What is the treatment for dengue?

Treatment of Dengue

Dengue treatment is primarily supportive with no specific antiviral therapy available, focusing on careful fluid management, acetaminophen for symptom control, and strict avoidance of aspirin and NSAIDs. 1, 2

Risk Stratification and Treatment Setting

Classify patients into three categories to determine management approach: 1, 2

• Dengue without warning signs: Outpatient management with aggressive oral hydration (>2,500 mL daily), acetaminophen for symptoms, and daily monitoring 2, 3
• Dengue with warning signs: Hospitalization required for close monitoring during the critical phase (days 3-7 of illness) 3
• Severe dengue: Immediate ICU admission for dengue shock syndrome, severe bleeding, or organ impairment 1

Warning signs requiring hospitalization include: severe abdominal pain, persistent vomiting, mucosal bleeding, lethargy/restlessness, rising hematocrit with rapidly falling platelet count, hepatomegaly, and clinical fluid accumulation. 3

Fluid Management Algorithm

For Patients Without Shock

• Oral rehydration is the cornerstone: Encourage 5+ glasses throughout the day, targeting 2,500-3,000 mL daily using water, oral rehydration solutions, cereal-based gruels, soup, or rice water (avoid soft drinks due to high osmolarity) 1, 3
• Critical pitfall: Avoid routine bolus IV fluids in patients with severe febrile illness who are NOT in shock—this increases fluid overload and respiratory complications without improving outcomes 1

For Dengue Shock Syndrome

Immediate resuscitation protocol: 1

1. Initial bolus: Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) over 5-10 minutes 1, 3
2. Reassess immediately after each bolus for signs of improvement (improved tachycardia, tachypnea, capillary refill) 1
3. Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists 1
4. Escalate to colloids (dextran, gelafundin, or albumin) if shock persists—moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09,95% CI 1.00-1.19) and reduce total volume needed (31.7 mL/kg vs 40.63 mL/kg for crystalloids) 1

For Refractory Shock

Do not delay vasopressor therapy—delays are associated with major increases in mortality: 1

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1
• Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1
• Begin peripheral inotropic support immediately if central access is not readily available 1

Symptomatic Management

• Acetaminophen (paracetamol) at standard doses is the ONLY acceptable analgesic for pain and fever control 1, 2, 3
• Never use aspirin or NSAIDs under any circumstances—these worsen bleeding tendencies and platelet dysfunction 1, 2, 3

Monitoring Parameters

Daily complete blood count is essential to track platelet counts and hematocrit levels: 1, 2

• Watch for high hematocrit with rapidly falling platelet count 1
• Monitor for signs of adequate tissue perfusion: normal capillary refill, absence of skin mottling, warm/dry extremities, well-felt peripheral pulses, baseline mental status, adequate urine output (>0.5 mL/kg/hour in adults) 1

Stop fluid resuscitation immediately if hepatomegaly or pulmonary rales develop—switch to inotropic support instead 1

Management of Complications

• Significant bleeding: Blood transfusion may be necessary with close monitoring of hemoglobin and hematocrit 1, 3
• Persistent tissue hypoperfusion: Vasopressors required despite adequate fluid resuscitation 1
• Secondary bacterial infections: Obtain blood/urine cultures and chest radiograph if fever persists beyond expected course 2, 3

Critical Pitfalls to Avoid

• Do not continue aggressive fluid resuscitation once signs of fluid overload appear (hepatomegaly, rales, respiratory distress)—this leads to pulmonary edema, particularly during recovery phase 1
• Do not fail to recognize the critical phase (days 3-7 of illness) when plasma leakage can rapidly progress to shock 1
• Do not delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Do not use restrictive fluid strategies in dengue shock syndrome—moderate-quality evidence shows no survival benefit, and three RCTs demonstrate near 100% survival with aggressive fluid management 1

Discharge Criteria

Patients can be safely discharged when ALL of the following are met: 2, 3

• Afebrile for ≥48 hours without antipyretics 2, 3
• Resolution or significant improvement of symptoms 2
• Stable hemodynamic parameters for ≥24 hours without support 2, 3
• Adequate oral intake and urine output (>0.5 mL/kg/hour in adults) 2, 3
• Laboratory parameters returning to normal ranges 2, 3

Post-discharge instructions: Monitor temperature twice daily; return immediately if temperature ≥38°C on two consecutive readings or if any warning signs develop. 2