Varicelle : personnes

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_at_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 199828692-712
• British Society for the Study of Infection
• J infect 1998 36(suppl1)31-38
• German Dermatology Society
• J Clin Vir 200326277-289

4
Introduction

• VZV causes 2 distinct clinical diseases
• Varicella or chickenpox
• Occurs in 90 children lt 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 gt 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 gt 200/mm3)

20
Prophylaxis
21
Post exposure prophylaxis

• VZV immune globulin should be considered as soon
  as possible after exposure to varicella (lt 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 gt 50 years with herpes zoster
  to prevent PHN
• Discussed for varicella in non compromised host
  and for prophylaxis