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Dengue recent guidelines

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WHO dengue guidelines clinical management 2024 2025 warning signs fluid management

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dengue clinical management

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https://www.cdc.gov/dengue/hcp/clinical-care/index.html

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site:who.int dengue clinical management guidelines treatment warning signs 2025

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PMID: 41037858

Current dengue clinical-management guidance

There is no specific antiviral treatment for dengue. Management is supportive, with early recognition of the short critical phase, usually around defervescence on illness days 3-7. The recent WHO primary-care resource and current CDC approach retain the WHO 2009 clinical classification: dengue without warning signs, dengue with warning signs, and severe dengue. CDC clinical-care guidance and the WHO/primary-care document emphasize structured triage and close follow-up.

1. Identify warning signs: admit or urgently assess

Warning signs generally occur as fever settles and include:
  • Severe abdominal pain or abdominal tenderness
  • Persistent vomiting
  • Mucosal bleeding, such as gum or nose bleeding
  • Clinical fluid accumulation, such as ascites or pleural effusion
  • Lethargy, restlessness, irritability, or confusion
  • Hepatomegaly
  • Reduced urine output
  • Rising hematocrit with a rapidly falling platelet count
Textbook criteria also include respiratory difficulty and early shock features. Severe dengue is defined by shock or respiratory distress from plasma leakage, severe bleeding, or severe organ involvement. Red Book 2021, p. 520.
Immediate emergency referral is needed for fainting, cold/clammy extremities, severe bleeding, breathing difficulty, confusion, inability to drink, very little urine, or shock.

2. Triage and management groups

Clinical groupUsual dispositionCore management
No warning signs, drinking well, stable vitalsHome/outpatient care with daily review during the risk periodOral fluids or ORS, paracetamol for fever/pain, monitor urine output and warning signs
Warning signs or important comorbidityHospital admissionClose vital-signs, urine-output, hematocrit and clinical fluid-balance monitoring; carefully titrated isotonic IV crystalloid if oral intake is inadequate or plasma leakage is suspected
Severe dengueHigh-dependency/ICU-level carePrompt shock resuscitation with isotonic crystalloid, frequent reassessment, treatment of significant bleeding/organ dysfunction, and senior critical-care input
Coexisting conditions that lower the threshold for admission include pregnancy, infancy or older age, diabetes, kidney, liver or heart disease, anticoagulant use, inability to return for follow-up, and poor oral intake. CDC categorizes patients with warning signs as inpatients and severe dengue as requiring intensive care. CDC’s group-based approach.

3. Fluids: the central treatment principle

  • Use oral rehydration when the patient can drink and has no warning signs.
  • Use isotonic crystalloid IV fluid only when clinically indicated and reassess frequently.
  • The aim is adequate perfusion and urine output while avoiding fluid overload.
  • Rising hematocrit can support plasma leakage. A falling hematocrit with unstable circulation raises concern for bleeding.
  • Fluid needs often fall quickly after the 24-48 hour leakage period. Continued liberal IV fluid then can cause pulmonary edema or other overload.
A recent systematic review likewise found that management remains supportive, centered on clinical-status-guided fluid resuscitation, vital-sign monitoring, and judicious blood-product use (Yang et al., 2025).

4. Drugs and blood products

  • Use paracetamol/acetaminophen for fever and pain.
  • Avoid aspirin, ibuprofen, diclofenac, naproxen and other NSAIDs because of bleeding risk.
  • Avoid intramuscular injections where possible.
  • A low platelet count alone is not an indication for platelet transfusion. Treat clinically significant bleeding and follow local hematology/transfusion protocols.
  • Do not give routine antibiotics unless bacterial infection is suspected.

5. Monitoring and discharge

During the febrile and critical phases, reassess:
  • Blood pressure, pulse pressure, capillary refill, extremity temperature
  • Mental status, respiratory status and urine output
  • Oral intake, vomiting and bleeding
  • Hematocrit trend and platelet trend, interpreted with the clinical picture
Discharge only after clinical improvement through the critical phase, stable vital signs without IV fluids, improving appetite and urine output, no respiratory distress or bleeding, and a stable or improving hematocrit.

Practical patient advice

A patient with suspected dengue should drink frequent small amounts of ORS, water, soups or similar fluids if able, rest, use paracetamol only, avoid NSAIDs, and seek urgent care if fever subsides but any warning sign begins. The fall in fever is not always recovery: it may mark entry into the critical phase. Red Book 2021, p. 520.
The WHO primary-care and home-based-care guidance can be opened here:
This is general clinical information, not an individual treatment plan. IV-fluid volume and blood-product decisions require in-person assessment and local protocol.
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