Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

WHO group C (established warning signs)

1st line – emergency medical intervention

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ACUTE
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WHO group C (established warning signs)
1st line – 

emergency medical intervention

Group C: established warning signs; in the critical phase of infection with severe plasma leakage (with or without shock), severe haemorrhage, or severe organ impairment (e.g., hepatic or renal impairment, cardiomyopathy, encephalopathy, or encephalitis).[2]

Patients require emergency medical intervention. Access to intensive care facilities and blood transfusion should be available. An attempt should be made to work out how long the patient has been in the critical phase, and the previous fluid balance.[2]

In dengue-endemic regions, triage of patients with suspected dengue infection should be carried out in a specifically designated area of the hospital. Suspected, probable, and confirmed cases of dengue infection should be reported to relevant authorities as soon as possible, so appropriate measures can be instituted to prevent dengue transmission.[2]

Plus – rapid administration of intravenous fluids

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ACUTE
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WHO group C (established warning signs)
Plus – 

rapid administration of intravenous fluids

Treatment recommended for ALL patients in selected patient group

Rapid administration of intravenous crystalloids and colloids is recommended, according to algorithms produced by the WHO, for 24 to 48 hours.[1][75] The infusion rate may be gradually reduced once the rate of plasma leakage decreases.[2]

The following formula may be used; however, other formulas have been reported, so local protocols should be consulted. Maintenance (M) + 5% fluid deficit (M = 100 mL/kg for the first 10 kg of body weight, 50 mL/kg for the second 10 kg of body weight, and 20 mL/kg for every kilogram over 20 kg of body weight up to 50 kg; and 5% fluid deficit is calculated as 50 mL/kg of body weight up to 50 kg) given over 48 hours.[1][75] For example, for an adult who weighs 50 kg or more, the total fluid quota for 48 hours would be 4600 mL.

Pre-pregnancy body weight should be used in the formula for pregnant women.[1][101] Ideal body weight should be used in the formula for children. Plasma leakage in children may be shorter and respond faster to fluid resuscitation.[1]

There is no clinical advantage to giving colloids (e.g., dextran 70) over crystalloids (e.g., 0.9% normal saline, Ringer's lactate).[98][99][100] WHO guidelines clearly indicate when colloids should be used (e.g., intractable shock, resistance to crystalloid resuscitation).[1][2]

Patients may develop a diuresis with hypokalaemia. If this occurs, intravenous fluids should be discontinued and a potassium-rich fluid given.

Caution is advised when administering intravenous fluids, to avoid fluid overload. Consensus is now for early use of colloids and blood transfusion in refractory unstable patients.

Plus – monitoring

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ACUTE
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WHO group C (established warning signs)
Plus – 

monitoring

Treatment recommended for ALL patients in selected patient group

Patients should be monitored closely throughout, including vital signs, peripheral perfusion, fluid balance, haematocrit, platelet count, urine output, temperature, blood glucose, LFTs, renal profile, coagulation profile, and other organ function tests as indicated.[2]

Pregnancy is associated with various physiological changes; therefore, baseline parameters should be noted on the first day of infection and subsequent results interpreted with caution. Conditions such as pre-eclampsia and HELLP syndrome may also alter laboratory parameters.[1][101]

Detection of plasma leakage (e.g., ascites, pleural effusion) is difficult in pregnant women, and early use of ultrasound is recommended.[1][101]

As the tendency for children to develop severe infection is increased, laboratory parameters such as haematocrit, platelet count, and urine output should be monitored regularly.

Consider – investigation and management of other causes

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ACUTE
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WHO group C (established warning signs)
Consider – 

investigation and management of other causes

Additional treatment recommended for SOME patients in selected patient group

Usually, the patient's condition will become stable within a few hours of fluid therapy. If the patient remains unstable, other contributory causes such as metabolic acidosis, electrolyte imbalances (e.g., hypocalcaemia, hypoglycaemia), myocarditis, or hepatic necrosis should be investigated and managed appropriately.

Consider – blood transfusion

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ACUTE
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WHO group C (established warning signs)
Consider – 

blood transfusion

Additional treatment recommended for SOME patients in selected patient group

If the patient is not improving and the haematocrit falls, internal bleeding should be suspected and a blood transfusion administered immediately; however, caution is advised due to risk of fluid overload. Consensus is now for early use of colloids and blood transfusion in refractory unstable patients.[2]

Prophylactic platelet transfusions are rarely required (even with very low platelet counts) and are not recommended except in situations where there is active bleeding.[2]

One multi-centre, open-label, randomised trial found that prophylactic platelet transfusion plus supportive care was not superior to supportive care alone in preventing bleeding in adults with dengue and thrombocytopenia, and may actually be associated with adverse events (e.g., urticaria, anaphylaxis, transfusion-related acute lung injury, fluid overload).[103]

Plus – hospital discharge planning

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ACUTE
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WHO group C (established warning signs)
Plus – 

hospital discharge planning

Treatment recommended for ALL patients in selected patient group

Convalescence is indicated by the improvement in clinical parameters, as well as the patient's appetite and well-being.

Once well-being is achieved and patient remains afebrile for 48 hours, with a rising platelet count and stable haematocrit, the patient can be discharged.[2]

WHO group B (developing warning signs)

1st line – hospital admission

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ACUTE
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WHO group B (developing warning signs)
1st line – 

hospital admission

Group B: developing warning signs (i.e., abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation such as ascites or pleural effusion, mucosal bleeding, lethargy/restlessness, liver enlargement >2 cm, increase in haematocrit concurrent with rapid decrease in platelet count); co-existing risk factors for serious infection (e.g., pregnancy, extremes of age, obesity, diabetes, renal impairment, haemolytic diseases); poor family or social support (e.g., patients who live alone or live far from medical facilities, without reliable transport); increasing haematocrit or a rapidly decreasing platelet count.[2]

Patients require hospital admission. Severity of infection should be assessed and what stage of infection the patient is in (i.e., febrile or critical).[2]

In dengue-endemic regions, triage of patients with suspected dengue infection should be carried out in a specifically designated area of the hospital. Suspected, probable, and confirmed cases of dengue infection should be reported to relevant authorities as soon as possible, so appropriate measures can be instituted to prevent dengue transmission.[2]

Plus – oral or intravenous fluids

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ACUTE
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WHO group B (developing warning signs)
Plus – 

oral or intravenous fluids

Treatment recommended for ALL patients in selected patient group

If patient is not in early critical phase (i.e., with plasma leakage), they are encouraged to take fluids orally (e.g., approximately 2500 mL/24 hours for an adult, or age-appropriate maintenance fluid requirement for children).

If this is not possible, or if patient enters critical phase (indicated by rising haematocrit, hypoalbuminaemia, progressive leukopenia, thrombocytopenia, third space fluid loss, and narrowing of pulse pressure with postural drop), intravenous fluid replacement therapy with 0.9% saline (or Ringer's lactate) should be started and continued for 24 to 48 hours.[1][75] The infusion rate may be gradually reduced once the rate of plasma leakage decreases.[2]

The following formula may be used; however, other formulas have been reported, so local protocols should be consulted. Maintenance (M) + 5% fluid deficit (M = 100 mL/kg for the first 10 kg of body weight, 50 mL/kg for the second 10 kg of body weight, and 20 mL/kg for every kilogram over 20 kg of body weight up to 50 kg; and 5% fluid deficit is calculated as 50 mL/kg of body weight up to 50 kg) given over 48 hours.[1][101] For example, for an adult who weighs 50 kg or more, the total fluid quota for 48 hours would be 4600 mL.

Pre-pregnancy body weight should be used in the formula for pregnant women.[1][101] Ideal body weight should be used in the formula for children. Plasma leakage in children may be shorter and respond faster to fluid resuscitation.[1]

There is no clinical advantage to giving colloids (e.g., dextran 70) over crystalloids (e.g., 0.9% normal saline, Ringer's lactate).[98][99][100] WHO guidelines clearly indicate when colloids should be used (e.g., intractable shock, resistance to crystalloid resuscitation).[1][2]

Patients may develop a diuresis with hypokalaemia. If this occurs, intravenous fluids should be discontinued and a potassium-rich fluid given.

Caution is advised when administering intravenous fluids, to avoid fluid overload.

Plus – monitoring

Back
ACUTE
|
WHO group B (developing warning signs)
Plus – 

monitoring

Treatment recommended for ALL patients in selected patient group

Patients should be monitored closely throughout treatment, including vital signs, peripheral perfusion, fluid balance, haematocrit, platelet count, urine output, temperature, blood glucose, liver function tests (LFTs), renal profile, and coagulation profile.[2]

Pregnancy is associated with various physiological changes; therefore, baseline parameters should be noted on the first day of infection and subsequent results interpreted with caution. Conditions such as pre-eclampsia and HELLP syndrome may also alter laboratory parameters.[1][101]

Detection of plasma leakage (e.g., ascites, pleural effusion) is difficult in pregnant women, and early use of ultrasound is recommended.[1][101]

As the tendency for children to develop severe infection is increased, laboratory parameters such as haematocrit, platelet count, and urine output should be monitored regularly.

Plus – hospital discharge planning

Back
ACUTE
|
WHO group B (developing warning signs)
Plus – 

hospital discharge planning

Treatment recommended for ALL patients in selected patient group

Convalescence is indicated by the improvement in clinical parameters, as well as the patient's appetite and well-being.

Once well-being is achieved and patient remains afebrile for 48 hours with a rising platelet count and stable haematocrit, the patient can be discharged.[2]

WHO group A (no warning signs)

1st line – home management

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ACUTE
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WHO group A (no warning signs)
1st line – 

home management

Group A: no warning signs (particularly when fever subsides); able to tolerate an adequate volume of oral fluids and pass urine at least once every 6 hours; near-normal blood counts and haematocrit.[2]

Patients can be sent home and reviewed for disease progression on a daily basis until they are out of critical period.[2]

In dengue-endemic regions, suspected, probable, and confirmed cases of dengue infection should be reported to relevant authorities as soon as possible so that appropriate measures can be instituted to prevent dengue transmission.[2]

Plus – oral fluids

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ACUTE
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WHO group A (no warning signs)
Plus – 

oral fluids

Treatment recommended for ALL patients in selected patient group

Patients should be encouraged to rest and take oral fluids (e.g., approximately 2500 mL/24 hours for an adult, or age-appropriate maintenance fluid requirement for children).[1]

Oral rehydration products, fruit juices, and clear soups are better than water. Red- or brown-coloured fluids should be avoided, as these may lead to confusion about the presence of haematemesis if the patient vomits.

Plus – monitoring

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ACUTE
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WHO group A (no warning signs)
Plus – 

monitoring

Treatment recommended for ALL patients in selected patient group

Patients should be monitored for development of warning signs. An instruction leaflet outlining signs should be given to the patient, as well as advice to return to hospital immediately if any warning signs develop. Blood counts should be performed on a daily basis.[2]

Warning signs include abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleed, lethargy/restlessness, liver enlargement >2 cm, and an increase in haematocrit with rapid decrease in platelet count.[2]

Consider – tepid sponging and/or paracetamol

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ACUTE
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WHO group A (no warning signs)
Consider – 

tepid sponging and/or paracetamol

Additional treatment recommended for SOME patients in selected patient group

Tepid sponging may be used for fever.

Paracetamol may be used in normal doses for pain or fever; however, non-steroidal anti-inflammatory drugs should be avoided, as they increase bleeding tendency.[2]

Primary options

paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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