Sequential use of intravenous and oral acyclovir in the therapy of varicella in immunocompromised children

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Abstract
Immunocompromised children are at risk for disseminated varicella infections. Standard management involves hospitalization and intravenous acyclovir for 7 to 10 days. This approach is expensive, is inconvenient and may not be necessary. We undertook a pilot study to assess the safety and efficacy of an alternative approach that utilized a combination of intravenous (iv) followed by oral (po) acyclovir in a cohort of immunocompromised children. The cohort consisted of 26 immunocompromised children between the ages of 1.5 and 12.7 years (mean, 6.3). Therapy was commenced with iv acyclovir (1500 mg/m2/day in 3 divided doses). Concurrent management included holding or reducing immunosuppressive therapy (by 50%) and administering varicellazoster immunoglobulin in 69% (11 of 16) of cases where exposure to chickenpox was recognized. Patients were eligible to switch to po therapy after receiving a minimum of 48 h of iv acyclovir therapy provided they were afebrile; had no new lesions for 24 h; had no internal organ involvement and were able to tolerate oral medications. Patients were observed in hospital for a further 24 h and then discharged provided they remained well. Oral acyclovir was continued for a total of 7 to 10 days (iv plus po). Of the 26 patients 25 were successfully switched from iv to po after 4.1 ± 1.2 days (mean ± SD) (range, 2.3 to 6) Children had fever for a mean of 2.0 ± 1.6 days (range, 0 to 5) and developed new lesions for 2.9 ± 0.7 days (range, 2 to 4). All 25 patients switched to po therapy had resolution of their disease and no patient required resumption of iv therapy. The sequential use of iv followed by po acyclovir is feasible in the treatment of varicella in immunocompromised children and results in a reduction in duration of intravenous therapy and hospitalization.