What is the treatment for Dengue (Dengue Fever)?

Treatment of Dengue Fever

There is no specific antiviral therapy for dengue; treatment is entirely supportive, focusing on aggressive fluid management to prevent progression to shock, acetaminophen for symptom control, and strict avoidance of aspirin and NSAIDs. 1, 2, 3

Risk Stratification and Triage

Classify all dengue patients into three categories to guide management 1, 4:

• Dengue without warning signs: Outpatient management with oral hydration
• Dengue with warning signs: Hospitalization required for close monitoring during the critical phase (days 3-7 of illness) 4
• Severe dengue: Immediate ICU admission for dengue shock syndrome, severe bleeding, or organ impairment 1

Warning Signs Requiring Hospitalization

Watch for these indicators of impending severe disease 4:

• Severe abdominal pain or persistent vomiting
• Mucosal bleeding (gums, nose, vaginal bleeding)
• Lethargy, restlessness, or altered mental status
• Rising hematocrit with rapidly falling platelet count (platelets <100,000/mm³)
• Hepatomegaly or clinical fluid accumulation

Fluid Management Strategy

For Stable Patients Without Shock

• Oral rehydration is the cornerstone: Target >2,500-3,000 mL daily using any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1
• Avoid soft drinks due to high osmolality 1
• Encourage 5 or more glasses of fluid throughout the day 1

For Dengue Shock Syndrome

Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes, with immediate reassessment after each bolus. 1, 4

• If shock persists, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour 1
• Colloids (gelafundin, albumin, or dextran) achieve faster resolution of shock and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids alone) and should be considered for severe shock with pulse pressure <10 mmHg 1
• Three RCTs demonstrate near 100% survival with aggressive fluid management 1

Critical Monitoring During Resuscitation

Stop fluid resuscitation immediately if these signs of fluid overload appear 1:

• Hepatomegaly
• Pulmonary rales on lung examination
• Respiratory distress

Monitor for adequate tissue perfusion 1:

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

Management of Refractory Shock

If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch from aggressive fluid administration to inotropic support 1:

• For cold shock with hypotension: Titrate epinephrine as first-line vasopressor 1
• For warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 1
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy are associated with major increases in mortality 1

Symptomatic Management

• Acetaminophen (paracetamol) at standard doses is the ONLY acceptable analgesic for pain and fever control 1, 5, 4
• Never use aspirin or NSAIDs under any circumstances due to increased bleeding risk and platelet dysfunction 1, 5, 4, 6

Laboratory Monitoring

• Daily complete blood count to track platelet counts and hematocrit levels 1, 5
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 1
• Falling hematocrit suggests successful plasma expansion 1
• Obtain blood and urine cultures and chest radiograph if fever persists beyond expected course 5

Management of Complications

Significant Bleeding

• Blood transfusion may be necessary with close monitoring of hemoglobin and hematocrit 1, 4
• Target hemoglobin >10 g/dL if ScvO2 <70% 1

Fluid Overload

• After initial shock reversal, fluid removal may be necessary 1
• Evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops 1

Discharge Criteria

Patients can be safely discharged when ALL of the following are met 5, 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 (>0.5 mL/kg/hour in adults)
• Laboratory parameters returning to normal ranges

Post-Discharge Instructions

• Monitor and record temperature twice daily 5
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 5

Critical Pitfalls to Avoid

• Do NOT give routine bolus IV fluids to patients with "severe febrile illness" who are NOT in shock—this increases fluid overload and respiratory complications without improving outcomes 1
• Do NOT delay fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow 1
• Do NOT continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 1
• Do NOT prescribe antibiotics empirically for dengue fever without evidence of bacterial co-infection, which occurs in <10% of cases 5
• Do NOT fail to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1

Special Populations

Pregnant Women

• Hospitalize all pregnant women with confirmed or suspected dengue due to risk of maternal death, hemorrhage, preeclampsia, and vertical transmission 5
• Test by NAAT for both dengue and Zika virus, regardless of outbreak patterns 5
• Acetaminophen remains the safest analgesic option 1, 5

Children

• Acetaminophen dosing should be carefully calculated based on weight 5
• Blood pressure alone is not a reliable endpoint in children 1