How to manage persistent fever in a case of Dengue (Dengue fever)?

Management of Persistent Fever in Dengue

For patients with persistent fever in dengue, continue supportive care with acetaminophen for fever management, ensure adequate oral hydration of >2500ml daily, monitor for warning signs of severe dengue, and consider secondary bacterial infection if fever persists beyond 5 days. 1

Assessment of Persistent Fever in Dengue

• Persistent fever is common in dengue and typically resolves within 5 days of treatment initiation 1
• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 2, 1
• Monitor for warning signs of severe dengue, including persistent vomiting, severe abdominal pain, lethargy, restlessness, mucosal bleeding, and rising hematocrit with falling platelet count 1, 3

Management Approach

Fever Management

• Acetaminophen at standard doses is recommended for pain and fever relief 2, 1
• Avoid aspirin and NSAIDs under any circumstances due to increased bleeding risk 2, 1, 3

Fluid Management

• For patients without shock, ensure adequate oral hydration with more than 2500ml daily 2, 1
• Consider using a fluid chart to monitor oral intake, which may help reduce hospitalization and IV fluid requirements 4
• For patients with signs of dehydration, provide oral rehydration solutions 1

Monitoring for Complications

• If fever persists with clinical deterioration, assess for:
  • Secondary bacterial infections 1
  • Development of dengue hemorrhagic fever or dengue shock syndrome 5
  • Plasma leakage signs (rising hematocrit >20% from baseline) 1, 6

Management of Complications

If Secondary Infection Suspected

• Consider empiric antibiotic therapy if there are signs suggesting secondary bacterial infection 1
• Obtain blood and urine cultures and chest radiograph if fever persists 7

For Dengue Shock Syndrome

• Administer an initial fluid bolus of 20 mL/kg crystalloid with careful reassessment afterward 2, 1
• For severe shock, consider colloid solutions when available 1, 8
• Monitor with continuous cardiac telemetry and pulse oximetry 7

For Significant Bleeding

• Blood transfusion may be necessary for significant bleeding 2, 1
• For persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors may be required 2, 1

Hospitalization Criteria

• Consider hospitalization for patients with:
  • Persistent vomiting or inability to maintain oral hydration 3
  • Rapidly decreasing platelet count 3
  • Warning signs of severe dengue 1
  • Hemodynamic instability 6

Common Pitfalls to Avoid

• Changing antibiotics or management based solely on persistent fever pattern without clinical deterioration or new findings 1
• Delaying fluid resuscitation in patients showing signs of shock 1
• Administering NSAIDs or aspirin for fever management 2, 1, 3
• Inadequate monitoring of fluid status and vital signs 6

Discharge Criteria

• Patients can be discharged when:
  • Afebrile for at least 48 hours without antipyretics 1
  • Symptoms have significantly improved 1
  • Hemodynamic parameters are stable for at least 24 hours 1
  • Adequate urine output (>0.5 mL/kg/hour in adults) 1
  • Laboratory tests previously abnormal are returning to normal ranges 1