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Pr Christian Chidiac Department of Infectious and Tropical Diseases Hôpital de la Croix Rousse F69317 Lyon christian.chi

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 christian.chidiac@chu-lyon.fr. Aim of the presentation. To present and discuss guidelines

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Pr Christian Chidiac Department of Infectious and Tropical Diseases Hôpital de la Croix Rousse F69317 Lyon christian.chi

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  1. 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 christian.chidiac@chu-lyon.fr

  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 • 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

  4. 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. 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

  7. 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

  8. 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

  9. VaricellaAntiviral 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. VaricellaAntiviral 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 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

  13. Herpes 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)

  14. Herpes 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

  15. 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)

  16. 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

  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

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