Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

symptomatic patients

1st line – supportive care

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ACUTE
|
symptomatic patients
1st line – 

supportive care

There is no specific antiviral treatment for VEEV infection.

Initial treatment for symptomatic patients is supportive care. Most cases of VEEV infection result in symptoms resembling influenza or dengue fever (e.g., acute onset fever, headache, malaise) that are mild in severity and self-limiting, and require only supportive therapy.

Mild infection is managed with ample oral fluid intake (i.e., enough fluids to be passing clear urine), and antipyretics and/or analgesics (e.g., paracetamol).

Pregnant women with VEEV infection are monitored carefully, because of reports of stillbirth and spontaneous abortion associated with maternal VEEV infection.[32]

Primary options

paracetamol: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Plus – oral or intravenous fluids + anti-emetic

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ACUTE
|
symptomatic patients
|
with vomiting and diarrhoea
Plus – 

oral or intravenous fluids + anti-emetic

Treatment recommended for ALL patients in selected patient group

Vomiting occurs in around 55% to 60% of patients with VEEV infection and diarrhoea occurs in around 23% of patients.​[4][5]​​[27]

If there is severe dehydration due to vomiting and diarrhoea, the patient is hospitalised, if possible, and oral or intravenous fluids (crystalloids e.g., normal saline or Ringer’s lactate solution) are administered along with an anti-emetic agent (e.g., ondansetron).

Initial administration of a single oral dose of ondansetron may obviate the need for intravenous fluids or hospitalisation in children.[41] Other anti-emetics are not recommended due to lack of benefit and risk of adverse effects. 

Primary options

ondansetron: children ≥6 months of age and 8-15 kg body weight: 2 mg orally as a single dose; children 15-30 kg body weight: 4 mg orally as a single dose; children >30 kg body weight and adults: 6-8 mg orally as a single dose

Plus – hospitalisation + further supportive care

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ACUTE
|
symptomatic patients
|
with neurological involvement
Plus – 

hospitalisation + further supportive care

Treatment recommended for ALL patients in selected patient group

Patients with neurological involvement (e.g., encephalitis) are hospitalised and a neurologist consulted, if possible.

Neurological complications resulting from encephalitis (e.g., disorientation, ataxia, and seizures) are seen in up to 14% of patients with VEEV infection, with highest prevalence in children.[30]​​

If the patient has altered mental status (e.g., obtundation) the airway is secured by intubation and mechanical ventilation is initiated.

A cranial nerve examination, fundoscopic examination, and head CT or brain MRI is performed to evaluate for cerebral oedema and elevated intracranial pressure. If intracranial pressure is elevated, head elevation, hyperventilation, and intravenous mannitol may be considered to reduce pressure.[42]

Primary options

mannitol: children: 0.25 to 1 g/kg intravenously initially, followed by 0.25 to 0.5 g/kg every 4 hours; adults: 1-2 g/kg intravenously initially, followed by 0.25 to 1 g/kg every 4 hours

Plus – anticonvulsant

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ACUTE
|
symptomatic patients
|
with neurological involvement
Plus – 

anticonvulsant

Treatment recommended for ALL patients in selected patient group

Patients with neurological involvement are evaluated for seizures, and anticonvulsants administered if there is seizure activity or a history of seizures.

Benzodiazepines are preferred for the initial management of seizures, with lorazepam being most effective due to its long half-life.

Phenytoin is recommended if a second drug is needed to terminate seizures. In pregnant women, phenytoin is only used in life-threatening infection, because it is potentially teratogenic.

Serum drug levels are monitored to ensure that therapeutic levels are achieved.

Primary options

lorazepam: children: 0.05 to 0.1 mg/kg (maximum 4 mg/dose) intravenously as a single dose initially, may repeat once in 10-15 minutes if necessary; adults: 4 mg intravenously as a single dose initially, may repeat once in 10-15 minutes if necessary

Secondary options

phenytoin: children and adults: 15-20 mg/kg intravenously as a loading dose, followed by 5-10 mg/kg as a single dose if necessary; consult specialist for guidance on maintenance dose

Plus – aciclovir

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ACUTE
|
symptomatic patients
|
with neurological involvement
Plus – 

aciclovir

Treatment recommended for ALL patients in selected patient group

Treatment with intravenous aciclovir, to cover for possible herpes simplex virus infection, is recommended in patients with cerebrospinal fluid or imaging findings suggesting viral encephalitis; or if these results will not be available within 6 hours; or if the patient is deteriorating.[39]

Primary options

aciclovir: children: 10-20 mg/kg intravenously every 8 hours; adults: 10 mg/kg intravenously every 8 hours

Plus – empirical antibiotic therapy

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ACUTE
|
symptomatic patients
|
with neurological involvement
Plus – 

empirical antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Empirical antibiotic therapy should be started until bacterial encephalitis has been ruled out.[38]

Appropriate antibiotics should be guided by local protocols, but should be broad-spectrum.

Plus – blood transfusion + fluid resuscitation

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ACUTE
|
symptomatic patients
|
with haemorrhage
Plus – 

blood transfusion + fluid resuscitation

Treatment recommended for ALL patients in selected patient group

If a patient has a history of haemorrhage, the severity of the bleeding is assessed and the source investigated. Nasogastric aspiration may help to identify the source of the bleeding (to differentiate upper versus lower gastrointestinal (GI) bleeding). It is unclear whether bleeding may be stopped by endoscopic or surgical methods, but GI and surgical consultations are warranted.

Serial haemoglobin (Hb) measurements are performed. Blood transfusion and fluid resuscitation are usually initiated if Hb is <7 g/dL (<4.3 mmol/L). Blood transfusions are administered with the goal of maintaining Hb ≥7g/dL (≥4.3 mmol/L).

Intravenous access is established with bilateral, peripheral, large bore (16 g) intravenous lines, and fluid resuscitation commenced with crystalloids or colloids (administer 3 mL for every 1 mL lost).

If bleeding is brisk and the patient is hypovolemic, blood transfusions can be considered even if Hb is normal (i.e., 13.5 to 17.5 g/dL for men; 12.0 to 15.5 g/dL for women).

For patients with comorbidities that put them at risk of fluid overload (e.g., heart failure), monitoring by pulmonary artery catheter may be necessary.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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