What is the recommended management of acute hepatitis A in 2026, including supportive care, monitoring for hepatic decompensation, and post‑exposure prophylaxis?

Management of Acute Hepatitis A in 2026

Acute hepatitis A requires supportive care only, with no specific antiviral therapy indicated, while monitoring for the rare complication of acute liver failure. 1, 2, 3

Initial Diagnosis and Assessment

Confirm the diagnosis serologically with IgM anti-HAV antibodies, as hepatitis A cannot be distinguished from other viral hepatitides based on clinical presentation alone. 1 Obtain comprehensive laboratory evaluation including:

• Liver enzymes (ALT, AST, bilirubin) 2
• Prothrombin time/INR to assess for coagulopathy 2, 3
• Complete blood count and comprehensive metabolic panel 2

If INR is prolonged by ≥4-6 seconds (INR ≥1.5) with any mental status changes, immediately diagnose acute liver failure and transfer to ICU. 2

Supportive Care Management

The cornerstone of treatment is supportive care, as no virus-specific antiviral therapy has proven effective for hepatitis A. 1, 3

Strict avoidance measures:

• Eliminate all hepatotoxic medications, particularly acetaminophen 2, 3
• Complete abstinence from alcohol 2, 3
• Discontinue all non-essential medications 2

Monitoring schedule:

• Check hepatic panels (ALT, AST, bilirubin, INR) every 2-4 weeks until resolution 2, 3
• Watch specifically for signs of hepatic decompensation: rising bilirubin, prolonged INR, mental status changes 2

Clinical Course Expectations

Most patients recover completely within 2 months, though 10-15% experience relapsing illness over the first 6 months. 1, 4 Progression to acute liver failure can occur, particularly in patients with underlying chronic liver disease. 1 Chronic infection does not occur with hepatitis A. 5

Post-Exposure Prophylaxis for Contacts

Administer immune globulin (IG) to exposed unvaccinated contacts within 2 weeks of exposure, which is >85% effective in preventing disease. 1 Identify and treat:

• Household contacts and cellmates 1
• Sexual contacts 1
• Persons with ongoing close personal contact 1

Do not delay IG administration for anti-HAV testing, as this reduces effectiveness and is not cost-effective. 1 Hepatitis A vaccine alone is not recommended for post-exposure prophylaxis, though persons receiving IG who are also vaccine candidates should subsequently receive vaccination. 1

When to Consider Liver Transplantation

Immediately refer to a transplant center if the patient develops:

• INR >1.5 with any signs of hepatic encephalopathy 2
• Signs of fulminant hepatic failure 3

Contact the liver transplant unit early for all patients showing signs of acute liver failure. 2

Infectivity Period and Transmission Prevention

Patients are most infectious 14 days before and 7 days after jaundice develops. 5 Transmission occurs via the fecal-oral route, through person-to-person contact or contaminated food/water. 5, 6

Common Pitfalls to Avoid

• Do not use acetaminophen during acute hepatitis, even for symptom management 2
• Do not delay ICU transfer for patients with coagulopathy and mental status changes 2
• Do not routinely correct coagulation abnormalities without active bleeding 2
• Do not administer nephrotoxic agents 2
• Do not use benzodiazepines for sedation in patients with liver dysfunction 2

Prevention Through Vaccination

Routine hepatitis A vaccination is recommended for children 12-23 months of age and for high-risk populations including persons who use illegal drugs, travelers to endemic areas, incarcerated populations, and those with chronic liver disease or HIV infection. 5, 4 Universal childhood vaccination programs in intermediate endemicity countries have successfully reduced HAV incidence. 6