Persistent fever in severe dengue warrants workup for secondary bacterial infection: study

Clinical features of dengue are highly variable and it remains one of the leading cause of hospitalization in endemic areas. A majority of dengue fever patients recover with supportive management, but a few develop secondary sepsis the outcome of which is worse as compared to severe dengue alone. Dengue clinical management guidelines do not recommend the use of antibiotics during any of the stages of dengue due to sparse evidence of secondary bacterial infections in severe dengue patients.

Udayasankar et al conducted a study to assess the prevalence and predictors of bacterial infection among dengue fever patients with prolonged or recurrent fever after critical phase of illness and the findings were published in Journal of Pediatric critical care.

In this reterospective observational study, a total of 83 children who were positive for dengue infection by clinical criteria and serological evidence who had persistent fever for more than 5 days or recurrent fever were included. These children were evaluated for secondary bacterial infection and started on antibiotics as per hospital antibiotic policy(piptaz). Those who had any one positive culture were considered as definite secondary bacterial infection following dengue fever. Based on these, participants were divided into two groups: one with definite secondary bacterial infection and the other group whose cultures were negative. Among those with culture negative, probable secondary bacterial infection was considered if CRP was positive (>6 mg/L) or leukocytosis (>15,000/cu mm).

Key findings of the study are:

-A total 423 children were admitted in the pediatric department with a diagnosis of dengue fever during the study period out of which eighty-three children had persistent or recurrent fever were analysed. Twenty-nine children (34.9%) had any one culture positive which was labeled as definite secondary bacterial infection.

-Among 54 children who were culture negative, 7 patients had sepsis screen positive(raised CRP and leucocytosis).

-On analyzing the 29 children with secondary bacterial infection, 6 had bacteremia, 20 had urinary tract infection (UTI), 2 had UTI with bacteremia, and 1 had bacteremia with CSF culture positive.

-Researchers found secondary bacterial infection was higher in children with longer fever duration (>5 days), with P = 0.020 and seven out of eight children with severe dengue developed secondary bacterial infection (P = 0.016).

-Secondary bacterial infection may lead to prolonged hospital stay as compared to severe dengue.

Authors conclude-"A low threshold to work up for secondary infection is warranted in infants and children with severe dengue, and early initiation of antibiotics needs to be considered in appropriate situation."

Source: Journal of Pediatric Critical care