NUH Guide to the Clinical Management of Chicken Pox in Adults

Box 1
Box 2
 Chicken pox is the primary systemic infection with Varicella-Zoster virus (VZV)
Y Signs of severe infection include:
 Acute systemic VZV has increased mortality and morbidity in adolescents and adults compared to
1
children . Immunocompromised adults and non-immune pregnant women are at particular risk
2  Respiratory symptoms
(clinical resp signs often absent)
3  Densely cropping vesicles
 Prompt treatment with Aciclovir reduces duration and severity of symptoms
 Haemorrhagic rash
 There is no evidence of benefit of Aciclovir once the rash has been established for >48hrs
3  Bleeding
 Any neurological changes
 Infectivity: 2/7 prior to onset rash, until all vesicles crusted. Immunity in contacts can be assumed  Persisting fever with new vesicles
if clear history of clinical chicken pox >6 days after onset

 Incubation of chicken pox: 8-21 days

Patient unwell, with new Symptomatic treatment only, monitor

chicken pox vesicles N for signs of severe infection (Box 2)
within last 24-48 hrs?

Give oral Aciclovir

Y N 800mg x 5/day for 7
days (Box 3) and
monitor for signs of
Signs of severe severe infection
Pregnant? Y infection? (Box 2)

N
Y

Signs of severe infection? (Box 2)

Other risk factors for pneumonitis? Y

- smoker, chronic lung disease?  Admit to isolation bed in hospital for
regular monitoring by staff known to be
immune (inform Infection Control)
 Consider IV Aciclovir (10mg/kg tds)
N  Check LFTs, renal function and clotting
for DIC
 Review CXR for evidence of
pneumonitis, monitor pO2
 If temp fails to settle consider possible
o
2 Staph. aureus infection
Immunocompromised?  Switch to oral therapy as soon as
possible
 Current chemo-/radiotherapy, or
within last 6/12 (12/12 for Bone
marrow transplant) Y
 Steroids (>5mg/day) within last
3/12

 On Azathioprine or Methotrexate Box 3

Oral Treatment:
Give oral treatment (Box 3) +
N symptomatic relief Valaciclovir 1g tds 7 days
Advise re infection risk (Box 1) or Aciclovir 800mg x5/day
Monitor for severe infection (Box 2)
(NB: bioavailability of oral Aciclovir is poor)

Intravenous treatment:
Aciclovir 10mg/kg tds
References:
1. United Kingdom Advisory Group on Chickenpox. Consensus guidelines for management of varicella- Renal impairment: dose reduction required for
5
zoster infection. J. Infection 1998; 36 Suppl 1: 1-83 all forms of Aciclovir
2. Scientific Advisory Committee of Royal College of Obstetricians and Gynaecologists. Guidelines on
chickenpox in pregnancy. 2001; Guideline No. 13: 1-8 Pregnancy: No adverse data for use of
3. Wallace MR, Bowler WA, Murray NB, Brodine SK, Oldfield EC3rd Treatment of adult varicella with 5
Aciclovir, data inadequate for Valaciclovir
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

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