BNF for Children 2011-2012

322 5.3.2 Herpesvirus infections BNFC 2011–20125 InfectionsSpecialist advice should be sought for systemic treatmentof herpes simplex infection in pregnancy.Varicella–zoster infections Regardless of immunefunction and the use of any immunoglobulins, neonateswith chickenpox should be treated with a parenteralantiviral to reduce the risk of severe disease. Oraltherapy is not recommended as absorption is variable.Chickenpox in otherwise healthy children between 1month and 12 years is usually mild and antiviral treatmentis not usually required. Chickenpox is more severein adolescents than in children; antiviral treatmentstarted within 24 hours of the onset of rash may reducethe duration and severity of symptoms in otherwisehealthy adolescents. Antiviral treatment is generallyrecommended in immunocompromised patients andthose at special risk (e.g. because of severe cardiovascularor respiratory disease or chronic skin disorder); insuch cases, an antiviral is given for 10 days with at least7 days of parenteral treatment.In pregnancy severe chickenpox may cause complications,especially varicella pneumonia. Specialist adviceshould be sought for the treatment of chickenpox duringpregnancy.Neonates and children who have been exposed tochickenpox and are at special risk of complicationsmay require prophylaxis with varicella-zoster immunoglobulin(see under Disease-specific Immunoglobulins,section 14.5.2). Prophylactic intravenous aciclovirshould be considered for neonates whose mothersdevelop chickenpox 4 days before to 2 days afterdelivery.In herpes zoster (shingles) systemic antiviral treatmentcan reduce the severity and duration of pain, reducecomplications, and reduce viral shedding. Treatmentwith the antiviral should be started within 72 hours ofthe onset of rash and is usually continued for 7–10 days.Immunocompromised patients at high risk of disseminatedor severe infection should be treated with a parenteralantiviral drug. Chronic pain which persists afterthe rash has healed (postherpetic neuralgia) requiresspecific management (section 4.7.3).Choice Aciclovir is active against herpesviruses butdoes not eradicate them. Uses of aciclovir include systemictreatment of varicella–zoster and the systemicand topical treatment of herpes simplex infections ofthe skin (section 13.10.3) and mucous membranes (section7.2.2). It is used by mouth for severe herpeticstomatitis (see also p. 545). Aciclovir eye ointment (section11.3.3) is used for herpes simplex infections of theeye; it is combined with systemic treatment forophthalmic zoster.Famciclovir, a prodrug of penciclovir, is similar toaciclovir and is licensed in adults for use in herpeszoster and genital herpes; there is limited informationavailable on use in children. Penciclovir itself is used as acream for herpes simplex labialis (section 13.10.3).Valaciclovir is an ester of aciclovir, licensed in adults forherpes zoster and herpes simplex infections of the skinand mucous membranes (including genital herpes); it isalso licensed in children over 12 years for preventingcytomegalovirus disease following solid organ transplantation.Valaciclovir may be used for the treatmentof mild herpes zoster in immunocompromised childrenover 12 years; treatment should be initiated underspecialist supervision.ACICLOVIR(Acyclovir)Cautions maintain adequate hydration (especially withinfusion or high doses, or during renal impairment);interactions: Appendix 1 (aciclovir)Renal impairment see Cautions above; also risk ofneurological reactions increased; use normal intravenousdose every 12 hours if estimated glomerularfiltration rate 25–50 mL/minute/1.73 m 2 (every 24hours if estimated glomerular filtration rate 10–25 mL/minute/1.73 m 2 ); consult product literature forintravenous dose if estimated glomerular filtrationrate less than 10 mL/minute/1.73 m 2 . For herpeszoster, use normal oral dose every 8 hours if estimatedglomerular filtration rate 10–25 mL/minute/1.73 m 2 (every 12 hours if estimated glomerular filtrationrate less than 10 mL/minute/1.73 m 2 ). Forherpes simplex, use normal oral dose every 12 hours ifestimated glomerular filtration rate less than 10 mL/minute/1.73 m 2Pregnancy not known to be harmful—manufacturersadvise use only when potential benefit outweighs riskBreast-feeding significant amount in milk after systemicadministration; not known to be harmful butmanufacturers advise cautionSide-effects nausea, vomiting, abdominal pain, diarrhoea,headache, fatigue, rash, urticaria, pruritus,photosensitivity; very rarely hepatitis, jaundice, dyspnoea,neurological reactions (including dizziness,confusion, hallucinations, convulsions, ataxia, dysarthria,and drowsiness), acute renal failure, anaemia,thrombocytopenia, and leucopenia; on intravenousinfusion, severe local inflammation (sometimes leadingto ulceration), and very rarely agitation, tremors,psychosis and feverLicensed use tablets and suspension not licensed forsuppression of herpes simplex or for treatment ofherpes zoster in children (age range not specified bymanufacturer); intravenous infusion not licensed forherpes zoster in children under 18 years; tablets andsuspension not licensed for attenuation of chickenpox(if varicella-zoster immunoglobulin not indicated)in children under 18 yearsIndication and doseHerpes simplex treatment. By mouthChild 1 month–2 years 100 mg 5 times daily,usually for 5 days (longer if new lesions appearduring treatment or if healing incomplete); dosedoubled if immunocompromised or if absorptionimpairedChild 2–18 years 200 mg 5 times daily, usually for5 days (longer if new lesions appear during treatmentor if healing incomplete); dose doubled ifimmunocompromised or if absorption impaired. By intravenous infusionNeonate 20 mg/kg every 8 hours for 14 days (21days if CNS involvement)Child 1–3 months 20 mg/kg every 8 hours for 14days (21 days if CNS involvement)Child 3 months–12 years 250 mg/m 2 every 8hours usually for 5 days, doubled to 500 mg/m 2every 8 hours if CNS involvement (given for up to21 days) or if immunocompromised