Guidelines for Admission in Common Fevers and Infectious Diseases

Any of the following criteria are to be met for admission in a hospital and in-hospital treatment:

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 OP treatments – worsening symptoms 
• Along with any or all of following: Headache, Dizziness, Pain in Muscles and Joints, Weakness 
• Patients presenting with 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 – having: drowsiness of altered sensorium / hypotension or cardiac suppression / repeated vomiting or loose stools with signs of dehydration / not able take orally with signs of dehydration / oliguria)
• Other signs such as those mentioned below can also justify admission
• Severe Hypotension
• Toxic look
• Febrile Seizures
• Petechial or purpuric rash
• Elderly patients more than 65 years of age with comorbid conditions 
• Respiration: respiratory rate more than 22/min; cyanosis; arterial oxygen saturation less than 92% on room air
• Circulation – blood pressure – systolic less than 100mm Hg; capillary refill > 3 secs
• Very high WBC count(>12,000/cmm) – indicating septicaemia 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

Admission Criteria for Fever in Children

• Seizures, difficulty to stay awake, and stiff neck
• Toxic appearance, listlessness
• Lethargy 
• Irritability 
• Dehydration 
• Severe malnutrition 
• Toxic appearance 
• 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, bleeding from nose or gums, vomiting blood, black stools, heavy menstruation/vaginal bleeding  - Petechiae or purpura
• Frequent vomiting 
• Severe abdominal pain 
• Drowsiness, mental confusion, or seizures 
• Pale, cold, or clammy hands and feet 
• Difficulty breathing - 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

Admission Criteria for Dengue fever

• 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% 
• 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) with the following criteria:

• 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/Guillane-Barre Syndrome • Transverse myelitis 
• Gastrointestinal system :  Hepatitis/fulminant hepatic failure • Acalculous cholecystitis • Acute pancreatitis • Hyperplasia of Peyer’s patches • Acute parotitis 
• Kidney : Acute renal failure • 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 purura (ITP) • Spontaneous splenic rupture • Lymph node infarction
• Eye - Macular haemorrhage • Impaired visual acuity • Optic neuritis

INDICATIONS FOR PLATELET TRANSFUSION

• For adults: platelets < 40000 and with bleeding symptoms
• Platelet count less than 10000.
• 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 here . Accessed on: 03 September 2021
• National Health Mission. Guidelines for management of dengue fever. Available at: https://www.nhm.gov.in/images/pdf/ guidelines/nrhm-guidelines/stg/dengue.pdf. Accessed on: 03 September 2021

Admission Criteria for Pneumonia in Children

Important Signs

• Cough , cold with or without Fever, that includes fast breathing and chest indrawing
• Along with inability to drink or persistent vomiting or convulsions or lethargy/unconscious, Stridor or severe Malnutrition
• Admission justified in severe pneumonia as per ICMR protocols

References

Admission Criteria for Pneumonia in Adult

• Breathlessness, Pleuritic Chest pain, Malaise, arthralgia, Hemoptysis
• Criticality parameters – Respiratory Rate - >30/min, Abdominothoracic respiration, Cyanosis, Inability to speak long sentences
• ARDS 
• Breathlessness at rest or on exertion 
• Oxygen saturation less than 92%
• With COPD or Interstitial lung disease or any restrictive lung disease
• Admission – Score 1 to 4 are advised admission as per ICMR protocols

References 

Admission Criteria in Diarrhea/Acute Gastroenteritis

• >3 loose or watery stools per day or blood in stool (Dysentery)
• And any 2 of the following signs
  • Lethargy/Unconscious
  • Sunken eyes
  • Not able to Drink/Drinking poorly
  • Skin pinch – goes back slowly 

Admission Criteria for Hepatitis / other Jaundice

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

References

Admission criteria for Acute Rhinosinusitis /URI

• Known Diabetic /Immunocompromised
• Suspicion of Complications like 
  • Orbital involvement (Periorbital edema/Erythema, Displaced globe, Ophthalmoplegia, Visual Disturbances)
  • Meningitis/ Altered Sensorium
  • Frontal Fullness
• Non Resolution with Oral antibiotics for 7 days
• Pointers for invasive Fungal sinusitis (Facial Hypoesthesia, facial skin,/palatal/turbinate discoloration)

References:

Reference 1 - Refer Pg8 

Reference 2

The participating hospitals are requested to take herewith the above guidelines for admission and basic treatment as a guidepost to decide upon admission and basic treatment for the commonly encountered fevers and infections as mentioned above – in exceptional cases the protocol may be decided by the treating Doctor as the case may be and depending on the clinical scenario and clinical features of the patient. 

Request that any deviation from the above published guidelines should be justified clinically and supported with any suitable nationally or internationally accepted published guidelines.