Guidelines for Admission in Common Fevers and Infectious Diseases

Febrile Illness – Clinical Key Pointers for Admission

• Fever ≥ 38.3°C or ≥ 101°F for more than 2 days
• Any fever for more than 5 days, not responding to outpatient treatments or worsening symptoms
• Fever accompanied by any or all of the following: headache, dizziness, pain in muscles/joints and weakness
• Acute Febrile Illness (AFI) and signs of organ dysfunction and symptoms/signs suggestive of sepsis, like
  • Grossly deranged liver function tests, renal function tests
  • Patches in lungs / ARDS
  • Deranged CNS:
    • Drowsiness
    • Altered sensorium
    • Hypotension
    • Cardiac suppression
    • Repeated vomiting or diarrhea with dehydration
    • Inability to take oral fluids
    • Oliguria
• Other signs:
  • Severe hypotension
  • Toxic look
  • Febrile seizures
  • Petechial or purpuric rash
• Elderly patients more than 65 years of age with comorbid conditions
• Respiratory distress: respiratory rate >22/min, cyanosis, oxygen saturation <92% on room air
• Circulation: systolic BP <100 mmHg, capillary refill >3 seconds
• Very high WBC count (>12,000/cmm) indicating septicemia or sepsis
• Hemophagocytic Lymphohistiocytosis (HLH)

References

• IMA Guidelines
• Bhargava A, Ralph R, Chatterjee B, et al. Assessment and initial management of acute undifferentiated fever in tropical and subtropical regions. BMJ. 2018;363: k4766. Published 2018 Nov 29. DOI:10.1136/bmj. k4766

Antibiotic use: As per the approved antibiotic policy of the hospital.

Fever in Children – Admission Criteria

• Seizures, difficulty to stay awake and stiff neck
• Toxic appearance, listlessness
• Lethargy
• Irritability
• Dehydration
• Severe malnutrition
• Inability to feed
• A 14-day illness without a confirmed diagnosis

Other Red Flags

Additional signs that warrant immediate attention and potential hospital admission include:

• Bleeding: red spots or patches on the skin, nose or gum bleeding, vomiting blood, black stools, heavy menstruation, petechiae or purpura
• Frequent vomiting
• Severe abdominal pain
• Drowsiness, mental confusion or seizures
• Pale, cold or clammy hands and feet
• Respiratory distress
• Signs of dehydration
• Lethargy or unconsciousness
• Sunken eyes
• Slow skin pinch recoil
• Red maculopapular rash: May be associated with conditions like measles, rubella, or dengue
• Fine generalized maculopapular rash with systemic dysfunction/shock: Could be indicative of meningococcemia 

References

• IMA Guidelines
• Schellack N, Schellack, G. An overview of the management of fever and its possible complications in infants and toddlers. SA Pharm J. 2018. 85. 26–33

Dengue Fever – Admission Criteria

• Persistent vomiting
• Dehydration
• Abdominal tenderness
• Hepatomegaly
• Ascites
• Oedema
• Mucosal bleed
• Blood in vomit or stool
• Pale and cold skin
• Respiratory distress
• Pleural effusion
• Hypotension/shock - drop in Systolic BP of ≥20mmHg and diastolic of ≥10 mmHg indicates postural hypotension
• Oliguria
• Rising haematocrit >60%
• Rapid fall in platelets or bleeding with thrombocytopenia
• Drastic rapid decrease in platelets or any platelet count with bleeding symptoms
• Ascites/ pleural effusion / hypotension / polyserositis / dengue haemorrhagic fevers / dengue shock
• Dengue haemorrhagic fever – thrombocytopenia – mucosal and gastrointestinal bleeds – rise in haematocrit
• Dengue shock syndrome – weak pulse – hypotension
• Expanded dengue syndrome – encephalitis – myocarditis – hepatitis – renal failure – ARDS – haemophagocytosis

Dengue Haemorrhagic Fever (DHF) Grading

• Metabolic acidosis / hyperpnoea / Kussmaul’s breathing
• Oliguria or anuria
• Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) ≥ 1000 units/L
• Impaired consciousness (GCS < 9)
• Febrile seizures in young children
• Nervous system: Encephalopathy, encephalitis / aseptic meningitis
• Intracranial haemorrhages / thrombosis, subdural effusions
• Mononeuropathies / polyneuropathies / Guillain–Barré syndrome
• Transverse myelitis
• Gastrointestinal system: Hepatitis / fulminant hepatic failure, acalculous cholecystitis, acute pancreatitis, hyperplasia of Peyer’s patches, acute parotitis
• Kidney: Acute renal failure and hemolytic uremic syndrome (HUS)
• Heart: Conduction abnormalities, myocarditis, pericarditis
• Lungs: Acute respiratory distress syndrome, pulmonary haemorrhage
• Musculoskeletal system: Myositis with raised creatine phosphokinase (CPK), rhabdomyolysis
• Lymphoreticular system: Infection-associated haemophagocytic syndrome, haemophagocytic lymphohistiocytosis (HLH), idiopathic thrombocytopenic purpura (ITP), spontaneous splenic rupture, lymph node infarction
• Eye: Macular haemorrhage, impaired visual acuity, optic neuritis

Indications for Platelet Transfusion

• Adults: platelets <40,000 with bleeding
• Platelet count <10,000
• Prolonged shock with coagulopathy
• Systemic massive bleeding

References

• IMA Guidelines
• National Vector Control Board Guidelines (followed by AIIMS / Ministry of Family Health & Welfare – Guidelines – 2008 and 2023)
• WHO Guidelines
• The Indian Society of Critical Care Medicine Tropical Fever Group, Singhi S, Chaudhary D, et al. Tropical fevers: Management guidelines. Indian J Crit Care Med. 2014;18(2):62–69. DOI:10.4103/0972–5229.126074
• Guidelines for management of co-infection of COVID-19 with other seasonal epidemic prone diseases. Available at: Ministry of Health & Family Welfare . Accessed on: 03 September 2021
• National Health Mission. Guidelines for management of dengue fever. Available at: National Health Mission . Accessed on: 03 September 2021

Pneumonia in Children – Admission Criteria

• Cough, cold with or without fever, including fast breathing and chest indrawing
• Inability to drink, persistent vomiting, convulsions, lethargy/unconsciousness, stridor, or severe malnutrition
• Admission justified in severe pneumonia as per ICMR protocols

Reference: ICMR Guidelines – Pediatric Severe Pneumonia

Pneumonia in Adults – Admission Criteria

• Breathlessness, pleuritic chest pain, malaise, arthralgia, hemoptysis
• Critical parameters: Respiratory Rate >30/min, abdominothoracic respiration, cyanosis, inability to speak long sentences
• ARDS
• Breathlessness at rest or on exertion
• Oxygen saturation < 92%
• COPD, interstitial lung disease, or any restrictive lung disease
• Admission recommended for score 1 to 4 as per ICMR protocols

Reference: ICMR Guidelines – Adult Pneumonia

Diarrhea / Acute Gastroenteritis – Admission Criteria

• >3 loose or watery stools per day or blood in stool (dysentery)
• Plus any two of the following:
  • Lethargy/unconsciousness
  • Sunken eyes
  • Inability to drink properly
  • Skin pinch goes back slowly

Hepatitis / Jaundice – Admission Criteria

• INR >1.5 or rising INR
• Altered sensorium
• Bleeding
• Recurrent vomiting with dehydration
• Hypotension (Systolic BP < 90 mmHg)

Reference: ICMR Guidelines – Pediatric Diarrhea

Acute Rhinosinusitis / URI – Admission Criteria

• Known diabetic or immunocompromised
• Suspicion of complications:
  • Orbital involvement (periorbital edema/erythema, displaced globe, ophthalmoplegia, visual disturbances)
  • Meningitis / altered sensorium
  • Frontal fullness
• No resolution with oral antibiotics for 7 days
• Pointers for invasive fungal sinusitis (facial hypoesthesia, facial skin/palatal/turbinate discoloration)

References: ICMR ENT Guidelines Pg 8, ICMR ENT – Pharyngitis and Sore Throat

Note

• The participating hospitals are requested to take herewith the above guidelines for admission and basic treatment as a guidepost for the commonly encountered fevers and infections as mentioned above. In exceptional cases, the protocol may be decided by the treating doctor depending on the clinical scenario and clinical features of the patient.
• Any deviation from the above published guidelines should be justified clinically and supported with any suitable nationally or internationally accepted published guidelines.