Management of Acute Hepatitis A
Primary Management Approach
Acute hepatitis A requires only supportive care, as no antiviral therapy has proven effective for this self-limiting infection. 1, 2, 3
Supportive Care Measures
- Provide symptomatic relief for nausea, vomiting, and malaise as they occur, with no specific dietary or activity restrictions required. 3
- Maintain adequate hydration through oral fluids, which is typically sufficient for most patients. 3
- Advise complete avoidance of all hepatotoxic medications, particularly acetaminophen, and alcohol during the acute illness. 1, 2
- Allow patients to eat and resume activities according to their tolerance level. 3
Clinical Monitoring
- Monitor hepatic panels (ALT, AST, bilirubin, INR) every 2-4 weeks until complete resolution of laboratory abnormalities. 1, 2
- Watch closely for signs of acute liver failure, including coagulopathy (INR ≥1.5), altered mental status, and rapidly rising bilirubin levels. 1, 3
- Expect complete clinical recovery with normalization of serum bilirubin and aminotransferases within 6 months in nearly all adult patients, though 10-15% may experience a relapsing illness during this period. 1, 4
Indications for Hospitalization
Admit patients who develop any of the following:
- Severe dehydration from intractable nausea and vomiting that cannot be managed with oral rehydration. 3
- Signs or symptoms of acute liver failure, including encephalopathy, coagulopathy (prolonged INR by 4-6 seconds or more), or rapidly rising bilirubin. 1, 3
- Pre-existing chronic liver disease (particularly chronic hepatitis B or C), as these patients face substantially higher risk for fulminant hepatic failure and mortality. 3, 5, 6
Critical caveat: Older adults have higher risk of acute liver failure and warrant closer monitoring even without chronic liver disease. 3
Post-Exposure Prophylaxis for Contacts
Administer hepatitis A immune globulin (IG) at 0.02 mL/kg body weight intramuscularly to unvaccinated close contacts as soon as possible, but not more than 2 weeks after the last exposure. 7, 3
- Target IG administration to household members, co-habitants, sexual partners, and any persons with ongoing close personal contact with the index case. 7, 3
- Do not delay IG administration while awaiting anti-HAV antibody testing, as delays reduce prophylactic effectiveness. 1
- IG provides >85% protection against infection when given within the appropriate timeframe. 1, 3
- If the contact has indications for hepatitis A vaccination, vaccine should be administered either at the same time or at a later date. 7
Infection Control Measures
- Implement standard (universal) precautions for all contact with blood or body fluids from infected patients. 7
- Report all cases of acute hepatitis A to the appropriate public health jurisdiction (county or state health department). 7
- Initiate epidemiologic investigation by correctional or public health officials to identify the source of infection and all potential contacts who may have been exposed. 7
Special Populations Requiring Enhanced Vigilance
- Patients with chronic hepatitis B or C: These individuals experience higher rates of morbidity and mortality from acute hepatitis A superinfection, with mortality rates particularly elevated in chronic hepatitis C patients. 5, 6
- Patients with any chronic liver disease: Worse outcomes are apparent compared to previously healthy individuals, warranting closer monitoring and lower threshold for hospitalization. 5, 6
- Older adults: Age-dependent severity means older patients face higher risk of fulminant hepatitis even without underlying liver disease. 3, 4
Common Pitfalls to Avoid
- Do not prescribe drugs primarily metabolized by the liver without careful assessment, as hepatic clearance is impaired during acute infection. 1
- Do not overlook the possibility of chronic liver disease in the initial assessment, as this dramatically changes risk stratification. 3
- Do not assume initial negative anti-HAV IgM testing rules out hepatitis A if clinical suspicion remains high—repeat testing may be warranted as antibodies can be undetectable early in the illness. 8
- Do not routinely correct coagulation abnormalities in the absence of active bleeding. 1