What are the clinical practice guidelines (CPG) for managing Dengue fever?

Dengue Fever Clinical Practice Guidelines

Immediate Risk Stratification and Triage

All patients with suspected dengue must be immediately classified into one of three risk categories to determine outpatient versus inpatient management, with hospitalization mandatory for those exhibiting warning signs, severe dengue, or belonging to high-risk populations. 1

Hospitalization Criteria (Admit Immediately)

• Warning signs present: persistent vomiting, abdominal pain/tenderness, clinical fluid accumulation, mucosal bleeding, lethargy/restlessness, hepatomegaly, or hematocrit rise with concurrent thrombocytopenia 2
• Severe dengue: severe plasma leakage, severe bleeding, organ failure, or dengue shock syndrome (narrow pulse pressure ≤20 mmHg, hypotension, or hemodynamic instability) 1
• High-risk populations: pregnant women (due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission), patients with rising hematocrit (>20% increase from baseline), or thrombocytopenia ≤100,000/mm³ with rapid decline 1

Outpatient Management Criteria

• Platelet count >100,000/mm³ without rapid decline 1
• Stable hematocrit without hemoconcentration 1
• No warning signs present 1
• Ability to maintain adequate oral hydration 1

Diagnostic Testing Algorithm

Days 1-7 of Symptoms

• Order dengue PCR/NAAT on serum as first-line test (most effective during viremia) 1, 2
• NS1 antigen detection is useful from day 1 to day 10 after symptom onset 2
• For pregnant women, test by NAAT for both dengue and Zika virus simultaneously, regardless of outbreak patterns 1

After Day 5-7 of Symptoms

• Order IgM capture ELISA if PCR is unavailable or negative 1
• Rapid diagnostic tests combining NS1 antigen and IgG have very high positive likelihood ratios 1

Essential Monitoring

• Daily complete blood count to track platelet counts and hematocrit levels 1
• Document vaccination history to avoid cross-reactivity with yellow fever, Japanese encephalitis, and tick-borne encephalitis 1

Fluid Management Protocol

Outpatient Fluid Management (No Warning Signs)

• Ensure oral hydration exceeding 2500ml daily using oral rehydration solutions 1
• Provide fluid chart and measuring cup (200ml) to track intake 3
• Aggressive oral hydration reduces hospitalization and intravenous fluid requirements 3

Dengue Shock Syndrome Fluid Resuscitation

• Administer initial fluid bolus of 20 mL/kg isotonic crystalloid over 5-10 minutes 1, 4
• Reassess immediately after bolus completion; consider additional boluses if necessary (2-3 boluses may be needed in profound shock) 1, 4
• For severe shock with pulse pressure <10 mmHg, consider colloid solutions (medium-molecular-weight preparations preferred) 1, 5
• Switch from crystalloid to colloid if patient remains unresponsive despite adequate crystalloid resuscitation 6
• Critical pitfall: Avoid over-resuscitation, as excessive fluids worsen outcomes given underlying plasma leakage pathophysiology 2
• Monitor for fluid overload: Reduce and discontinue fluids after hemodynamic stabilization to avoid pulmonary edema 6

Fluid Management in Resource-Limited Settings

• In settings without mechanical ventilation and inotropic support, aggressive fluid boluses may increase mortality; however, for dengue shock specifically, colloids show benefit for time to resolution of shock 1

Pain and Fever Management

Safe Analgesics

• Acetaminophen at standard doses is the only recommended analgesic for pain and fever relief 1
• For pregnant women, acetaminophen remains the safest option 1
• In children, calculate acetaminophen dosing carefully based on weight 1

Absolute Contraindications

• Never use aspirin or NSAIDs due to high bleeding risk and potential for worsening hemorrhagic complications 1, 7
• This prohibition applies whenever dengue cannot be excluded 1

Management of Complications

Bleeding Management

• Blood transfusion indicated for significant bleeding, hemoglobin <4 g/dL, or hemoglobin <6 g/dL with clinical deterioration 1
• Fresh frozen plasma and platelet transfusions for disseminated intravascular coagulation 4

Shock Refractory to Fluids

• Consider vasopressors (dopamine or epinephrine) for persistent tissue hypoperfusion despite adequate fluid resuscitation 1
• Norepinephrine should be considered when fluid leakage leads to pulmonary edema and restricts further fluid administration 6

Pleural Effusion and Ascites

• Avoid drainage of polyserositis (pleural effusion, ascites) as it can lead to severe hemorrhages and sudden circulatory collapse 4

Secondary Bacterial Infections

• Obtain blood and urine cultures, chest radiograph if fever persists beyond expected timeline 1
• Initiate broad-spectrum antibiotic coverage empirically while awaiting culture results if fever recurs after afebrile period 7

Critical Monitoring Parameters

Warning Signs Requiring Escalation (Days 3-7 of Illness)

• Persistent vomiting 2
• Abdominal pain or tenderness (particularly right upper quadrant) 2
• Clinical fluid accumulation 2
• Mucosal bleeding 2
• Lethargy or restlessness 2
• Hepatomegaly 2
• Hematocrit rise of 20% with concurrent platelet drop (critical indicator for onset of shock) 4

Dengue Shock Syndrome Diagnostic Criteria

• Systolic blood pressure <90 mmHg for >30 minutes 2
• Pulse pressure <20 mmHg (earlier and more sensitive indicator than absolute hypotension) 2
• Cold, clammy extremities or livedo reticularis 2
• Capillary refill time ≥3 seconds 2
• Elevated lactate >2 mmol/L 2

Discharge Criteria

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

• Afebrile for ≥48 hours without antipyretics 1
• Resolution or significant improvement of symptoms 1
• Stable hemodynamic parameters for ≥24 hours without support (normal heart rate, stable blood pressure, normal capillary refill time) 1
• Adequate oral intake 1
• Adequate urine output (>0.5 mL/kg/hour in adults) 1
• Laboratory parameters returning to normal ranges 1

Post-Discharge Instructions

• Monitor and record temperature twice daily 1
• Return immediately if: temperature rises to ≥38°C on two consecutive readings or any warning signs develop 1

Management of Persistent or Recurrent Fever

Expected Timeline

• Typical dengue fever resolves within 5-7 days 7
• Persistent fever is common and typically resolves within 5 days of treatment initiation 1
• Fever recurring after 4 afebrile days falls outside expected dengue pattern and mandates investigation for alternative causes 7

Diagnostic Workup for Recurrent Fever

• Perform chest radiography 7
• Obtain urine cultures 7
• Check complete blood count with attention to platelet count and hematocrit 7
• Conduct meticulous physical examination focusing on catheter sites and new infection sites 7
• Re-evaluate for warning signs of severe dengue 7

Management Approach

• Do not change antibiotics based solely on persistent fever pattern without clinical deterioration or new findings 1
• Broaden management to include coverage for secondary infections if patient remains hemodynamically unstable 1
• Continue supportive dengue management with adequate hydration 7

Common Pitfalls to Avoid

• Never delay fluid resuscitation in patients showing signs of shock 1
• Narrow pulse pressure (<20 mmHg) is more sensitive than absolute hypotension for detecting early shock 2
• Over-resuscitation with fluids can precipitate pulmonary edema and worsen cerebral edema 2
• Changing management based solely on fever pattern without clinical deterioration is inappropriate 1
• Draining pleural effusions or ascites can cause severe hemorrhage and circulatory collapse 4