Guidelines For Tropical fevers in ICU


Tropical fevers in ICU

The study was conceived and planned by Dr N Rungta, Dr Ashish Bhalla and Dr Dhruva Chaudhry helped in drafting study protocols and proforma.

Background: : Infecions in Tropical and subtropical regions are often present with fever and organ failures and have overlapping features. Specific etiology is almost indiscernible at admission whereas empiric therapy is warranted at outset. Paucity of literature on this area made us to conduct this study to identify the clinical profile, etiology, treatment patterns and outcome of tropical fevers admitted to ICUs in India.

Methods: Study design, setting and participants: This was a nation-wide multicentre prospective observational study conducted in adult and pediatric ICUs between June 2014 and October 2015. All ICUs in the country were encouraged to participate and enroll patients presenting with Fever without focus of 48 hours duration and onset 14 days with any of the following:

  1. Thrombocytopenia
  2. Respiratory distress/ARDS
  3. Jaundice
  4. Encephalopathy
  5. Renal failure
  6. Multiorgan failure. Data on demographic, clinical, laboratory and outcome were collected prospectively till discharge, death or 90 days of hospital stay and were entered ‘on–line’ using a pre-tested format.

Results: A total of 456 patients were enrolled from 34 Intensive care units from different parts of India. Children younger than 12 years constituted 38% (n=173). Thrombocytopenia was the commonest presentation seen in 60% followed by respiratory distress (46%), encephalopathy (29%), renal failure (24%), jaundice (20%). Nearly a fifth (19%) had multiorgan failure at admission. An etiological diagnosis could be made in 367 (81.5%) cases. Dengue was the commonest tropical fever seen in 105 (23%) cases. Scrub typhus (n=83, 18%), meningitis and encephalitis (n=44, 9.6%), malaria (n=37, 8%) and bacterial sepsis (n=32, 7%) were the other major diagnoses. Thrombocytopenia was seen with dengue (91%), malaria (65%) and scrub typhus (60%). Patients with dengue had higher mean hemoglobin (12.8g/dl). Severe hypoalbuminemia (2.4g/dl) was a feature of scrub typhus and sepsis. More than a third of patients with tropical fevers (n=160, 35%) received invasive mechanical ventilation. A quarter (24%) was treated with vaso-active drugs and 9% required renal replacement therapy. At 28 days, 76.3% survived without any disability and another 4.4% had some disability. 19.3% (80) patients died.

strong>Conclusions: : Dengue, scrub typhus, malaria, typhoid and bacterial sepsis common causes of tropical fevers presenting with thrombocytopenia and/ or organ involvement. Point of care testing for dengue, malaria and typhoid can rule in or rule out these diagnoses at admission and help in instituting specific therapy. Ceftriaxone with doxycycline or azithromycin would be appropriate for empirical therapy while acyclovir may be considered in addition for patients presenting with encephalopathy while waiting for laboratory reports.

Professor Sunit C. Singhi