Syndrome based treatment guidelines for critical tropical infections.

Sir,

I read the guidelines from the Indian Society of Critical Care Medicine Tropical fever Group in the article “Tropical fevers: Management guidelines” by Singhi et al. with great interest.[1] At the outset I congratulate the Journal, Indian Society of Critical Care Medicine and the members of the expert Review Committee for the recommendations on a neglected issue of public health concern particularly with availability of limited epidemiological data. The syndrome-based approach, especially in the monsoon and post monsoon season (seasonal fever) may not be specific for the cause of fever; however the algorithm is very relevant as the treatment is specific for the differential diagnosis. The favorable climatic conditions are a fertile ground for certain infections particularly the arthropod-borne. Our primary and secondary care hospitals, which attend majority of these patients are resource-limited and lack access to diagnostic tests. Further, the diagnosis of some of these infections is serology based, which may be negative initially. Hence, sensitizing clinicians across the country regarding the “syndromic approach” is justified particularly for seasonal tropical fevers.

However, there are the following areas of concern:

Fever with encephalopathy: These patients should also receive doxycycline. Meningoencephalitis is a known complication of scrub typhus in addition to focal neurological deficits[234]

Dose of ceftriaxone: The 2 g intravenous BD recommended daily dose of ceftriaxone in this syndromic approach is debatable. The recommended empirical daily dose of ceftriaxone for enteric fever is 1-2 g/daily or 2 g/once a day.[56] The recommended daily dose of ceftriaxone for leptospirosis is 1 g/once a day[78]

Dose of oseltamivir: The 150 mg BD recommended daily dose of tablet oseltamivir in this syndromic approach is again debatable. The recommended adult dose (>40 kg weight) of oseltamivir is 75 mg BD.[9]