What is the recommended management for patients with dengue fever without warning signs?

Management of Dengue Without Warning Signs

For patients with dengue fever without warning signs, outpatient management with aggressive oral hydration (targeting >2,500-3,000 mL daily), acetaminophen for symptom relief, strict avoidance of aspirin/NSAIDs, and daily monitoring for warning signs is the recommended approach. 1, 2

Outpatient Management Protocol

Hydration Strategy

• Encourage oral fluid intake of at least 5 glasses throughout the day, targeting approximately 2,500-3,000 mL daily 1, 2
• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 2
• Avoid soft drinks due to high osmolality 2
• Evidence from a pilot study showed that structured fluid monitoring with a fluid chart increased daily oral intake to approximately 3,000 mL compared to 2,500 mL in controls, with trends toward reduced hospitalization (10.0% vs 17.6%) and decreased IV fluid requirements (12.9% vs 22.1%), though not statistically significant 3

Pain and Fever Management

• Acetaminophen (paracetamol) at standard doses (10-15 mg/kg every 4-6 hours, not exceeding 4 g/day in adults) is the only recommended analgesic 1, 4, 2
• Monitor liver function tests when using acetaminophen, particularly in patients with pre-existing liver disease 4
• Never use aspirin or NSAIDs under any circumstances due to high bleeding risk 5, 1, 4, 2

Daily Monitoring Requirements

• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 1, 2
• Patients should monitor and record temperature twice daily 1
• Watch for warning signs that indicate progression to severe dengue 1, 2:
  • Persistent vomiting
  • Severe abdominal pain
  • Lethargy or restlessness
  • Mucosal bleeding
  • Rising hematocrit with rapidly falling platelet count

Return Precautions

• Patients must return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 1
• The critical phase typically occurs on days 3-7 of illness when plasma leakage can rapidly progress to shock 4, 2

Discharge Criteria (When Transitioning from Hospital Care)

Patients can be safely discharged when ALL of the following are met 1:

• Afebrile for ≥48 hours without antipyretics
• Resolution or significant improvement of symptoms
• Stable hemodynamic parameters for ≥24 hours without support
• Adequate oral intake maintained
• Adequate urine output (>0.5 mL/kg/hour in adults)
• Laboratory parameters returning to normal ranges

Special Populations

Pregnant Women

• Acetaminophen remains the safest analgesic option 1, 4
• Maintain heightened vigilance for warning signs 1

Children

• Acetaminophen dosing should be carefully calculated based on weight (10-15 mg/kg per dose) 1, 4
• Resume age-appropriate diet as soon as appetite returns 2

Critical Pitfalls to Avoid

• Do not fail to recognize the critical phase (days 3-7) when patients can rapidly deteriorate 4, 2
• Never delay seeking medical attention if warning signs develop 1, 2
• Avoid inadequate monitoring during the critical phase of illness 2
• Do not use aspirin or NSAIDs which can worsen bleeding tendencies 1, 4, 2

Supportive Measures

• Rest is an essential component of recovery 4
• Adequate hydration supports symptom management and prevents progression 1, 4
• The typical clinical course involves fever, headache, retro-orbital pain, myalgia, arthralgia (particularly back pain), and rash during the acute febrile phase 5, 1, 4