1. Management of VZV infections :
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

2. 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

3. Main references IHMF : International Herpes Manag²ement Forum
SPILF (French Society for Infectious Diseases)
Med mal inf 1998;28:
British Society for the Study of Infection
J infect (suppl1):31-38
German Dermatology Society
J Clin Vir 2003;26:

4. VZV causes 2 distinct clinical diseases
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

5. Management of varicella in the immunocompetent host

6. 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

7. 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

8. 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

9. 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

10. 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

11. Management of herpes zoster in immunocompetent host

12. 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

13. 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)

14. 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

15. 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)

16. 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

17. Management of VZV infections in immunocompromised host

18. 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
* varicella

19. 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)

20. Prophylaxis

21. 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)

22. Conclusion

23. 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