› Hydration and nutrition
› Oral hydration strategies
› Frequent small volumes
› Electrolyte solutions if vomiting or diarrhea
› IV fluids for dehydration
› 0.9% sodium chloride 10 to 20 mL/kg bolus
› Reassess after each bolus
› Repeat as needed based on perfusion and urine output
› Analgesia and antipyresis
› Acetaminophen
› 15 mg/kg PO q6h PRN
› Maximum 60 mg/kg/day
› Adult maximum 3000 mg/day when outpatient
› Ibuprofen
› 10 mg/kg PO q6h to q8h PRN
› Maximum 40 mg/kg/day
› Adult maximum 2400 mg/day OTC aligned dosing
› Avoid acetaminophen overdose in hepatitis
› Use lowest effective dose
› Review combination cold products
Corticosteroids and escalation therapies
› Steroids are not routine for uncomplicated infectious mononucleosis
› Evidence quality mixed and routine symptom benefit not established
› Use limited to severe complications
› Indications for corticosteroids
› Impending airway obstruction from tonsillar hypertrophy
› Dexamethasone 10 mg IV or IM once
› Pediatrics 0.6 mg/kg IV or IM once
› Maximum 10 mg
› Prednisone 40 to 60 mg PO daily for 3 to 5 days as alternative
› Taper usually not required for short course
› Severe hemolytic anemia or severe thrombocytopenia
› Prednisone 1 mg/kg/day PO
› Hematology consultation for duration and taper
› IVIG consideration if refractory thrombocytopenia
Antimicrobials and co infection
› Antibiotics only for proven bacterial co infection
› Group A streptococcal pharyngitis positive testing
› Penicillin V 500 mg PO BID for 10 days
› Pediatric dosing per weight based local standard
› Avoid in true penicillin allergy
› Cephalexin 500 mg PO BID for 10 days if non anaphylactic penicillin allergy
› Avoid if immediate hypersensitivity history
› Azithromycin 500 mg PO day 1 then 250 mg PO daily days 2 to 5 if anaphylactic beta lactam allergy
› Local resistance considerations
› QT risk review
› Avoid aminopenicillins in suspected EBV infection
› Amoxicillin associated rash common in EBV
› Rash is not reliably a true IgE mediated allergy
Activity restriction and prevention
› Splenic rupture risk mitigation
› No contact sports and no collision activities for at least 3 weeks from symptom onset
› Longer restriction if persistent symptoms
› Shared decision making for return to play
› Avoid heavy lifting during early illness
› Increased intraabdominal pressure risk
› Gradual return with symptom guided progression
› Transmission reduction
› Avoid sharing drinks and utensils
› Avoid kissing while symptomatic and early convalescence
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