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ECC RICAI
Paris December 1-3, 2004
Management of VZV infections :
Current guidelines
Pr Christian Chidiac
Department of Infectious and Tropical Diseases
Hôpital de la Croix Rousse F69317 Lyon
[email protected]
Aim 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
Main references

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
Introduction
 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
Varicella
Antiviral 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
Varicella
Antiviral 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
Varicella
Antiviral 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
Antiviral 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
Varicella
Antiviral 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
Management of herpes zoster in
immunocompetent host
Herpes zoster
Main 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
Herpes zoster
Antiviral 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)
Herpes zoster
Steroids
 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 zoster
Acute 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)
Herpes zoster
Acute 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
Management of VZV infections in
immunocompromised host
VZV infections in immunocompromised pts
Antiviral treatment (1)


IHMF, SPILF, German guidelines, UK* :
IV ACV therapy is the standard of care

Recommended dose
 for imunocompromised patients
 with disseminated VZV disease,
 including those with complications such as
varicella pneumonia
 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)



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)
Prophylaxis
Post 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)
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