Pr Christian ChidiacDepartment of Infectious and Tropical DiseasesHôpital de la Croix Rousse F69317 [email protected]
Pr Christian ChidiacDepartment of Infectious and Tropical DiseasesHôpital de la Croix Rousse F69317 [email protected]
Management of VZV infections :Current guidelines
Management of VZV infections :Current guidelines
ECC RICAIParis December 1-3, 2004
Aim of the presentationAim of the presentation
To present and discuss guidelines
For treatment and prophylaxis of Varicella and herpes zoster
• For immunocompetent pts
• For immunocompromised pts
Neonates management and vaccine are
excluded from this presentation
To present and discuss guidelines
For treatment and prophylaxis of Varicella and herpes zoster
• For immunocompetent pts
• For immunocompromised pts
Neonates management and vaccine are
excluded from this presentation
IHMF : International Herpes Manag²ement Forum
www.ihmf.org
SPILF (French Society for Infectious Diseases) Med mal inf 1998;28:692-712
British Society for the Study of Infection J infect 1998 36(suppl1):31-38
German Dermatology Society J Clin Vir 2003;26:277-289
IHMF : International Herpes Manag²ement Forum
www.ihmf.org
SPILF (French Society for Infectious Diseases) Med mal inf 1998;28:692-712
British Society for the Study of Infection J infect 1998 36(suppl1):31-38
German Dermatology Society J Clin Vir 2003;26:277-289
Main referencesMain references
IntroductionIntroduction
VZV causes 2 distinct clinical diseases Varicella or chickenpox
• Occurs in 90% children < 13 years
Herpes zoster or shingles• Recurrent localized infection• Occurs likely in elderly
Complications : More severe : Immunocompromised host +++ Elderly : PHN after herpes zoster
VZV causes 2 distinct clinical diseases Varicella or chickenpox
• Occurs in 90% children < 13 years
Herpes zoster or shingles• Recurrent localized infection• Occurs likely in elderly
Complications : More severe : Immunocompromised host +++ Elderly : PHN after herpes zoster
Management of varicella in the immunocompetent host
Management of varicella in the immunocompetent host
VaricellaAntiviral treatment for healthy children VaricellaAntiviral treatment for healthy children
Oral aciclovir (ACV) Recommended by IHMF
20 mg/kg up to 800 mg/d for 5 d
Not recommended in French guidelines (SPILF) Not a severe disease Risk of viral resistance related to antiviral use No evidence that ACV may prevent complication Cost/effectiveness not established in France
Oral aciclovir (ACV) Recommended by IHMF
20 mg/kg up to 800 mg/d for 5 d
Not recommended in French guidelines (SPILF) Not a severe disease Risk of viral resistance related to antiviral use No evidence that ACV may prevent complication Cost/effectiveness not established in France
VaricellaAntiviral for adults and adolescents (1)VaricellaAntiviral for adults and adolescents (1)
Recommended by IHMF Complications more likely and frequently more serious
than in children
Secondary cases more severe in households
Oral ACV 800 mg four to five times daily 5-7 d
V-ACV and FCV likely to be as effective as ACV• But no controlled trials
Not recommended by SPILF as routine
Recommended by IHMF Complications more likely and frequently more serious
than in children
Secondary cases more severe in households
Oral ACV 800 mg four to five times daily 5-7 d
V-ACV and FCV likely to be as effective as ACV• But no controlled trials
Not recommended by SPILF as routine
VaricellaAntiviral for adults and adolescents (2)VaricellaAntiviral for adults and adolescents (2)
Varicella-associated pneumonia :
Recommended by IHMF and SPILF
• Whether pregnant or not (IHMF)
• IV ACV 10 mg/kg/8h
More severe cases in adults and adolescents and
other at-risk individuals
Antiviral treatment recommended by IHMF as a priority
Varicella-associated pneumonia :
Recommended by IHMF and SPILF
• Whether pregnant or not (IHMF)
• IV ACV 10 mg/kg/8h
More severe cases in adults and adolescents and
other at-risk individuals
Antiviral treatment recommended by IHMF as a priority
VaricellaAntiviral for pregnant womenVaricellaAntiviral for pregnant women Recommended by IHMF
Oral ACV, V-ACV or FCV When varicella occurs in their second or third trimester BUT
• Recommendation based on anecdotal evidence• Drugs no licensed for use during pregnancy
SPILF Not recommended as routine But in case of risk of delivery in days following the rash
Severe and/or complicated varicella Recommended by IHMF and SPILF
Recommended by IHMF Oral ACV, V-ACV or FCV When varicella occurs in their second or third trimester BUT
• Recommendation based on anecdotal evidence• Drugs no licensed for use during pregnancy
SPILF Not recommended as routine But in case of risk of delivery in days following the rash
Severe and/or complicated varicella Recommended by IHMF and SPILF
VaricellaAntiviral for pts with serious complicationsVaricellaAntiviral for pts with serious complications
Cerebral ataxia, varicella-associated pneumonia, VZV encephalitis and cutaneous bacterial complications
Recommended by IHMF IV ACV 10 mg/kg Based on anecdotal evidence
Recommended by SPILF ACV licensed for severe manifestations of VZV
infections
Cerebral ataxia, varicella-associated pneumonia, VZV encephalitis and cutaneous bacterial complications
Recommended by IHMF IV ACV 10 mg/kg Based on anecdotal evidence
Recommended by SPILF ACV licensed for severe manifestations of VZV
infections
Management of herpes zoster in immunocompetent host
Management of herpes zoster in immunocompetent host
Herpes zosterMain problem is PainHerpes zosterMain problem is Pain
Definition Zoster Associated Pain (ZAP) :
• a continuum of pain from prodrome to PHN and as long as pain persists
Postherpetic Neuralgia (PHN) :• Established persisting pain and/or
dysaesthesia
Definition Zoster Associated Pain (ZAP) :
• a continuum of pain from prodrome to PHN and as long as pain persists
Postherpetic Neuralgia (PHN) :• Established persisting pain and/or
dysaesthesia
Herpes zosterAntiviral therapyHerpes zosterAntiviral therapy
Recommended by IHMF, SPILF, German guidelines For immunocompetent adults > 50 years Within 72 hours of lesion onset Oral route
• V-ACV 1000 mg three times a days, 7 d• FCV 250 or 500 mg three times a day• ACV 800 mg five time a day not preferred • Brivudin 125 mg once a day (Germany)
Recommended by IHMF, SPILF, German guidelines For immunocompetent adults > 50 years Within 72 hours of lesion onset Oral route
• V-ACV 1000 mg three times a days, 7 d• FCV 250 or 500 mg three times a day• ACV 800 mg five time a day not preferred • Brivudin 125 mg once a day (Germany)
Herpes zosterSteroidsHerpes zosterSteroids
Recommended by IHMF and German guidelines To reduce the inflammation that may contribute
to acute pain Provided there are no contra-indications Reduce acute symptoms and may facilitate
return to normal quality of life But do not prevent PHN
Recommended by IHMF and German guidelines To reduce the inflammation that may contribute
to acute pain Provided there are no contra-indications Reduce acute symptoms and may facilitate
return to normal quality of life But do not prevent PHN
Herpes zosterAcute pain (1)Herpes zosterAcute pain (1) Main cases
1st step : non steroidal analgesics (e.g. paracetamol) 2nd step : additional low potency opioid analgesic
(tramadol, codein) in combined preparations if needed 3rd step : in addition to a peripheral analgesic,
administration of high-potency central opioid (e.g. buprenorphine, oral morphine)
Severe neuralgic pain Anti-convulsivants (carbamazepine) Gabapentine Antidepressants amitryptillin and neuroleptics
(levomepromazin)
Main cases 1st step : non steroidal analgesics (e.g. paracetamol) 2nd step : additional low potency opioid analgesic
(tramadol, codein) in combined preparations if needed 3rd step : in addition to a peripheral analgesic,
administration of high-potency central opioid (e.g. buprenorphine, oral morphine)
Severe neuralgic pain Anti-convulsivants (carbamazepine) Gabapentine Antidepressants amitryptillin and neuroleptics
(levomepromazin)
Herpes zosterAcute pain (2)Herpes zosterAcute pain (2)
German guidelines
Early presentation to pain therapist or pain outpatient
clinic is suggested
IHMF, SPILF
Presence of risk factors for the development of PHN
should be assessed and documented for each patient
German guidelines
Early presentation to pain therapist or pain outpatient
clinic is suggested
IHMF, SPILF
Presence of risk factors for the development of PHN
should be assessed and documented for each patient
Management of VZV infections in immunocompromised host
Management of VZV infections in immunocompromised host
VZV infections in immunocompromised pts Antiviral treatment (1)VZV infections in immunocompromised pts Antiviral treatment (1)
IHMF, SPILF, German guidelines, UK* : IV ACV therapy is the standard of care
for imunocompromised patients with disseminated VZV disease, including those with complications such as
varicella pneumonia Recommended dose
Adults : 10 mg/kg every 8 h Children
• UK, France : 500 mg/m2 body surface area every 8 h• USA : 20 mg/kg every 8 h
IHMF, SPILF, German guidelines, UK* : IV ACV therapy is the standard of care
for imunocompromised patients with disseminated VZV disease, including those with complications such as
varicella pneumonia Recommended dose
Adults : 10 mg/kg every 8 h Children
• UK, France : 500 mg/m2 body surface area every 8 h• USA : 20 mg/kg every 8 h
* varicella
VZV infections in immunocompromised pts Antiviral treatment (2)VZV infections in immunocompromised pts Antiviral treatment (2)
IHMF, SPILF : Oral antiviral therapy Anecdotal evidence suggests that oral antiviral
therapy may be appropriate for the treatment of VZV disease in some immunocompromised individuals Varicella (IHMF) Herpes zoster (IHMF, SPILF), specially for segmented
herpes zoster without any dissemination, and with moderate immunosuppression (e.g HIV pts with CD4 > 200/mm3)
IHMF, SPILF : Oral antiviral therapy Anecdotal evidence suggests that oral antiviral
therapy may be appropriate for the treatment of VZV disease in some immunocompromised individuals Varicella (IHMF) Herpes zoster (IHMF, SPILF), specially for segmented
herpes zoster without any dissemination, and with moderate immunosuppression (e.g HIV pts with CD4 > 200/mm3)
ProphylaxisProphylaxis
Post exposure prophylaxisPost exposure prophylaxis
VZV immune globulin should be considered as soon as possible after exposure to varicella (< 72 h) for Immunocompromised individuals (IHMF, UK) Pregnant woman (IHMF, SPILF, UK)
Oral ACV recommended for pregnant woman (IHMF) Suppressive antiviral therapy (IV ACV) should be
considered for : Transplant pts (BMT) : (IHMF) Pts with immunosuppression for GVHD : (IHMF) Stem cell transplant recipient : (SPILF)
VZV immune globulin should be considered as soon as possible after exposure to varicella (< 72 h) for Immunocompromised individuals (IHMF, UK) Pregnant woman (IHMF, SPILF, UK)
Oral ACV recommended for pregnant woman (IHMF) Suppressive antiviral therapy (IV ACV) should be
considered for : Transplant pts (BMT) : (IHMF) Pts with immunosuppression for GVHD : (IHMF) Stem cell transplant recipient : (SPILF)
ConclusionConclusion
Conclusion Conclusion
Guidelines may differ among countries IV ACV is the standard of care for severe
VZV infections Oral antiviral therapy :
Recommended for pts > 50 years with herpes zoster to prevent PHN
Discussed for varicella in non compromised host and for prophylaxis
Guidelines may differ among countries IV ACV is the standard of care for severe
VZV infections Oral antiviral therapy :
Recommended for pts > 50 years with herpes zoster to prevent PHN
Discussed for varicella in non compromised host and for prophylaxis