🌡️ TROPICAL FEVER EMERGENCIES

COMPREHENSIVE DUAL-LEVEL CARE PROTOCOL

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PRIMARY CARE → SECONDARY CARE

📋 For Doctors Only | Not for Public Use

Covers: Dengue | Malaria | Scrub Typhus | Leptospirosis | Enteric Fever (Typhoid)

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🏥 LEVEL OF CARE OVERVIEW

Procedure/Action	Primary Care	Secondary/Tertiary Care
Clinical recognition	✅	✅
Rapid diagnostic tests (RDT)	✅	✅
Oral rehydration / IV fluids	✅	✅
Oral antimalarials	✅	✅
IV Artesunate (severe malaria)	⚠️ (if available)	✅
Empiric Doxycycline (Scrub Typhus)	✅	✅
IV Ceftriaxone	✅	✅
Blood transfusion	❌	✅
Platelet transfusion	❌	✅
Dialysis	❌	✅
Mechanical ventilation	❌	✅
ICU-level care	❌	✅

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⏱️ CRITICAL TIME TARGETS

Milestone	Target Time
Recognize warning signs	Immediate
Blood glucose check	≤ 5 min
IV access (if warning signs)	≤ 10 min
Rapid diagnostic tests	≤ 30 min
Start empiric antibiotics (if indicated)	≤ 1 hour
Start IV Artesunate (severe malaria)	Immediate
Transfer (if needed)	ASAP after stabilization

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📖 OVERVIEW OF TROPICAL FEVERS IN INDIA

Seasonal Patterns

Quick Comparison Table

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🟢 PART 1 — PRIMARY CARE

Goal: Recognise → Identify Warning Signs → Start Treatment → Refer if Needed

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1️⃣ APPROACH TO ACUTE UNDIFFERENTIATED FEVER

Initial Assessment

Action	Details
History	Duration, travel, occupation, animal contact, water exposure, sick contacts
Examine	Rash, eschar, jaundice, hepatosplenomegaly, lymphadenopathy, bleeding
Vitals	Temperature, BP, HR, RR, SpO₂
Warning signs	Check for each disease-specific warning sign
Blood glucose	Rule out hypoglycemia

Key History Questions

Question	Significance
Duration of fever?	< 7 days vs > 7 days
Travel to endemic area?	Malaria, Scrub Typhus
Occupation?	Farmer, sewage worker (Leptospirosis)
Wading through flood water?	Leptospirosis
Animal contact?	Leptospirosis
Bite/eschar noticed?	Scrub Typhus
Unsafe water/food?	Enteric fever
Mosquito exposure?	Dengue, Malaria, Chikungunya
Similar illness in family/area?	Epidemic (Dengue, Chikungunya)

Clinical Clues to Differentiate

Finding	Suggests
Eschar (painless black scab)	Scrub Typhus
Conjunctival suffusion (redness without discharge)	Leptospirosis
Muscle tenderness (especially calf)	Leptospirosis
Relative bradycardia (HR not ↑ with fever)	Enteric Fever, Scrub Typhus
Severe thrombocytopenia (< 50,000)	Dengue
Splenomegaly prominent	Malaria, Enteric Fever
Altered sensorium + fever	Cerebral Malaria, Scrub Typhus, Leptospirosis
Jaundice + fever + renal failure	Leptospirosis, Severe Malaria
Pulmonary involvement (ARDS)	Scrub Typhus, Leptospirosis
Bleeding (petechiae, mucosal, GI)	Dengue

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2️⃣ RAPID DIAGNOSTIC TESTS AT PRIMARY CARE

Available Tests

Disease	Rapid Test	When Positive	Sensitivity
Dengue	NS1 antigen	Day 1-5	80-90%
	IgM antibody	Day 5+	90-95%
	IgG antibody	Day 7+ (or secondary infection)	Variable
Malaria	RDT (Pf/Pv)	Any time during infection	90-95%
	Peripheral smear	Any time	Gold standard
Scrub Typhus	IgM rapid test	Day 7+	Variable (60-90%)
Leptospirosis	IgM rapid test	Day 7+	Variable (50-80%)
Enteric Fever	Widal test	Day 7+	Poor specificity
	Typhidot IgM	Day 4+	Moderate

Interpretation Notes

Test	Note
Dengue NS1	Best in first 5 days; negative doesn't rule out
Dengue IgM	Becomes positive around day 5; use combo kit
Malaria RDT	Can remain positive after treatment; smear better for follow-up
Widal	Single titre unreliable; rising titre more useful; avoid if possible
Scrub Typhus IgM	May be negative early; treat empirically if clinical suspicion

📌 In endemic season with compatible syndrome, treat empirically – do not wait for test results

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3️⃣ DENGUE – PRIMARY CARE MANAGEMENT

Definition & Classification (WHO 2009)

Category	Features
Dengue without Warning Signs	Fever + ≥ 2 of: nausea/vomiting, rash, aches, leukopenia, positive tourniquet test
Dengue with Warning Signs	Above + any warning sign (see below)
Severe Dengue	Severe plasma leakage, severe bleeding, or severe organ impairment

Warning Signs (MUST Recognize)

Warning Sign	Indicates
Abdominal pain or tenderness	Plasma leakage
Persistent vomiting	Dehydration risk
Clinical fluid accumulation	Pleural effusion, ascites
Mucosal bleeding	Coagulopathy
Lethargy / Restlessness	Impending shock
Liver enlargement > 2 cm	Hepatic involvement
Laboratory: Hct increase with rapid platelet drop	Hemoconcentration

Phases of Dengue

Phase	Day	Features
Febrile	1-3	High fever, headache, myalgia, rash
Critical	4-6 (around defervescence)	⚠️ Maximum risk of shock; plasma leakage
Recovery	7-10	Fluid reabsorption; risk of fluid overload

📌 Critical phase occurs when fever subsides – monitor closely during defervescence

Who Can Be Managed at Primary Care?

Can Manage	Must Refer
Dengue without warning signs	Any warning sign present
Tolerating oral fluids	Severe dengue
Adequate urine output	Bleeding
Stable vitals	Shock / Hypotension
Hct stable	Rising Hct with falling platelets
Platelets > 50,000	Platelets < 20,000

Fluid Management – Dengue WITHOUT Warning Signs

Patient Type	Fluid
Tolerating orals	ORS, coconut water, fruit juices, rice kanji
Target	2-3 liters/day orally
Avoid	NSAIDs (bleeding risk), Aspirin, IM injections
Paracetamol	500-1000 mg every 6 hrs (max 4 g/day)

Fluid Management – Dengue WITH Warning Signs

Step	Action
1	Start IV crystalloid (NS or RL)
2	Initial bolus: 5-7 mL/kg/hr for 1-2 hours
3	If improving: Reduce to 3-5 mL/kg/hr for 2-4 hrs
4	If stable: Reduce to 2-3 mL/kg/hr
5	Monitor: Vitals hourly, Hct every 4-6 hrs
6	TRANSFER to higher centre

Fluid Calculation by Weight

Weight	5 mL/kg/hr	3 mL/kg/hr	2 mL/kg/hr
50 kg	250 mL/hr	150 mL/hr	100 mL/hr
60 kg	300 mL/hr	180 mL/hr	120 mL/hr
70 kg	350 mL/hr	210 mL/hr	140 mL/hr
80 kg	400 mL/hr	240 mL/hr	160 mL/hr

When to Suspect Dengue Shock

Sign
Tachycardia with narrow pulse pressure (< 20 mmHg)
Cold, clammy extremities
Delayed capillary refill (> 3 seconds)
Weak pulse
Restlessness or lethargy
Reduced urine output

Dengue Shock – Immediate Actions at Primary Care

Step	Action
1	IV crystalloid bolus 10-20 mL/kg over 15-30 min
2	Reassess: If improving, reduce rate
3	If no improvement: Repeat bolus
4	If still no improvement: May need colloid (at higher centre)
5	TRANSFER URGENTLY

What NOT to Do in Dengue

⛔ Avoid
NSAIDs (Ibuprofen, Diclofenac) – increases bleeding
Aspirin – increases bleeding
IM injections – hematoma risk
Excessive IV fluids in recovery phase – pulmonary edema
Prophylactic platelet transfusion (not indicated unless severe bleeding or < 10,000)
Steroids (no proven benefit)

Primary Care Summary – Dengue

Scenario	Action
No warning signs, tolerating orally	Oral fluids, Paracetamol, monitor daily
Warning signs	IV fluids, TRANSFER
Shock	IV bolus 10-20 mL/kg, TRANSFER URGENTLY

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4️⃣ MALARIA – PRIMARY CARE MANAGEMENT

Classification

Category	Features
Uncomplicated Malaria	Fever with positive test, no danger signs
Severe Malaria	Any danger sign present (see below)

Danger Signs (Severe Malaria)

Danger Sign	Clinical Feature
Impaired consciousness	GCS < 11 or unable to sit/stand/localize pain
Prostration	Unable to walk or sit without support
Multiple convulsions	> 2 episodes in 24 hrs
Respiratory distress	Acidotic breathing, SpO₂ < 92%
Shock	SBP < 80 mmHg, cold extremities
Severe anemia	Hb < 5 g/dL or Hct < 15%
Jaundice	Visible icterus + parasitemia
Significant bleeding	Spontaneous bleeding
Hypoglycemia	Blood glucose < 40 mg/dL
Metabolic acidosis	pH < 7.25 or bicarbonate < 15
Renal impairment	Creatinine > 3 mg/dL or oliguria
Hyperparasitemia	> 10% parasitized RBCs (or > 250,000/μL)
Pulmonary edema/ARDS	Radiological evidence
Hemoglobinuria	Dark/black urine

Malaria Species in India

Species	Prevalence	Features
P. falciparum	~50%	Severe malaria, cerebral malaria, death
P. vivax	~50%	Relapsing; can cause severe disease
P. malariae	Rare	Chronic infection
P. ovale	Very rare	Similar to vivax
Mixed	Common	Both Pf and Pv

Diagnosis

Test	When to Use
RDT (Rapid Diagnostic Test)	First-line in primary care
Peripheral smear	Gold standard; species identification; parasite count
QBC	If available; sensitive

Treatment – Uncomplicated P. falciparum or Mixed

Drug	Dose	Duration
Artesunate-Lumefantrine (AL)	Weight-based (see below)	3 days
OR Artesunate + Sulfadoxine-Pyrimethamine (AS+SP)	As per NVBDCP	3 days + single dose
+ Primaquine	0.25 mg/kg	Day 1 only (single dose for gametocidal)

Artesunate-Lumefantrine (Coartem) Dosing

Weight	Tablets (20/120 mg) per dose	Doses
5-14 kg	1 tablet	At 0, 8, 24, 36, 48, 60 hrs (6 doses)
15-24 kg	2 tablets	6 doses
25-34 kg	3 tablets	6 doses
≥ 35 kg	4 tablets	6 doses

Treatment – Uncomplicated P. vivax

Drug	Dose	Duration
Chloroquine	25 mg base/kg over 3 days (10+10+5 mg/kg)	3 days
+ Primaquine	0.25 mg/kg/day	14 days (for radical cure)

📌 Primaquine is contraindicated in G6PD deficiency and pregnancy – test if possible before 14-day course

Chloroquine Dosing (for P. vivax)

Day	Dose (mg base/kg)
Day 1	10 mg/kg
Day 2	10 mg/kg
Day 3	5 mg/kg

Chloroquine-Resistant P. vivax

If Chloroquine-resistant area (NE India, some parts)
Use ACT (Artesunate-Lumefantrine) + Primaquine 14 days

Treatment – Severe Malaria

⚠️ IV/IM Artesunate is the drug of choice

Drug	Dose	Route	Timing
Artesunate	2.4 mg/kg	IV or IM	At 0, 12, 24 hrs, then every 24 hrs
If Artesunate unavailable:
Artemether	3.2 mg/kg loading, then 1.6 mg/kg	IM	Every 24 hrs
Quinine (last resort)	20 mg/kg loading, then 10 mg/kg	IV infusion	Every 8 hrs

Pre-Referral Dose (Before Transfer)

If Artesunate Available	If Artesunate NOT Available
Artesunate 2.4 mg/kg IM/IV single dose	Artemether 3.2 mg/kg IM single dose
Then transfer	OR Quinine 20 mg/kg IV loading

📌 Give pre-referral dose and transfer immediately – do not delay

What NOT to Do in Malaria

⛔ Avoid
Chloroquine for P. falciparum (resistance widespread)
Oral treatment for severe malaria
Primaquine in pregnancy or G6PD deficiency
Delaying parenteral treatment for severe malaria

Primary Care Summary – Malaria

Scenario	Action
Uncomplicated Pf or mixed	ACT (Artesunate-Lumefantrine) × 3 days
Uncomplicated Pv	Chloroquine × 3 days + Primaquine × 14 days
Severe / Any danger sign	Pre-referral Artesunate 2.4 mg/kg IM/IV → TRANSFER

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5️⃣ SCRUB TYPHUS – PRIMARY CARE MANAGEMENT

Key Features

Feature	Details
Cause	Orientia tsutsugamushi (rickettsial)
Vector	Larval mites (chiggers)
Incubation	6-21 days
Classic triad	Fever + Eschar + Lymphadenopathy
Eschar	Painless, black, necrotic, often in hidden areas
Season	Post-monsoon (Sep-Nov) in India

Eschar – Highly Specific Finding

Eschar Characteristics
Painless black scab with erythematous halo
5-10 mm diameter
Often in hidden areas: axilla, groin, waist, behind ear
May be missed if not actively searched
Present in 40-80% cases

Common Eschar Locations (Search Carefully)

Location
Axilla
Groin / Inguinal area
Waistband area
Under breasts
Behind ears
Intergluteal fold
Scalp (in children)

Clinical Features

System	Features
Constitutional	High fever, headache, myalgia
Skin	Eschar, maculopapular rash (trunk)
Lymph nodes	Regional lymphadenopathy (near eschar)
Respiratory	Cough, ARDS (common cause of mortality)
CNS	Meningoencephalitis, altered sensorium
Hepatic	Hepatomegaly, transaminitis
Renal	AKI
Cardiac	Myocarditis

Diagnosis

Test	Timing	Notes
Clinical (fever + eschar)	Any	Treat empirically if suspected
IgM ELISA	Day 7+	Most useful; may be negative early
Weil-Felix (OX-K)	Day 7+	Low sensitivity/specificity; avoid if possible
PCR	Any	Expensive; limited availability

📌 IgM may be negative in first week – if clinical suspicion is high, TREAT EMPIRICALLY

Treatment

Drug	Dose	Route	Duration
Doxycycline (First-line)	100 mg BD	PO or IV	Until afebrile for 3 days (min 7 days)
Azithromycin (Alternative)	500 mg OD	PO or IV	5-7 days
Azithromycin (Pregnancy/Children < 8 yrs)	10 mg/kg Day 1, then 5 mg/kg	PO	5 days

Doxycycline in Children

Consideration	Current Recommendation
Age < 8 years	May use Doxycycline for short courses in severe disease
Dental staining risk	Minimal with short courses (< 21 days)
CDC/AAP	Doxycycline is drug of choice for rickettsial diseases in all ages
Alternative	Azithromycin 10 mg/kg/day

When to Suspect Scrub Typhus

Clinical Scenario
Fever > 5 days without focus
Post-monsoon season
Rural/agricultural area or travel to endemic region
Eschar present
ARDS/Respiratory failure with fever
Multi-organ dysfunction with fever
Not responding to usual antibiotics

Complications

Complication	Management
ARDS	Oxygen, ventilation, continue Doxycycline
Shock	Fluids, vasopressors, Doxycycline
Meningoencephalitis	IV Doxycycline, supportive
Myocarditis	Supportive, Doxycycline
AKI	Fluids, may need dialysis
DIC	Supportive

Primary Care Summary – Scrub Typhus

Scenario	Action
Suspected (fever + eschar/endemic area)	Start Doxycycline 100 mg BD immediately
Mild disease	Doxycycline orally, monitor
Severe/MODS/ARDS	IV Doxycycline + TRANSFER
Pregnancy	Azithromycin 500 mg OD × 5 days
Child < 8 yrs (severe)	Doxycycline (CDC allows); OR Azithromycin

📌 Do NOT wait for serology – empiric Doxycycline is life-saving

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6️⃣ LEPTOSPIROSIS – PRIMARY CARE MANAGEMENT

Key Features

Feature	Details
Cause	Leptospira interrogans (spirochete)
Source	Urine of infected animals (rats, dogs, cattle)
Transmission	Contact with contaminated water/soil through skin/mucosa
Incubation	5-14 days
Risk factors	Flooding, wading through water, agriculture, sewage work

Classic Clinical Features

Feature	Description
Conjunctival suffusion	Redness without discharge – highly suggestive
Muscle tenderness	Especially calf muscles
Jaundice	Hepatorenal involvement
Oliguria	Renal failure
Hemorrhage	Pulmonary hemorrhage (severe form)

Clinical Spectrum

Form	Features	Mortality
Anicteric (Mild)	Fever, myalgia, headache, conjunctival suffusion	Low
Icteric (Weil's disease)	Jaundice + Renal failure + Hemorrhage	5-15%
Pulmonary hemorrhage (SPHS)	Massive hemoptysis, ARDS	50-70%

Danger Signs

Danger Sign
Jaundice
Oliguria / Anuria
Hemoptysis
Hypotension / Shock
Altered sensorium
Severe dyspnea
Bleeding manifestations

Diagnosis

Test	Timing	Notes
IgM ELISA	Day 5-7+	Most useful
MAT (Microscopic Agglutination Test)	Day 10+	Gold standard but delayed
Dark-field microscopy	First week	Low sensitivity
PCR	First week	If available

📌 Early in illness, tests may be negative – treat empirically if clinical suspicion high

Laboratory Findings

Finding	Details
Leukocytosis	Often with neutrophilia
Thrombocytopenia	Mild-moderate
Elevated bilirubin	Direct hyperbilirubinemia
Elevated creatinine	Non-oliguric AKI common initially
Elevated transaminases	Usually < 5× ULN (unlike viral hepatitis)
Elevated CPK	Myositis
Abnormal urinalysis	Proteinuria, pyuria, casts

Treatment

Severity	Drug	Dose	Duration
Mild	Doxycycline	100 mg BD PO	7 days
	OR Azithromycin	500 mg OD PO	3-5 days
	OR Amoxicillin	500 mg TID PO	7 days
Severe	Ceftriaxone	1-2 g IV OD	7 days
	OR Penicillin G	1.5 million units IV q6h	7 days
	OR Doxycycline	100 mg IV BD	7 days

Jarisch-Herxheimer Reaction

Feature	Details
Timing	Within hours of first antibiotic dose
Features	Fever spike, rigors, hypotension, tachycardia
Cause	Release of bacterial toxins
Management	Supportive; does NOT mean stop antibiotics

Primary Care Summary – Leptospirosis

Scenario	Action
Suspected (flood exposure + fever + myalgia ± jaundice)	Start Doxycycline 100 mg BD
Mild disease	Oral Doxycycline, monitor
Severe / Jaundice / Renal impairment	IV Ceftriaxone 2g + TRANSFER
Hemoptysis / ARDS	IMMEDIATE TRANSFER

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7️⃣ ENTERIC FEVER (TYPHOID) – PRIMARY CARE MANAGEMENT

Key Features

Feature	Details
Cause	Salmonella enterica serovar Typhi (or Paratyphi)
Transmission	Fecal-oral (contaminated water/food)
Incubation	7-21 days
Key feature	Stepladder fever, relative bradycardia, hepatosplenomegaly

Clinical Features

Week	Features
Week 1	Gradually rising fever (stepladder), headache, malaise
Week 2	High sustained fever, abdominal pain, hepatosplenomegaly
Week 3-4	Complications: perforation, bleeding, encephalopathy

Characteristic Signs

Sign	Description
Stepladder fever	Gradually rising temperature over days
Relative bradycardia	Pulse rate not matching fever (Faget sign)
Coated tongue	White coating with red edges
Hepatosplenomegaly	Soft, non-tender enlargement
Rose spots	2-4 mm salmon-colored macules on trunk (uncommon)
Abdominal tenderness	RIF (ileocecal region)

Diagnosis

Test	Timing	Notes
Blood culture	Week 1-2	Gold standard; sensitivity 60-80%
Widal test	Week 2+	Unreliable; avoid if possible
Typhidot IgM	Day 4+	More reliable than Widal
Stool culture	Week 2-3	Lower yield
Bone marrow culture	Any	Highest yield; rarely done

Problems with Widal Test

Issue
Single titre unreliable (endemic areas have baseline positivity)
False positives: Other Salmonella, cross-reactions, infections
False negatives: Early disease, antibiotic use
Requires paired sera (acute + convalescent) for confirmation

📌 Treat based on clinical suspicion + blood culture; do not rely solely on Widal

🇮🇳 Antibiotic Resistance in India

Resistance Pattern	Current Status in India
Fluoroquinolone (Cipro, Levo)	80-90% resistance/reduced susceptibility
Chloramphenicol	Mostly sensitive now (resistance declined)
Ampicillin	Variable (40-60% resistant)
Cotrimoxazole	Variable
Ceftriaxone	< 5% resistance (first-line)
Azithromycin	< 5% resistance

Treatment – Uncomplicated Enteric Fever (India)

Drug	Dose	Route	Duration
Ceftriaxone (First-line)	2 g OD	IV	10-14 days
	75 mg/kg/day (child)	IV	10-14 days
Azithromycin (Alternative)	500 mg OD (or 1 g Day 1 then 500 mg)	PO	7 days
	20 mg/kg/day (child)	PO	7 days
Cefixime (Oral, mild cases)	200 mg BD	PO	14 days
	20 mg/kg/day (child)	PO	14 days

⚠️ Do NOT use Fluoroquinolones (Ciprofloxacin, Levofloxacin) empirically in India – high resistance

Treatment – Severe / Complicated Enteric Fever

Drug	Dose	Route	Duration
Ceftriaxone	2 g OD	IV	14 days
+ Consider Azithromycin	500 mg OD	IV/PO	7 days
For encephalopathy: Add Dexamethasone	3 mg/kg loading, then 1 mg/kg q6h	IV	48 hrs

Complications

Complication	Timing	Management
Intestinal perforation	Week 2-3	Surgical emergency
GI bleeding	Week 2-3	Transfusion, surgery if massive
Typhoid encephalopathy	Week 2-3	Dexamethasone + antibiotics
Myocarditis	Variable	Supportive
Relapse	Week 2 after stopping Rx	Repeat course of antibiotics
Chronic carrier	After recovery	Prolonged antibiotics (4-6 weeks)

Primary Care Summary – Enteric Fever

Scenario	Action
Suspected enteric fever (clinical + endemic area)	Ceftriaxone 2g IV OD OR Azithromycin 500 mg PO
Mild, tolerating orally	Azithromycin 500 mg OD × 7 days or Cefixime 200 mg BD × 14 days
Severe / Complications	IV Ceftriaxone + TRANSFER

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8️⃣ EMPIRIC APPROACH – UNDIFFERENTIATED FEVER

When to Treat Empirically

Indication
Fever > 5 days with no clear focus
Endemic season (monsoon/post-monsoon)
Severe illness / Organ dysfunction
Clinical features suggestive of specific disease
Cannot wait for test results

Empiric Treatment at Primary Care

Clinical Scenario	Empiric Treatment
Fever + Eschar (any area)	Doxycycline 100 mg BD (Scrub Typhus)
Fever + Flood/water exposure + Myalgia ± Jaundice	Doxycycline 100 mg BD OR Ceftriaxone 2g (Leptospirosis)
Fever + Splenomegaly + Endemic area	RDT for Malaria → ACT if positive
Fever + Thrombocytopenia + Monsoon	Suspect Dengue; monitor closely; fluids
Fever + Relative bradycardia + Hepatosplenomegaly	Ceftriaxone 2g (Enteric Fever)
Fever + ARDS/Multi-organ dysfunction	Doxycycline + Ceftriaxone (cover Scrub Typhus + Leptospirosis + Sepsis)

Combination Empiric Therapy (Severe Undifferentiated Fever)

Combination	Covers
Doxycycline 100 mg IV BD + Ceftriaxone 2g IV OD	Scrub Typhus, Leptospirosis, Enteric Fever, Bacterial sepsis
Add Artesunate 2.4 mg/kg IV	If Malaria cannot be ruled out

📌 This combination covers most life-threatening tropical infections

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9️⃣ TRANSFER PROTOCOL

Transfer Indications

Condition	Transfer Indication
Dengue	Any warning sign, severe dengue, shock
Malaria	Any danger sign, severe malaria
Scrub Typhus	ARDS, shock, encephalitis, MODS
Leptospirosis	Jaundice, renal failure, pulmonary hemorrhage
Enteric Fever	Perforation, bleeding, encephalopathy
Any	Not responding to treatment, deteriorating

Pre-Transfer Checklist

Item	Done?
IV access secured	☐
IV fluids running (appropriate rate)	☐
Empiric antibiotics/antimalarials given	☐
Blood glucose checked	☐
Vital signs documented	☐
All investigations documented	☐
Receiving hospital pre-alerted	☐

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🔵 PART 2 — SECONDARY/TERTIARY CARE

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🔟 EMERGENCY DEPARTMENT PROTOCOL

Immediate Assessment

Action	Target Time
Primary survey (ABCDE)	Immediate
Blood glucose	≤ 5 min
IV access (if not present)	≤ 10 min
Draw blood samples	≤ 15 min
Rapid tests (Dengue, Malaria)	≤ 30 min
Empiric treatment (if indicated)	≤ 1 hour

Investigations

Investigation	Purpose
CBC with differential	Thrombocytopenia, leukopenia/leukocytosis
Peripheral smear	Malaria parasites, platelet count
Malaria RDT	Rapid diagnosis
Dengue NS1/IgM combo	Dengue confirmation
Liver function (LFT)	Hepatic involvement
Renal function (RFT)	AKI
Blood glucose	Hypoglycemia (malaria)
Electrolytes	Hyponatremia, hypokalemia
Coagulation (PT, aPTT)	Coagulopathy
ABG	Acidosis, oxygenation
Blood cultures	Bacterial infection, enteric fever
Urine analysis	Proteinuria (leptospirosis)
Chest X-ray	ARDS, pulmonary edema, hemorrhage
Lactate	Tissue perfusion
Procalcitonin	Bacterial vs viral differentiation
Scrub Typhus IgM	If suspected
Leptospira IgM	If suspected

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1️⃣1️⃣ DENGUE – SECONDARY CARE MANAGEMENT

Severe Dengue – Definition

Category	Features
Severe plasma leakage	Shock (DSS), fluid accumulation with respiratory distress
Severe bleeding	GI bleeding, menorrhagia, etc.
Severe organ impairment	Liver (AST/ALT > 1000), CNS (encephalopathy), Heart (myocarditis)

Dengue Shock Syndrome (DSS) Management

Step	Action
1	Crystalloid bolus 10-20 mL/kg over 15-30 min
2	Reassess (BP, pulse, Hct, urine output)
3	If improving: Reduce rate stepwise
4	If not improving: Repeat crystalloid bolus
5	If still not improving: Colloid 10-20 mL/kg (Dextran 40 or Starch)
6	If refractory: Blood transfusion if Hct falling

Fluid Algorithm – Compensated Shock

Time	Action
0-1 hr	NS/RL 10-20 mL/kg over 1 hr
1-2 hr	If improving: 10 mL/kg over 1 hr
2-3 hr	If stable: 7 mL/kg/hr
3-4 hr	Reduce to 5 mL/kg/hr
Next	Stepwise reduction

Fluid Algorithm – Hypotensive Shock

Step	Action
1	Crystalloid bolus 20 mL/kg over 15-30 min
2	If no improvement: Repeat crystalloid 10-20 mL/kg
3	If still no improvement: Colloid 10-20 mL/kg
4	If Hct dropping: Blood transfusion
5	If Hct rising despite fluids: Consider more colloid

Hematocrit Interpretation

Hct Change	Interpretation	Action
Rising Hct	Ongoing plasma leak	More IV fluids
Falling Hct rapidly	Occult bleeding	Blood transfusion
Stable Hct	Adequate resuscitation	Maintain fluids

Blood Product Transfusion

Packed RBCs	Significant bleeding + Hct drop	Hct > 30%
Platelets	Active bleeding + platelets < 20,000	—
	Anticipated procedure + platelets < 50,000	—
	⛔ NOT indicated prophylactically	—
FFP	Coagulopathy with bleeding	Correct PT/aPTT

📌 Prophylactic platelet transfusion is NOT recommended in dengue

Monitoring in Severe Dengue

Parameter	Frequency
Vitals (BP, HR, RR)	Every 15-30 min in shock; hourly if stable
Hct	Every 4-6 hrs (more frequent in shock)
Urine output	Hourly (catheterize if needed)
Blood glucose	Every 4-6 hrs
Platelet count	Daily
Clinical assessment	Continuous

Recovery Phase Management

Issue	Management
Fluid overload	Stop IV fluids; oral fluids only; diuretics if needed
Pulmonary edema	Diuretics, oxygen, reduce IV fluids
Bradycardia	Normal in recovery; monitor
Rash (confluent with islands of sparing)	Common; self-limiting

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1️⃣2️⃣ SEVERE MALARIA – SECONDARY CARE MANAGEMENT

IV Artesunate Protocol

Timing	Dose
0 hours	2.4 mg/kg IV
12 hours	2.4 mg/kg IV
24 hours	2.4 mg/kg IV
Then	2.4 mg/kg IV every 24 hrs
Duration	Until patient can take oral; minimum 24 hrs (3 doses)
Follow with	Oral ACT to complete 3 days

Artesunate Preparation

Preparation	Details
Vial contents	60 mg powder + solvent
Reconstitute	With 1 mL 5% sodium bicarbonate
Dilute	With 5 mL NS to get 10 mg/mL
Administration	IV bolus over 1-2 min OR IM

Artesunate Dose Calculation

Weight (kg)	Dose (2.4 mg/kg)	Volume (10 mg/mL)
40	96 mg	9.6 mL
50	120 mg	12 mL
60	144 mg	14.4 mL
70	168 mg	16.8 mL
80	192 mg	19.2 mL

Specific Complications – Management

Complication	Management
Cerebral malaria	Artesunate; avoid lumbar puncture if raised ICP; seizure control; nursing care
Severe anemia (Hb < 5)	Blood transfusion; target Hb > 7 g/dL
Hypoglycemia	50% dextrose 50 mL IV; D10% infusion; monitor closely
AKI	Fluids; may need dialysis
ARDS	Low tidal volume ventilation; minimize fluids
Acidosis	Treat underlying cause; fluids; may need bicarbonate if pH < 7.1
Shock	Fluids; vasopressors; exclude gram-negative sepsis
DIC	Supportive; blood products if bleeding
Blackwater fever	Fluids; transfusion; stop quinine if being used

Post-Artesunate Delayed Hemolysis (PADH)

Feature	Details
Timing	7-21 days after artesunate treatment
Mechanism	Delayed clearance of pitted RBCs
Features	Recurrent anemia, jaundice, hemolysis
Risk	More common in non-immune travelers; high parasitemia
Management	Monitor Hb weekly × 4 weeks; transfuse if needed

Primaquine in Severe Malaria

For P. falciparum	For P. vivax
Single dose 0.25 mg/kg after recovery	14-day course 0.25 mg/kg/day after recovery
Gametocidal	Radical cure (anti-hypnozoite)
Check G6PD if possible	Check G6PD before 14-day course

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1️⃣3️⃣ SCRUB TYPHUS – SECONDARY CARE MANAGEMENT

IV Doxycycline Protocol

Drug	Dose	Frequency	Duration
Doxycycline	100 mg (or 2.2 mg/kg)	BD	at least until 3 days of fever resolution (min 7-14 days)

Doxycycline Preparation for IV Use

Preparation	Details
Doxycycline vial	100 mg powder
Reconstitute	With 10 mL sterile water
Dilute	In 100-250 mL NS or D5W
Infuse	Over 1-4 hours
⚠️ Avoid	Rapid infusion (thrombophlebitis)

Adjunctive Therapies

Therapy	Indication	Notes
Steroids	ARDS, shock, myocarditis	Controversial; some use methylprednisolone 1-2 mg/kg
Vasopressors	Refractory shock	Norepinephrine first-line
Mechanical ventilation	ARDS	Lung-protective strategy
Dialysis	AKI with indication	Standard RRT indications

Monitoring

Parameter	Frequency
Temperature	Every 4-6 hrs
Vitals	Continuous/hourly if unstable
SpO₂	Continuous
Urine output	Hourly
LFT, RFT	Daily
Chest X-ray	Daily if ARDS

Expected Response

Response	Timing
Defervescence	Within 24-48 hrs of Doxycycline
Clinical improvement	48-72 hrs
If no response by 72 hrs	Reconsider diagnosis; ensure compliance

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1️⃣4️⃣ LEPTOSPIROSIS – SECONDARY CARE MANAGEMENT

Antibiotic Protocol

Severity	Drug	Dose	Duration
Severe	Ceftriaxone	1-2 g IV OD	7 days
	OR Penicillin G	1.5 million units IV q6h	7 days
	OR Doxycycline	100 mg IV BD	7 days

Severe Pulmonary Hemorrhage Syndrome (SPHS)

Management	Details
Antibiotics	IV Ceftriaxone or Penicillin immediately
Oxygen	High-flow; may need intubation
Mechanical ventilation	Lung-protective; PEEP
Blood transfusion	If significant blood loss
Steroids	Controversial; Methylprednisolone 1 g IV × 3 days used in some centres
Plasma exchange	Case reports of benefit
ECMO	Last resort

📌 SPHS has very high mortality (50-70%); early recognition and aggressive ICU care is essential

Weil's Disease (Icteric Leptospirosis)

Feature	Management
Jaundice	Antibiotics; supportive
Hepatorenal syndrome	Fluids; dialysis if needed
Coagulopathy	Vitamin K, FFP if bleeding
Thrombocytopenia	Usually mild; transfuse if bleeding

Dialysis Indications

Indication
Oliguria/anuria not responding to fluids
Severe hyperkalemia
Refractory acidosis
Uremic complications
Fluid overload

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1️⃣5️⃣ ENTERIC FEVER – SECONDARY CARE MANAGEMENT

IV Antibiotic Protocol

Drug	Dose	Duration
Ceftriaxone	2 g IV OD (75 mg/kg/day in children)	10-14 days
+ Azithromycin (severe cases)	500 mg IV/PO OD	7 days

Complicated Enteric Fever

Typhoid Encephalopathy

Treatment	Dose
Dexamethasone	3 mg/kg IV loading over 30 min
Then	1 mg/kg IV every 6 hrs × 8 doses (48 hrs)
Continue	IV Ceftriaxone

📌 Dexamethasone reduces mortality in severe typhoid encephalopathy (Hoffman trial)

Intestinal Perforation

Management
Surgical emergency
NPO
IV fluids
IV antibiotics (Ceftriaxone + Metronidazole)
Urgent surgery – primary repair or resection

GI Bleeding

Management
NPO
IV fluids
Blood transfusion if needed
Correct coagulopathy
Surgery if massive/uncontrolled

Relapse and Chronic Carrier

Scenario	Treatment
Relapse (fever returns after stopping Rx)	Repeat full course of antibiotics
Chronic carrier (stool positive > 1 year)	Ciprofloxacin 750 mg BD × 4 weeks OR Amoxicillin 2g TID + Probenecid × 6 weeks OR Cholecystectomy (if gallstones)

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1️⃣6️⃣ COINFECTIONS & OVERLAPPING SYNDROMES

Common Coinfections in India

Coinfection	Scenario
Dengue + Malaria	Common in endemic areas during monsoon
Dengue + Scrub Typhus	Post-monsoon period
Scrub Typhus + Leptospirosis	Both post-monsoon; similar exposures
Malaria + Enteric Fever	Endemic areas

Approach to Possible Coinfection

Principle	Action
Test for multiple diseases	Especially if atypical features
Treat for most life-threatening first	Malaria, Scrub Typhus
Combination empiric therapy	If undifferentiated and severe
Monitor response	Modify treatment based on results

Empiric Combination for Severe Undifferentiated Fever

Combination	Covers
Ceftriaxone 2g IV OD	Enteric fever, Leptospirosis, Bacterial sepsis
+ Doxycycline 100 mg IV BD	Scrub Typhus, Leptospirosis
+ Artesunate 2.4 mg/kg IV	Malaria (if cannot be ruled out)

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1️⃣7️⃣ SUPPORTIVE CARE (ALL)

ICU Monitoring

Parameter	Frequency
Vitals	Continuous/hourly
SpO₂	Continuous
Urine output	Hourly
Blood glucose	4-6 hourly
Hematocrit (Dengue)	4-6 hourly
Parasitemia (Malaria)	Every 12-24 hrs until negative
LFT, RFT, Coagulation	Daily

Supportive Measures

Aspect	Recommendation
Fluids	Careful titration; avoid overload
Glucose	Maintain euglycemia; D10% if hypoglycemic
Electrolytes	Correct abnormalities
Nutrition	Enteral preferred; start early if stable
DVT prophylaxis	Mechanical (IPC); avoid pharmacological if bleeding risk
Stress ulcer prophylaxis	PPI if high-risk
Fever	Paracetamol; avoid NSAIDs in Dengue

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1️⃣8️⃣ DISCHARGE PLANNING

Discharge Criteria

Disease	Discharge Criteria
Dengue	No fever × 48 hrs without antipyretics; improving appetite; stable Hct; platelets rising; no warning signs
Malaria	Completed treatment; afebrile; tolerating orally; parasitemia clearing
Scrub Typhus	Afebrile × 3 days; stable; completing oral Doxycycline
Leptospirosis	Afebrile; renal function stable/improving; completing antibiotics
Enteric Fever	Afebrile × 5-7 days; tolerating orally; no complications

Follow-up

Disease	Follow-up
Dengue	Review in 1 week; watch for delayed recovery
Malaria (Pf)	Day 28 smear; watch for PADH (Hb check weekly × 4)
Malaria (Pv)	Complete Primaquine 14 days; watch for relapse
Scrub Typhus	Complete antibiotics; watch for relapse
Leptospirosis	Renal function check; complete antibiotics
Enteric Fever	Stool culture to confirm clearance (especially food handlers)

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📌 QUICK REFERENCE CARDS

🔴 PRIMARY CARE – TROPICAL FEVER CARD

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💊 ANTIBIOTIC QUICK REFERENCE (INDIA-SPECIFIC)

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🚨 DANGER SIGNS SUMMARY

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🌡️ DIFFERENTIATION TABLE

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⚠️ CRITICAL WARNINGS

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🇮🇳 INDIA-SPECIFIC REMINDERS

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📚 ABBREVIATIONS

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📖 REFERENCES

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Document Version: 1.0

India-Specific Notes:

• High fluoroquinolone resistance in Enteric Fever – avoid Ciprofloxacin empirically
• Scrub Typhus is underdiagnosed – always search for eschar
• Coinfections are common in monsoon season
• Doxycycline + Ceftriaxone covers most severe tropical infections
• Artesunate is first-line for severe malaria (not Quinine)

Disclaimer: This protocol provides general guidance. Clinical judgment must be exercised. Local epidemiology and resistance patterns should guide treatment. Regional NVBDCP and state health guidelines may have specific recommendations.