What is the recommended management approach for dengue (Dengue Fever) in a General Practice (GP) clinic?

Management of Dengue in GP Clinic

In a GP clinic setting, dengue management centers on risk stratification, aggressive oral hydration (>2500ml daily), acetaminophen for symptom control, daily monitoring of complete blood counts and warning signs, with clear criteria for hospital referral when shock or severe complications develop. 1, 2

Initial Assessment and Diagnosis

• Suspect dengue in patients presenting with fever, headache, retro-orbital pain, myalgia, arthralgia, and rash, particularly with an incubation period of 4-8 days after potential mosquito exposure. 1
• Confirm diagnosis with PCR for early presentation or IgM capture ELISA for symptoms present >5-7 days. 1
• Perform baseline complete blood count to establish platelet and hematocrit levels for subsequent monitoring. 1, 2

Risk Stratification for Outpatient vs Hospital Management

Patients can be managed as outpatients if they have no warning signs and can maintain adequate oral intake. 1, 2

Warning Signs Requiring Hospital Referral:

• Persistent vomiting preventing adequate oral intake 1, 2
• Severe abdominal pain 2
• Lethargy, restlessness, or altered mental status 1, 2
• Mucosal bleeding (epistaxis, gum bleeding, hematemesis) 1, 2
• Rising hematocrit with rapidly falling platelet count 2
• Clinical fluid accumulation (ascites, pleural effusion) 3
• Hepatomegaly 3

Signs of Shock Requiring Immediate Hospital Transfer:

• Tachycardia with hypotension or narrow pulse pressure 1, 3
• Poor capillary refill time 2
• Cold, clammy extremities or skin mottling 2
• Altered mental status 3

Outpatient Management Protocol

Fluid Management:

• Prescribe oral rehydration solutions with a target of >2500ml daily for adults. 1, 2
• Consider providing a fluid chart and measuring cup (200ml) to help patients track intake, as this simple intervention may reduce hospitalization rates. 4
• Instruct patients to increase fluid intake if they develop vomiting or diarrhea. 1

Pain and Fever Control:

• Prescribe acetaminophen at standard doses (650-1000mg every 4-6 hours, maximum 4g/24 hours) for pain and fever relief. 1
• Strictly avoid aspirin and NSAIDs (ibuprofen, naproxen, diclofenac) due to increased bleeding risk. 1, 2, 3

Monitoring Requirements:

• Order daily complete blood counts to track platelet counts and hematocrit levels. 1, 2, 3
• Instruct patients to monitor temperature twice daily and record readings. 1
• Schedule daily clinic follow-up during the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock. 2, 3

Critical Phase Monitoring (Days 3-7)

This is the highest-risk period when plasma leakage occurs and patients can deteriorate rapidly. 2, 3

Key Laboratory Trends to Watch:

• Rising hematocrit (>20% increase from baseline) indicates plasma leakage 2
• Falling platelet count, particularly if <50,000/μL 1
• Both trends occurring simultaneously are particularly concerning 2

Clinical Examination Focus:

• Assess for signs of fluid accumulation: hepatomegaly, ascites, pleural effusion 3
• Check capillary refill time and peripheral perfusion 2
• Monitor for mucosal bleeding 1, 2
• Assess mental status and level of alertness 2, 3

Discharge Criteria for Patients Initially Managed as Outpatients

Patients can continue outpatient management if they maintain:

• Afebrile for ≥48 hours without antipyretics 1
• Stable or improving symptoms 1
• Adequate oral intake and urine output 1
• Stable hemodynamic parameters 1
• No warning signs developing 1, 2

Clear Instructions for When to Return

Instruct patients to return immediately if:

• Temperature rises to ≥38°C on two consecutive readings 1
• Any warning signs develop (persistent vomiting, severe abdominal pain, bleeding, lethargy, restlessness) 1, 2
• Decreased urine output 1
• Difficulty breathing or chest pain 1

Special Populations

Pregnant Women:

• Acetaminophen remains the safest analgesic option 1
• Lower threshold for hospital admission due to increased risk 1

Children:

• Calculate acetaminophen dosing carefully based on weight (10-15mg/kg/dose every 4-6 hours) 1
• May require more frequent monitoring due to faster progression 1

Common Pitfalls to Avoid in GP Setting

• Do not prescribe NSAIDs or aspirin under any circumstances, even if patients request them for better pain control. 1, 2, 3
• Do not fail to recognize the critical phase (days 3-7) when patients need most intensive monitoring. 2, 3
• Do not delay hospital referral when warning signs appear, as dengue shock can develop rapidly. 2, 3
• Do not assume persistent fever alone indicates treatment failure; fever typically resolves within 5 days and does not require antibiotic coverage unless clinical deterioration or new findings suggest secondary infection. 1
• Do not order prophylactic platelet transfusions for low platelet counts alone without active bleeding. 5

Prevention Counseling

• Educate patients that Aedes mosquitoes (particularly Aedes aegypti) are day-biting vectors. 1
• Recommend mosquito avoidance measures including repellents, protective clothing, and elimination of standing water. 1
• Discuss vaccination after documented initial infection for future prevention. 6