What is the next best step in managing a dengue patient with persistent fever and chills despite initial treatment with IV fluids, ceftriaxone, and pantoprazole, with improved platelet count and normal LFTs?

Management of Persistent Fever in Dengue Patient

The next best step in managing this dengue patient with persistent fever and chills despite improved platelet count is to evaluate for secondary bacterial infection and consider changing the antibiotic therapy to a different broad-spectrum agent.

Clinical Assessment

• Persistent fever with chills despite 5 days of treatment in a dengue patient suggests a possible secondary bacterial infection or inadequate response to current antimicrobial therapy 1
• The patient shows improvement in laboratory parameters (normalized LFTs, improved platelet count from 26,000 to 64,000), but persistent fever indicates the need for reassessment 2
• History of alcohol use and black stool suggests possible gastrointestinal bleeding, which is a known complication in dengue patients 3

Diagnostic Workup

• Perform a thorough reassessment including review of all previous culture results, meticulous physical examination, and chest radiography 1
• Obtain additional blood cultures to identify possible resistant organisms or secondary infections 1
• Consider abdominal imaging (ultrasound or CT) to evaluate for possible intra-abdominal sources of infection 1
• Evaluate for possible drug fever, as pantoprazole has been associated with adverse effects including fever 4

Management Recommendations

Antibiotic Therapy

• Consider changing the antibiotic regimen from ceftriaxone to a different broad-spectrum agent with better coverage for resistant organisms 1
• If the patient is clinically stable despite fever, you may continue the current regimen for up to 5 days before making changes, unless clinical deterioration occurs 1
• If the patient shows signs of clinical deterioration, immediately change to a broader-spectrum antibiotic regimen 1

Supportive Care

• Continue IV fluid therapy to maintain adequate hydration and renal perfusion 5
• Monitor for signs of plasma leakage and bleeding complications despite improving platelet count 6
• Continue fever management with paracetamol and avoid aspirin or NSAIDs due to bleeding risk in dengue 5

Platelet Management

• No need for prophylactic platelet transfusion as the count is improving (now 64,000) and there is no significant active bleeding 6
• Prophylactic platelet transfusion has not been shown to reduce clinical bleeding in dengue patients and may potentially delay platelet recovery 6

Special Considerations

• Persistent fever beyond 5-7 days in dengue patients should raise suspicion for secondary bacterial infection or other complications 2
• The presence of leukopenia (WBC 2600) may indicate ongoing viral infection, but could also mask signs of bacterial infection 5
• Monitor for warning signs of severe dengue despite improving laboratory parameters 2
• Consider discontinuing pantoprazole if no clear indication, as it has been associated with thrombocytopenia and could potentially contribute to the patient's condition 4

Follow-up Recommendations

• Daily complete blood counts to monitor platelet and WBC trends 2
• Reassess clinical status daily for signs of improvement or deterioration 1
• If fever persists beyond 7 days despite antibiotic changes, consider additional workup for fungal infections or non-infectious causes of fever 1