From the Guidelines
The management of Herpes Simplex Virus (HSV) primarily involves antiviral medications, with acyclovir, valacyclovir, and famciclovir being the mainstays of treatment, as recommended by the 1999 USPHS/IDSA guidelines 1.
Treatment Options
- For initial genital HSV outbreaks, recommended regimens include acyclovir 400mg orally three times daily for 7-10 days, valacyclovir 1g orally twice daily for 7-10 days, or famciclovir 250mg orally three times daily for 7-10 days.
- For recurrent episodes, shorter courses are effective: acyclovir 800mg three times daily for 2 days, valacyclovir 500mg twice daily for 3 days, or famciclovir 1g twice daily for 1 day.
- Suppressive therapy is recommended for patients with frequent recurrences (>6 episodes/year) using acyclovir 400mg twice daily, valacyclovir 500mg daily (or 1g daily for patients with >10 episodes/year), or famciclovir 250mg twice daily.
Special Considerations
- For HSV keratitis, topical antivirals like trifluridine or ganciclovir gel are used.
- For HSV encephalitis, intravenous acyclovir 10mg/kg every 8 hours for 14-21 days is required.
- Patient education about transmission risk, even during asymptomatic periods, is essential for managing this chronic infection.
Prevention of Recurrence
- Daily suppressive therapy with oral acyclovir or famciclovir is recommended for persons who have frequent or severe recurrences of HSV disease (AI) 1.
- Valacyclovir is also an option for suppressive therapy (CIII).
- Intravenous foscarnet or cidofovir can be used to treat infection due to acyclovir-resistant isolates of HSV.
From the FDA Drug Label
Mucocutaneous Acyclovir Resistant HSV Infections FOSCAVIR is indicated for the treatment of acyclovir-resistant mucocutaneous HSV infections in immunocompromised patients. The management for HSV includes the use of foscarnet (IV) for the treatment of acyclovir-resistant mucocutaneous HSV infections in immunocompromised patients 2.
- Key points:
- Foscarnet is used for acyclovir-resistant mucocutaneous HSV infections
- It is indicated for immunocompromised patients
- The safety and efficacy of foscarnet have not been established for other HSV infections or nonimmunocompromised individuals.
From the Research
Management of HSV Infection
The management of Herpes Simplex Virus (HSV) infection involves the use of antiviral agents, with acyclovir being the primary treatment option 3, 4, 5. In immunocompetent patients, HSV is typically controlled rapidly by the host's immune system, and recurrent lesions are small and short-lived. However, in immunocompromised patients, HSV infection can be more severe and persistent, requiring alternative treatment options.
Treatment Protocol
The treatment protocol for HSV infection typically involves the following steps:
- Initiation of standard oral acyclovir therapy at a dose of 200 mg orally, five times a day for the first 3 to 5 days 3
- Cultures of the lesions should be obtained to verify HSV etiology prior to treatment 3
- If the response is poor, the dose of oral acyclovir should be increased to 800 mg five times a day 3
- If no response is seen after 5 to 7 days, alternative regimens such as intravenous foscarnet or cidofovir may be considered 3, 4, 6
Alternative Treatment Options
Alternative treatment options for acyclovir-resistant HSV infection include:
- Foscarnet: a potent inhibitor of HSV DNA polymerase that does not require phosphorylation for its antiviral activity 3, 4, 6
- Cidofovir: an antiviral agent that can be used as an alternative to foscarnet 3, 4
- Helicase primase inhibitors (HPIs): a new class of antiviral agents that have shown high efficacy and potential to overcome resistance 5
Special Considerations
Special considerations for the management of HSV infection include:
- Immunocompromised patients: require closer monitoring and alternative treatment options due to the increased risk of severe and persistent infection 3, 4, 6
- Recurrent lesions: require prompt treatment to prevent further complications 3
- Drug resistance: a growing concern that requires the development of new antiviral agents and treatment strategies 4, 5, 7