From the Guidelines
Airborne and contact precautions should be employed for all patients with varicella or disseminated herpes zoster (HZ) and for immunocompromised patients with localized HZ until disseminated infection is ruled out, as recommended by the Advisory Committee on Immunization Practices (ACIP) 1. To implement these precautions effectively, the following measures should be taken:
- Patients with varicella or disseminated HZ should be placed in negative air-flow rooms, if available, to minimize the risk of airborne transmission.
- If negative air-flow rooms are not available, patients should be isolated in closed rooms and should not have contact with persons without evidence of immunity to varicella.
- Healthcare workers entering the room should wear appropriate personal protective equipment, including gowns, gloves, and either an N95 respirator or a powered air-purifying respirator (PAPR).
- Immunocompromised staff and pregnant staff who are not immune to varicella should avoid contact with these patients.
- The isolation precautions should be maintained until all lesions have crusted over, as indicated by the ACIP guidelines 1. Key considerations for healthcare workers include:
- Only healthcare workers with evidence of immunity to varicella should care for patients who have confirmed or suspected varicella or HZ.
- Standard precautions and complete covering of the lesions are recommended for immunocompetent persons with localized HZ. By following these guidelines, the risk of transmission of varicella zoster virus can be minimized, and the safety of both patients and healthcare workers can be ensured, ultimately reducing morbidity, mortality, and improving quality of life 1.
From the FDA Drug Label
Varicella-Zoster Infections in Immunocompromised Patients A multicenter trial of Acyclovir for Injection at a dose of 500 mg/m2 every 8 hours for 7 days was conducted in immunocompromised patients with zoster infections (shingles). Ninety-four (94) patients were evaluated (52 patients were treated with acyclovir and 42 with placebo) Acyclovir was superior to placebo as measured by reductions in cutaneous dissemination and visceral dissemination.
The ER precautions for varicella zoster include administering acyclovir at a dose of 500 mg/m2 every 8 hours for 7 days in immunocompromised patients to reduce cutaneous and visceral dissemination 2.
- Key points:
- Dose: 500 mg/m2 every 8 hours
- Duration: 7 days
- Patient population: Immunocompromised patients with zoster infections (shingles)
- Main consideration: Reduction of cutaneous and visceral dissemination in immunocompromised patients.
From the Research
ER Precautions for Varicella Zoster
- Varicella-zoster virus causes both varicella (chickenpox) and herpes zoster (shingles), and severe or fatal complications may result from varicella transmission to at-risk individuals 3.
- Clinical management of individuals exposed to varicella-zoster virus should take into consideration the type of exposure, evidence of immunity, and host-immune status with regard to ability to receive varicella vaccination safely 3.
- Post-exposure varicella vaccination may prevent infection or mitigate disease severity in persons eligible for vaccination, while post-exposure prophylaxis with varicella zoster immune globulin is indicated for populations ineligible for vaccination, including immunocompromised children and adults, pregnant women, newborns of mothers with varicella shortly before or after delivery, and premature infants 3, 4.
Treatment and Prevention
- Antiviral agents such as acyclovir, valacyclovir, famciclovir, brivudine, and foscarnet are approved for antiviral therapy in zoster patients and should be administered within 72 h after rash onset to significantly shorten viral replication and reduce complications 4.
- Vaccination is the most effective strategy for prevention of herpes zoster and postherpetic neuralgia, and a live virus varicella vaccine has been shown to be safe and effective in reducing the opportunities for varicella-zoster virus introductions in health care settings 4, 5.
- New molecules such as valnivudine hydrochloride and valomaciclovir stearate are being developed as anti-VZV candidates, and famciclovir has been shown to be effective in treating varicella zoster virus infection resistant to acyclovir 6, 7.
High-Risk Individuals
- High-risk individuals, including pregnant women, immunocompromised patients, and newborns, require special consideration and may benefit from postexposure prophylaxis with varicella zoster immune globulin within 72-96 h after exposure 3, 4.
- Immunocompromised hosts are at high risk for severe varicella and other complications if exposed to the virus, and antiviral agents such as acyclovir and famciclovir may be effective in treating varicella zoster virus infection in these individuals 6, 7.