, which was also used as a prophylactic antibiotic regimen of choice for leech therapy [28]. A regular surveillance to detect resistant Aeromonas species in medical leeches, by controlling the water in which they are kept, was suggested. Chepeha et al. [29] used an antibiotic prophylaxis with double coverage during leech application and single coverage for 2 weeks after leech therapy is discontinued. In the Iowa Head and Neck Protocol [30], levaquin is administered before the first leech is applied to the skin and continued until 24 hours after leech therapy is discontinued. Use of narcotics and benzodiazepines should be minimized, because they could negatively influence leech activity, while the treated area should be photographed under the same light conditions using the same camera periodically to follow the progress of decongestion [29]. 3. The Medicinal Leech According to the literature, in most cases the medicinal leech Hirudo medicinalis was used. In some cases, similar results were also obtained with Hirudo verbana and Hirudo michaelseni [17, 31]. Using mitochondrial sequences and nuclear microsatellites, Siddall et al. [32] demonstrated that there are at least three species of European medicinal leech and that many of the leeches marketed as H. medicinalis in the USA, France, and Germany are actually H. verbana. Leeches should be purchased from recognized leech producing companies, where they are kept in appropriate farms and fed artificially with animal blood. In addition, leeches purchased from recognized leech farms are sufficiently starved prior to being sold and some of the leech farms have been approved by regulatory agencies. Leeches, which were collected from a natural environment, should not be used for hirudotherapy. Leeches can survive one year or more without a blood meal. Therefore, it is recommended to keep a large number of leeches in the laboratory by changing the water once or twice weekly. For this purpose, the leeches can be transferred every week to a second container, which was previously cleaned and rinsed thoroughly to remove any remains of disinfectants and where the water was kept for at least 24 hrs for dechlorination. The container should be filled up to 3/4 with water and covered with a towel or netting, which would allow the leeches to have access to fresh air, without being able to escape. A larger stone should be added into the container, which would help leeches during the process of shedding their integument. The container with leeches should be kept in a cool place (preferably 4–15°C). When leeches are kept at room temperature, attention should be paid that the ambient temperature does not exceed 25°C and that the container with leeches is not exposed to direct sunlight. When replacing leeches from one container to the other, the replacement water must be at the same