NUH Guide to the Clinical Management of Chicken Pox in Adults

Adapted from the BIS draft algorithm published March 2007 www.britishinfectionsociety.org
Box 1

Y


Patient unwell, with new
chicken pox vesicles
within last 24-48 hrs?
N
Symptomatic treatment only, monitor
for signs of severe infection (Box 2)
Pregnant? Y
N
Signs of severe
infection? (Box 2)
Give oral Aciclovir
800mg x 5/day for 7
days (Box 3) and
monitor for signs of
severe infection
Signs of severe infection? (Box 2)

Other risk factors for pneumonitis?
- smoker, chronic lung disease?

N
Y
N
Admit to isolation bed in hospital for
regular monitoring by staff known to be
immune (inform Infection Control)
Consider IV Aciclovir (10mg/kg tds)
Check LFTs, renal function and clotting
for DIC
Review CXR for evidence of
pneumonitis, monitor pO2
If temp fails to settle consider possible
2
o
Staph. aureus infection
Switch to oral therapy as soon as
possible
Immunocompromised?

Current chemo-/radiotherapy, or
within last 6/12 (12/12 for Bone
marrow transplant)

Steroids (>5mg/day) within last
3/12

On Azathioprine or Methotrexate
Box 3
Y
Y
N
Give oral treatment (Box 3) +
symptomatic relief
Advise re infection risk (Box 1)
Monitor for severe infection (Box 2)
Y
Oral Treatment:

Valaciclovir 1g tds 7 days
or Aciclovir 800mg x5/day

(NB: bioavailability of oral Aciclovir is poor)

Intravenous treatment:
Aciclovir 10mg/kg tds

Renal impairment: dose reduction required for
all forms of Aciclovir
5


Pregnancy: No adverse data for use of
Aciclovir, data inadequate for Valaciclovir
5


Chicken pox is the primary systemic infection with Varicella-Zoster virus (VZV)

Acute systemic VZV has increased mortality and morbidity in adolescents and adults compared to
children
1
. Immunocompromised adults and non-immune pregnant women are at particular risk
2

Prompt treatment with Aciclovir reduces duration and severity of symptoms
3

There is no evidence of benefit of Aciclovir once the rash has been established for >48hrs
3

Infectivity: 2/7 prior to onset rash, until all vesicles crusted. Immunity in contacts can be assumed
if clear history of clinical chicken pox

Incubation of chicken pox: 8-21 days
References:
1. United Kingdom Advisory Group on Chickenpox. Consensus guidelines for management of varicella-
zoster infection. J. Infection 1998; 36 Suppl 1: 1-83
2. Scientific Advisory Committee of Royal College of Obstetricians and Gynaecologists. Guidelines on
chickenpox in pregnancy. 2001; Guideline No. 13: 1-8
3. Wallace MR, Bowler WA, Murray NB, Brodine SK, Oldfield EC3rd Treatment of adult varicella with
oral aciclovir. A randomised, placebo-controlled trial.
Ann Intern Med. 1992 Sep 1:117(5): 358-63
4. Miller E, Marshall R, Vurdien J. Epidemiology, outcome and control of varicella-zoster infection.
Reviews in Med Micro 1993; 4: 222-30
5. Joint Formulary Committee. British National Formulary. 52 ed. London: British Medical Association
and Royal Pharmaceutical Society of Great Britain; Sept 06

Box 2
Signs of severe infection include:
Respiratory symptoms
(clinical resp signs often absent)
Densely cropping vesicles
Haemorrhagic rash
Bleeding
Any neurological changes
Persisting fever with new vesicles
>6 days after onset