What are the treatment and prevention options for dengue (Dengue Fever)?

Dengue Fever: Treatment and Prevention

Treatment Approach

There is no specific antiviral therapy for dengue—management is entirely supportive, focusing on aggressive hydration, careful monitoring during the critical phase (days 3-7), and acetaminophen for symptom control. 1, 2, 3

Risk Stratification and Triage

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

• Dengue without warning signs: Outpatient management with oral hydration exceeding 2,500 mL daily, acetaminophen for fever/pain, and daily monitoring 1, 4
• Dengue with warning signs: Hospitalization required for close observation during the critical phase 4
  • Warning signs include: severe abdominal pain, persistent vomiting, mucosal bleeding, lethargy/restlessness, rising hematocrit with rapidly falling platelets (<100,000/mm³), hepatomegaly, or clinical fluid accumulation 4
• Severe dengue: Immediate ICU admission for dengue shock syndrome, severe bleeding, or organ impairment 2

Diagnostic Testing

• Perform dengue PCR/NAAT on serum collected ≤7 days after symptom onset 5, 1
• Order IgM capture ELISA if PCR is negative or unavailable, or if symptoms present >5-7 days 5, 1
• Obtain daily complete blood counts to track platelet counts and hematocrit levels 1, 2

Fluid Management

For patients without shock:

• Ensure oral hydration with >2,500 mL daily using oral rehydration solutions, water, cereal-based gruels, soup, or rice water—avoid soft drinks due to high osmolality 1, 2

For dengue shock syndrome:

• Administer 20 mL/kg isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as rapid bolus over 5-10 minutes 1, 4, 2
• Reassess immediately after each bolus for improvement in tachycardia, tachypnea, capillary refill, and mental status 2
• Repeat crystalloid boluses up to 40-60 mL/kg in the first hour if shock persists 2
• Consider colloid solutions (dextran, gelafundin, or albumin) for severe shock with pulse pressure <10 mmHg—moderate-quality evidence shows colloids achieve faster resolution of shock (RR 1.09) and require less total volume (31.7 mL/kg versus 40.63 mL/kg for crystalloids) 4, 2

Critical pitfall: Stop fluid resuscitation immediately if hepatomegaly, pulmonary rales, or respiratory distress develop—switch to inotropic support instead 2

Pain and Fever Management

• Use acetaminophen at standard doses as the only acceptable analgesic 1, 4, 2
• Never use aspirin or NSAIDs under any circumstances—they increase bleeding risk and worsen platelet dysfunction 5, 1, 4, 2

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation 2:

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor
• Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%

Management of Bleeding Complications

• Blood transfusion may be necessary for significant bleeding with close monitoring of hemoglobin and hematocrit 1, 4, 2
• Major bleeding almost invariably occurs with profound shock, thrombocytopenia, hypoxia, and acidosis 6

Monitoring Parameters

Watch for clinical indicators of adequate tissue perfusion 2:

• Normal capillary refill time
• Absence of skin mottling
• Warm and dry extremities
• Well-felt peripheral pulses
• Return to baseline mental status
• Adequate urine output (>0.5 mL/kg/hour in adults)

Discharge Criteria

Patients can be safely discharged when all of the following are met 1, 4:

• Afebrile for ≥48 hours without antipyretics
• Resolution or significant improvement of symptoms
• Stable hemodynamic parameters for ≥24 hours without support
• Adequate oral intake and urine output
• Laboratory parameters returning to normal ranges

Post-discharge instructions: Monitor temperature twice daily and return immediately if fever ≥38°C on two consecutive readings or any warning signs develop 1

Special Populations

Pregnant women:

• Test by NAAT for both dengue and Zika virus regardless of outbreak patterns due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 1, 4
• Acetaminophen remains the safest analgesic option 1
• Hospitalization recommended for all pregnant women with confirmed or suspected dengue 1

Children:

• Calculate acetaminophen dosing carefully based on weight 1
• Use crystalloids as first-line fluid, with colloids reserved for severe cases 2

Prevention

Vector Control

• Dengue is transmitted by day-biting mosquitoes of the genus Aedes, particularly Aedes aegypti and Aedes albopictus 5, 1, 7
• Meticulous avoidance of mosquito bites is essential, especially during daytime hours 7
• Vector control remains the primary method for stopping disease spread 8

Vaccination

• Vaccination is recommended only after documented initial dengue infection 7
• No vaccine is currently commercially available for primary prevention in dengue-naive individuals 3, 8

Critical Pitfalls to Avoid

• Never delay fluid resuscitation in patients showing signs of dengue shock syndrome—cardiovascular collapse may rapidly follow once hypotension occurs 2
• Avoid aggressive fluid boluses in patients with severe febrile illness who are NOT in shock—this increases risk of fluid overload and respiratory complications without improving outcomes 2
• Do not continue aggressive fluid resuscitation once signs of fluid overload appear (hepatomegaly, rales, respiratory distress)—switch to inotropic support immediately 2
• Never fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 2
• Avoid restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit from colloid restriction, and aggressive fluid management demonstrates near 100% survival 2