| Condition | Major Pathogens | First Choice Therapy | Alternative Therapy | Comments |
|---|---|---|---|---|
| Immunocompetent Patient | ||||
| Varicella (primary infection) in immuno-competent host |
Varicella zoster virus Treatment is not routinely recommended in otherwise healthy children with varicella due to the self-resolving nature of infection and short window of viral replication (<72 hours from onset of rash) Consider treatment early in disease course in patients at increased risk for moderate to severe varicella based on one or more of the following criteria: Age> 12 years old not immunized against VZV Chronic cutaneous or pulmonary disorder Receiving long term salicylate therapy Receiving short or intermittent courses of systemic corticosteroids |
See 2nd column for treatment indications Outpatient/enteral therapy for patients at increased risk: Acyclovir OR Valacyclovir using dose below if patient is able to take pills IV therapy for patients requiring hospitalization due to varicella: Acyclovir |
ID consult recommended for patients hospitalized due to varicella or related complications Duration: 5 days for outpatient therapy, individualized based on response for hospitalized patients but usually 7-10 days similar to below for immuno-compromised patients |
|
| Herpes zoster (reactivation) in immuno-competent host |
Varicella zoster virus As with varicella there is a short window of viral replication (<72 hours from onset of rash); treatment is recommended if it can be initiated within this window or > 72 hours but patient presents with ongoing appearance of new lesions |
Valacyclovir (preferred if patient able to take pills) OR Acyclovir (if patient unable to take pills or otherwise to access valacyclovir) |
Duration: Antiviral therapy is typically given for 7-10 days or until lesions have crusted over | |
| Immunocompromised Patient | ||||
|
Varicella zoster virus infection in immuno-compromised hosts Includes manifestations of varicella (primary infection) or herpes zoster (reactivation) |
Varicella zoster virus
|
IV therapy: Acyclovir Enteral therapy:* Valacyclovir (preferred if patient able to take pills) OR Acyclovir (if patient unable to take pills or otherwise to access valacyclovir) |
Consider ID consultation Duration: Antiviral therapy is typically given for 7-10 days or until lesions have crusted over *Therapy may be initiated enterally in patients >= 2 yo with localized herpes zoster, without herpes zoster ophthalmicus or oticus, and without severe symptoms. For patients not meeting these criteria, initiation with IV therapy is recommended, with transition to enteral when the patient shows clinical improvement (no new lesions are appearing) |
|
References:
American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.
Pergam SA, et al. Varicella zoster virus in solid organ transplantation: guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019;33:e13622.
Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. Department of Health and Human Services.
Pediatric Empiric Antimicrobial Therapy Guidelines
This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites.
These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.
For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK.
The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.