Chicken Pox ( Varicella Zoster ) - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Last review: 31/12/2018  
Next review: 31/12/2021  
Clinical Guideline
CURRENT 
ID: 2263 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Varicella Zoster (Chicken Pox) in Primary Care


Seek urgent specialist advice if pregnant, breastfeeding, immunocompromised or neonate. 1B+ 

Seek urgent specialist advice about contacts who are pregnant, immunocompromised or neonate 1B+. 

Chicken Pox is usually self-limiting, however consider antiviral treatment for the following  patients:2-,4

  • onset of rash <24 hours and >14 years old

Particularly, if also

  • a smoker
  • oral/extensive rash (>100 vesicles)
  • taking steroids

 Preferred Option

Alternative Option

Notes

Aciclovir 3B+, 5A+
800mg five times a day
7 days B+

 

On specialist advice only

Urgent specialist advise if needed for above patient groups is available from duty virologist 0113 3928750 or via LTH switch board.

CKS
PHE
LHP1465

 

General Principles for Treating Infections


This summary table is based on the best available evidence, but use professional judgement and involve patients in management decisions.

  1. This summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.
  2. Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
  3. If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection
  4. Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.
  5. In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.
  6. Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example coamoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.
  9. Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.
  10. Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.
  11. Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects.
  12. Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

 

 

Provenance

Record: 2263
Objective:
Clinical condition:

Chicken Pox (Varicella Zoster)

Target patient group:
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

Evidence base

Grading of guidance recommendations
The strength of each recommendation is qualified by a letter in parenthesis.


Study design

Recommendation
grade

Good recent systematic review and meta-analysis of studies

A+

One or more rigorous studies; randomised controlled trials

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Non-analytic studies, eg case reports or case series

C

Formal combination of expert opinion

D

 

Varicella zoster/chicken pox 

  1. DH. Immunisation against infectious diseases – The Green book. Chapter 34. Varicella. Department of Health 2006. https://www.gov.uk/government/publications/varicella-the-green-book-chapter-34 Accessed 23.09.14.

    RATIONALE: Pregnant women are at greater risk of varicella pneumonia, and there is a risk to the fetus of congenital varicella syndrome if exposure occurs during the first 20 weeks of pregnancy, and severe disease in the neonate if varicella is contracted a week before delivery. Following infection in the second and third trimesters herpes zoster may present in otherwise healthy infants. Occasional cases of fetal damage comprising chorioretinal damage, microcephaly and skin scarring have been reported following maternal varicella infection between 20 and 28 weeks’ gestation but the risk is lower than for the first trimester. Neonates and immunocompromised individuals are at greater risk of disseminated or haemorrhagic varicella. Urgent specialist assessment is needed for all neonates, pregnant women, or immunocompromised individuals with varicella to assess the need for varicella immunoglobulin and antiviral treatment. 

  2. Klassen TP and Hartling L. Aciclovir for treating varicella in otherwise healthy children and adolescents. Cochrane Database of Systematic Reviews. 2005. Issue 4. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002980/frame.html Accessed 23.09.14. 
    RATIONALE: Pooled data from three studies who enrolled participants within 24 hours of rash onset found that aciclovir was associated with a small reduction in the number of days with fever (-1.1, 95% CI -1.3 to -0.9) and in reducing the maximum number of lesions. Results were less supportive of a reduction in the number of days of itching. There were no differences in complication rates between those treated with aciclovir or placebo. 
  3. Swingler G. Chicken Pox. In: Clinical Evidence Concise. London. BMJ Publishing Group. 2006;15:267-79. 
    RATIONALE: One systematic review was identified that found one RCT (n=148 adults) which compared early versus late administration of aciclovir 800mg five times a day compared with placebo. It found that aciclovir given within 24 hours of the onset of rash significantly reduced the maximum number of lesions (P < 0.01) and the time to full crusting of lesions (P=0.001) compared with placebo. It found no significant difference in time to full crusting of lesions if aciclovir was given 24–72 hours after the rash (P > 0.2). 

  4. Public Health England recommends that treatment with aciclovir should be considered (if it can be started within 24 hours of the rash) in those with severe chickenpox (including secondary cases) and in those at increased risk of complications (adults and adolescents aged 14 years and over, smokers, people on steroids). 
  5. Hope-Simpson RE. Postherpetic neuralgia. Brit J Gen Pract 1975;25:571-75. 
    RATIONALE: Study showing that incidence of post-herpetic neuralgia in a general practice population increases with age with a third of cases being among those over 80 years.

 

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