Table 36.1Treatment of HSV infections

Infections in immunosuppressed patients
Acute symptomatic first or recurrent episodes: IV acyclovir (5 mg/kg q 8 h), or oral acyclovir (400 mg qid), famciclovir (500 mg po tid) or valacyclovir (500 mg po bid). Treatment duration may vary from 7 to 14 days.
Suppression of reactivation disease: IV acyclovir (5 mg/kg q 8 h), valacyclovir (500 mg po bid) or oral acyclovir (400–800 mg 3–5 times per day) prevent recurrences during the immediate 30 day post transplantation period. Longer term suppression is often used for persons with continued immunosuppression. In bone marrow and renal transplant patients, valacyclovir 2 grams 4 times daily is also effective in preventing CMV infection (Dignani et al., 2002, Lowance et al.,1999). Valacyclovir 8 gm daily has been associated with thrombotic microangiopathy after extended use in HIV positive persons (Bell et al., 1997). In HIV-infected persons, oral famciclovir (500 mg bid) is effective in reducing clinical and subclinical reactivations of HSV-1 and 2, and valacyclovir 500mg bid decreases the frequency of genital HSV-2 recurrences (Schacker et al., 1998a, Romanowski et al., 2000, DeJesus et al., 2003).
Genital herpes
First episodes: Oral acyclovir (200 mg 5 times per day or 400 mg tid), oral valacyclovir (1000 mg bid) or famciclovir (250 mg bid) for 10–14 days are effective. IV acyclovir (5 mg/kg q 8 h for 5 days) is given for severe disease or neurologic complications such as aseptic meningitis.
Symptomatic recurrent genital herpes: Oral acyclovir (200 mg 5 times per day for 5 days, 800 mg po tid for 2 days), valacyclovir (500 mg bid for 3 or 5 days) or famciclovir (125 mg bid for 5 days). All these therapies are effective in shortening duration of lesions, viral shedding and symptoms.
Suppression of recurrent genital herpes: Oral acyclovir (200-mg capsules bid or tid, 400 mg bid, or 800 mg qd), famciclovir (250 mg bid), or valacyclovir (500 mg or 1000 mg qd or 500 mg bid) prevents symptomatic reactivation. Persons with frequent reactivation (<9 episodes) can take 500 mg daily; those with >9 should take 1000 mg/daily or 500 mg bid (Reitano et al., 1998).
Oral-labial HSV infections:
First episode: Oral acyclovir (200 mg) is given 4 or 5 times per day. Famciclovir (250 mg bid) or valacyclovir (1000 mg bid) has been used clinically.
Recurrent episodes: Valacyclovir 1000 mg bid for 1 day or 500 mg bid for 3 days is effective in reducing pain and speeding healing. Self-initiated therapy with 6 times daily topical penciclovir cream is effective in speeding the healing of oral-labial HSV, topical acyclovir cream has also been shown to speed healing (Spruance et al., 1997).
Suppression of reactivation of oral-labial HSV: Oral acyclovir (400 mg bid), if started before exposure and continued for the duration of exposure (usually 5–10 days), will prevent reactivation of recurrent oral-labial HSV infection associated with severe sun exposure (Spruance et al., 1988).
Herpetic whitlow: Regimens used for treating genital herpes can be utilized but clinical trial data are lacking.
HSV proctitis: Oral acyclovir (400 mg 5 times per day) is useful in shortening the course of infection (Rompalo et al., 1988); less frequent dosing is also likely to be effective. In immunosuppressed patients or in patients with severe infection, IV acyclovir (5 mg/kg q 8 h) may be useful.
Herpetic eye infections: In acute keratitis, topical trifluorothymidine, vidarabine, idoxuridine, acyclovir, penciclovir, and interferon are all beneficial. Debridement may be required; topical steroids may worsen disease.
CNS HSV infections
HSV encephalitis: Intravenous acyclovir (10 mg/kg q 8 h; 30 mg/kg per day) for 10 days is preferred.
HSV aseptic meningitis: No studies of systemic antiviral chemotherapy exist. If therapy is to be given, IV acyclovir (15–30 mg/kg per day) should be used in severely affected patients, followed by oral course of valacyclovir.
Autonomic radiculopathy: No studies are available.
Neonatal HSV infections: Acyclovir (60 mg/kg per day, divided into 3 doses) is given. The recommended duration of treatment is 21 days. Monitoring for relapse should be undertaken and some authorities recommend continued suppression with oral acyclovir suspension for 3 to 4 months (Kimberlin et al., 1996).
Visceral HSV infections
HSV esophagitis: Ⅳ acyclovir (15 mg/kg per day). In some patients with a milder degree of immunosuppression, oral therapy with valacyclovir or famciclovir is effective.
HSV pneumonitis: No controlled studies exist. IV acyclovir (15 mg/kg per day) should be considered.
Disseminated HSV infections: No controlled studies exist. Intravenous acyclovir nevertheless should be tried, and in some cases has been reported to result in survival.

From: Chapter 36, Persistence in the population: epidemiology, transmission

Cover of Human Herpesviruses
Human Herpesviruses: Biology, Therapy, and Immunoprophylaxis.
Arvin A, Campadelli-Fiume G, Mocarski E, et al., editors.
Cambridge: Cambridge University Press; 2007.
Copyright © Cambridge University Press 2007.

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