Common Pediatric ID Curbsides Susannah Kussmaul, MD Pediatric - - PDF document

Common Pediatric ID Curbsides

Susannah Kussmaul, MD Pediatric Infectious Diseases Kaiser Permanente Medical Center UCSF Volunteer Faculty

No disclosures

Curbside Question

Can I use ciprofloxacin and other fluoroquinolones in children?

Hampel, et al, Ped Inf Dis J 1997;16(1)

Fluoroquinolones (FQs) in Children

• Cartilage damage affecting weight-bearing joints

in beagle puppies (late 1970s)

• Avoidance of FQs when possible in children
• Accumulation of clinical experience suggested

as safe in children as adults

• Compassionate use of ciprofloxacin: 2030 treatment

courses in 1795 children:

• 1.5% with mild to moderate arthralgia
• 60% of those in patients with CF (long courses)
• All resolved off of cipro
• No reported cartilage damage

≠

• 2006: AAP supports use of IV FQs as alternative

therapy for resistant infections, or PO to avoid hospitalization

Fluoroquinolones (FQs) in Children

Noel et al, Ped Inf Dis J 2007; 26:879–891

Fluoroquinolones (FQs) in Children

• Children with community acquired pneumonia or

acute otitis were randomized to receive levofloxacin

• vs. comparator antibiotic
• Slight increase in musculoskeletal problems

(predefined as arthralgia, arthritis, tendinopathy, gait abnormality)

• Most were arthralgia
• All resolved without long-term issues (followed to 5 years)

% with musculoskeletal complaints FQ treated Control p‐value 2 months 2.1% 0.9% <0.05 12 months 3.4% 1.8% <0.05

http://clinicalpharmacy.ucsf.edu/idmp/antibiogram_home.htm

Fluoroquinolones (FQs) in Children

• Other studies have shown trends towards transient

musculoskeletal effects – used with some caution

• Concern for development of resistance: UCSF data

% Strains Susceptible to Ciprofloxacin at UCSF (2012)

Pathogen Adult inpatient Peds inpatient Acinetobacter baumanii

63 100

Citrobacter freundii

75 100

Enterobacter aerogenes

95 100

Enterobacter cloacae

89 95

E.coli

67 93

Klebsiella oxytoca

98 94

Klebsiella pneumonia

80 90

Proteus mirabilis

80 100

Pseudomonas aeruginosa

*does not include CF patients

74 100

Serratia marcescens

96 100

Bradley et al, Pediatrics 2011;128;e1034; Choi et al, Kor J Ped 2013:56(5):196-201

Fluoroquinolones (FQs): Review

• Musculoskeletal symptoms are feared, but are

transient and relatively uncommon

• Most common side effects:
• GI symptoms (N/V/D/abdominal pain); risk for C.difficile
• Rash, allergies, photosensitivity
• Characteristics:
• Bactericidal
• Good bioavailability (70-95%; nearly 100% for levofloxacin)
• Good penetration into cells, tissues, CSF

Fluoroquinolones (FQs): Spectrum

1st generation: nalidixic acid

• Gram negative rods (Enterobacteriacae) / UTIs
• FDA-approved in children > 3 months
• Not currently available in the US

2nd generation: ciprofloxacin/ofloxacin, levofloxacin

• Greater Gram negative activity (H.flu, Neisseria, Moraxella);

Pseudomonas (cipro>levo); S.aureus (levo>cipro); S.pneumo (levo)

• FDA-approved for children 1-17 years old (cipro) and for children >6

months (levo) for certain indications

3rd generation: gemfloxacin

• Increased S.pneumo and atypical coverage (e.g. Mycoplasma)
• Not FDA-approved in children

4th generation: moxifloxacin

• Comparable Gram positive and Gram negative coverage as

levofloxacin; increased anaerobic and mycobacterial coverage including MTB

• Not FDA-approved in children, but used off-label (community

acquired pneumonia, perioperative prophylaxis)

AAP, Pediatrics 2006;118:1287

FQs in Children: Clinical Uses

• FDA-approved indications
• Nalidixic acid: UTIs
• Ciprofloxacin: inhalational anthrax, complicated resistant

E.coli UTI/pyelonephritis

• Levofloxacin: inhalational anthrax

AAP, Pediatrics 2006;118:1287

FQs in Children: Clinical Uses

• 2006, American Academy of Pediatrics

Guidelines

• UTI with resistant organisms
• E.coli, Pseudomonas, Enterobacter, Citrobacter, Serratia
• Oral option for Pseudomonas infections
• Cystic fibrosis, chronic suppurative otitis
• Mycobacterial isolates (if susceptibility known)
• GI infections
• Resistant Shigella, Salmonella, Campylobacter, Vibrio

cholera

• Gram-negative bacterial infections in immunocompromised

hosts

• When oral therapy indicated or no other alternative
• Sepsis or meningitis from resistant organism
• Serious infections a patient with allergies

Bradley et al, Clin Inf Dis Aug 2011

FQs in Children: Clinical Uses

• More recent IDSA / PIDS guidelines
• Pediatric community acquired pneumonia (2011)
• Use of levofloxacin in children as young as 6 months

depending on allergies and pathogen

• First-line agent for highly resistant S.pneumo
• Pediatric bacterial sinusitis (2013)
• Use of levofloxacin in patients who are failing treatment with

augmentin

• Pediatric otitis media (2013)
• Use of levofloxacin as an “unconventional drug” (in

consultation with specialist) for certain highly resistant strains of S.pneumo

Lieberthal et al, Pediatrics 2013;131;e964 Wald et al, Pediatrics 2013;132;e262

• Epidemiologic study from 300 US surveillance labs
• Stratified by source (e.g. urine, blood), inpatient/outpatient, age,

sex, and year  results consistent across demographic and age groups, including outpatients

• Highest proportion of resistant isolates in children 1-5 yrs old
• Lower prevalence of resistant isolates in the upper Midwest

Logan et al, J Ped ID Soc, March 2014

Increasing Resistance in Children

Enterobacteriaceae isolates in children 1‐18 years old

1999‐2001 (start of study data) 2010‐2011 (end of study data) Total isolates during study period N = 368,398

3rd generation cephalosporin resistance 1.39% 3% 1.97% (7255 isolates) ESBL‐producers 0.28% 0.92% 0.47% (1734 isolates)

Curbside Question

How should in interferon-gamma release assay (IGRA) test such as the quantiferon (QFT) be used in children?

Why do we treat latent TB infection (LTBI)?

• LTBI vs. TB disease
• 9 months of INH decreases the risk of developing

subsequent TB disease by 90% (if adherent)

• Problem:
• TST (tuberculin skin test / PPD) cross-reactivity with non-

tuberculous mycobacteria, including BCG leads to

• verdiagnosis of LTBI
• Approach:
• Targeted rather than universal screening
• Utilize new diagnostics (e.g. IGRA) to identify the patients

most likely to benefit from LTBI therapy, and to inform decisions for BCG-vaccinated patients

American Academy of Pediatrics, Red Book 2012

Diagnosing LTBI in Children

• Universal / routine screening is discouraged
• Targeted TB screening should be based on

presence of risk factors

• Has a family member or contact had TB disease?
• Has a family member had a positive tuberculin skin test result?
• Was your child born in a high-risk country (countries other than

the United States, Canada, Australia, New Zealand, or Western and North European countries)?

• Has your child traveled (had contact with resident populations) to

a high-risk country for more than 1 week?

• Likely new addition: foreign-born parent
• Compared with US-born children with US-born parents, TB

rates are 32 times higher among foreign-born children, and 6 times higher among US-born children with foreign-born parents

Pang, et al. Pediatrics 2014;133;e494 American Academy of Pediatrics, Red Book 2012

Diagnosing LTBI in Children

Definition of positive PPD test also relates to risk:

Induration 5 mm or greater

• Children in close contact with known/suspected contagious people with TB disease
• Children suspected to have tuberculosis disease:

Findings on chest radiograph consistent with active or previous TB disease Clinical evidence of tuberculosis disease

• Children receiving immunosuppressive therapy or with immunosuppressive conditions,

including HIV

Induration 10 mm or greater

• Children at increased risk of disseminated tuberculosis disease:

Children younger than 4 years of age Children with other medical conditions (cancer, diabetes, renal failure, malnutrition)

• Children with likelihood of increased exposure to tuberculosis disease:

Children born in high-prevalence regions of the world

• Children who travel to high-prevalence regions of the world
• Children frequently exposed to adults with risk factors (HIV, homelessness, illicit drugs,

nursing home resident, incarceration, institutionalized)

Induration 15 mm or greater

• Children age 4 years or older without any risk factors

What is an interferon-gamma release assay (IGRA)?

• Blood test used to diagnose TB
• Does not distinguish LTBI from active disease
• Two FDA approved IGRAs available in the US
• Quantiferon-Gold, T-Spot
• What do they do?
• Detect interferon gamma released by lymphocytes after stimulation

with peptides simulating MTB

• More specific than TST (no BCG or MAC cross-reactivity)
• How do we use them?
• For children ≥ 5, they are about as sensitive as a PPD in the US

and other low-incidence settings

• Helpful in identifying LTBI in BCG-vaccinated persons
• Interpretation depends on age, prevalence of TB, risk of exposure,

and other factors -- an evolving science, especially in pediatrics http://www.cdc.gov/tb/publications/factsheets/testing/IGRA.htm

Quantiferon Test

Nil TB Antigen Mitogen

Test Results Units

Nil 0.09 IU/mL Mitogen – Nil > 10..00 IU/mL TB Ag – Nil > 10.00 IU/mL Quantiferon DETECTED

Result:

• Detected
• Not detected
• Indeterminate

Sample test result:

Why does a BCG-vaccinated person need to be treated for LTBI?

• BCG is used in countries with a high prevalence of

TB to prevent severe forms of TB (e.g. meningitis, miliary TB), which are more common in children

• Variable effectiveness against pulmonary TB

(~50%)

AAP Red Book, 2012

IGRA Testing in Children

• IGRAs are preferred in children > 4 years old with

history of BCG vaccine

• Neither TST nor IGRA tests are considered a “gold

standard” for diagnosis of LTBI

• Children with a positive result should be interpreted

as infected with MTB (LTBI or active disease)

• A negative IGRA result does not rule-out infection
• Indeterminate results do not exclude TB and should

not be used to make clinical decisions

Cruz and Starke, Curr Op Ped Feb 2014

Use of TST and IGRA in Children

TEST SCENARIO TST preferred, IGRA acceptable  < 5 years of age IGRA preferred, TST acceptable  BCG-vaccinated  Unlikely to return for TST reading Either TST or IGRA  Recent contacts >= 5 years old of persons with confirmed or suspected TB disease  Periodic screening of persons with ongoing exposure (e.g., correctional facilities) Both IGRA and TST*  Initial TST or IGRA is negative in the following situations:

• The risk for infection, progression, or a poor outcome is

increased (e.g., HIV infection, children <5 years old)

• Additional evidence of infection is required to encourage

adherence (e.g., positive TST result and history of BCG)

• Healthy persons with low risk for both infection & progression
• Clinical suspicion for TB disease, and confirmation of MTB

infection is desired (increase sensitivity by sending boh)  IGRA is indeterminate; an alternative to TST placement for children with one indeterminate IGRA is to obtain another IGRA result with the same testing product or the alternative product  Initial test is negative and risk of progression to disease is high

(from personal correspondance with Dr. Andrea Cruz)

General Approach to IGRAs

• Recognize limitations of TST and IGRAs
• If important to increase sensitivity, do both and believe either if

positive

• Huge variation in approach worldwide
• Interpretation depends on risk for infection

and risk for progression

• Routine screening (discouraged) vs. targeted screening (preferred)
• Patients being screened for LTBI require a TB symptom review,

physical examination, and CXR

• Remember that very young children are at higher risk for

progression AND they tend to tolerate LTBI medications very well

• Stay tuned for 2015 Red Book –

recommendations will likely change

• Still start with TST if no history of BCG
• Still start with IGRA if history of BCG
• Will likely accept IGRA results for children ≥ 3 years old

Curbside Question

How can I get this family to take LTBI medications? Are there alternatives for my patient who is experiencing side effects?

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258

Why Treat Children with LTBI?

• Late 1950s and 1960s: US public health service

collectively studied > 100,000 patients (including children)

• Decreased risk of developing TB by 90% among adherent

patients treated with INH for 12 months

• Subsequent observational study of ~2500 children

treated with INH daily x 12 months and followed for an average of 6 years:

• 99% protective efficacy among adherent patients

Why Treat Children with LTBI?

• Children and adolescents
• Long life = more years at risk for progression
• Generally tolerate the medications well
• No need for routine lab monitoring in healthy children
• Education about side effects and when to stop taking the meds

(e.g. severe abdominal pain especially RUQ, vomiting, jaundice) and monthly adherence and side effect checks sufficient

• Young children
• Are at higher risk for more severe forms of infection
• Were more recently exposed (and so at higher risk for

progression)

• Bottom line:
• Children stand to benefit more from therapy, with

increased risk of disease progression (especially in very young) and decreased toxicity risks compared with adults

• Ideally, we treat all children with LTBI

Pediatric LTBI: INH (6-9 mo)

• INH is the most studied LTBI drug in children
• If adherent, reduces risk of developing TB by at least 90%
• INH x 9 months for children is standard in US
• 270 doses within 12 calendar months
• 9 vs. 12 months – not much difference
• Adherence
• Challenging. ~50% adherence among adults
• DOT with twice-weekly INH is an alternative if adherence an

issue

• INH x 6 months may be acceptable
• 9 month regimen 20-30% more protective than 6 month regimen
• WHO uses duration of 6 months for children
• Used at SF TB clinic for patients ≥ 15 years
• If adherence becomes an issue late in treatment, may be

reasonable to consider accepting 6 months for some patients

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258

Pediatric LTBI: RIF (4-6 mo)

• 3 mo RIF equivalent to 6 mo of INH (RCT in adults)
• Improved adherence with RIF
• Discontinuation from adverse events less likely (RIF)
• 6 months RIF recommended by AAP for treatment of

LTBI if the source strain is INH-resistant

• Observational study: 6 months of RIF for 157 teens exposed to

INH-resistant TB  none developed TB during 2 year follow-up

• Acceptable alternative to INH for INH-susceptible strains,

too (adherence concerns, patient preference, etc…)

• RIF is more expensive
• Use of 6 months instead of 4 is not evidence-based
• Some experts advocate using 4 months of therapy in chidlren

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258; Villarino et al, Am J Resp Crit Care Med 1997;155:1735-8.

Pediatric LTBI: INH/RIF (3 mo)

• RCT of Greek children compared 3 months of

INH/RIF to 9 months INH

• Not powered for efficacy, but none of the 850 adherent patients

developed TB

• No patients developed serious adverse events or needed

treatment modification

• Improved adherence with INH/RIF (~85% vs. ~60%)
• Programmatic experience in Britain
• 3-6 months of INH/RIF combo used for pediatric LTBI for > 30

years

• Reduced incidence of childhood TB with INH/RIF compared

with historical controls receiving 9 months of INH

• Likely that adherence plays a role in efficacy of the shorter

regimen

• May be appropriate for some patients

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258; Spyridis et al, Clin Inf Dis 2007;45:715-22.; Ormerod et al, Arch Dis Child 1998;78:169-171.

Pediatric LTBI: INH/RPT (3 mo)

• Rifampentine (RPT) has longer half life and is more

potent than RIF

• Multicenter, open-label randomized non-inferiority

trial of 3 months of INH/RPT (as DOPT) vs. 9 months of self-administered INH

• Higher completion rates for the INH/RPT arm (82% vs. 69%)
• INH/RPT was non-inferior (HR 0.38 for combo therapy, 95% CI

0.15-0.99)

• Too few children enrolled to determine efficacy, but appeared

safe and tolerable in children

• More discontinuation from adverse events and side effects in

INH/RPT arm – but not in children

• Improved adherence in INH/RPT arm (DOT)

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258; Sterling et al, NEJM 2011;365:2155-66.

Pediatric LTBI: INH/RPT (3 mo)

• CDC in 2011 recommending 12 weekly DOT doses
• f INH/RIF as an alternative for patients ≥ 12 years

who are at high risk for progression

• Safety / tolerability data not available when the CDC

made this recommendation

• INH/RPT can be considered case-by-case for children 2-11 if

adherence is likely to be an issue, and the risk of disease progression is high (e.g. recent TB exposure, recent conversion to positive TB screening test, CXR showing healed pulmonary TB, HIV)

• Second-line alternative in children given lack of data
• Downside is requirement for DOT and logistics

required for that at your facility

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258; Sterling et al, NEJM 2011;365:2155-66.

Pediatric LTBI: RIF/PZA (2 mo)

• Studies of RIF/PZA regimen were all in adults
• Not recommended for LTBI therapy in adults due to high rates of

hepatotoxicity

• Not recommended for standard LTBI therapy in

children, but acceptable for children treated with initial 4-drug therapy (RIPE – rifampin, INH, pyrazinamide, ethambutol) for suspected active TB disease, once active disease has been ruled

• ut / when alternative diagnosis is made

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258

Pediatric LTBI: Summary

• INH is the best-studied drug in children
• 9 months INH is standard
• 6 months acceptable in some cases (WHO uses this; SF DPH

uses in children ≥ 15 years)

• RIF a good alternative and is standard in setting
• f INH resistance
• 4 months – LEFT OFF HERE
• 6 months

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258

Side Effects of LTBI Meds

• INH
• Hepatotoxicity:
• AST/ALT 2-3x ULN + symptoms
• AST/ALT 5x ULN + asymptomatic
• Occasional hyperbili, very rare liver failure
• Occurs in 0-6.5% on INH monotherapy; higher rates on

INH/RIF combo (up to ~15% in some studies)

• Peripheral neuropathy – give B6 for breastfed infants, HIV-

infected, pregnant, teens, malnutrition, or malabsorption

• GI upset – very common. Helps to give with food. Sorbitol-based

suspensions cause diarrhea  crush tablets (100 and 300 mg) and give with food

• Rash – in 2% on multidrug therapy (can be urticarial)

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258

Side Effects of LTBI Meds

• Rifampin, rifapentine
• Hepatotoxicity (same definition but less common than INH)
• AST/ALT 2-3x ULN + symptoms
• AST/ALT 5x ULN + asymptomatic
• Occasional hyperbili, very rare liver failure
• Occurs in on 0-2% on RIF monotherapy; higher rates in combination

with INH

• GI upset – very common (up to ~25%). Helps to give with food.
• Rash – in 2% on multidrug therapy
• Thrombocytopenia – in 3.4%; resolves after stopping RIF
• Pyrazinamide
• Hepatotoxicity – rare
• GI upset – abdominal pain in ~5% on multidrug therapy
• Rash – in 2% on multidrug therapy
• Joint pain – related to uric acid increases (which are common,

but usually within normal range and only rarely associated with joint pain)

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258

Addressing Barriers to Adherence

• Reasons for treating LTBI
• Educate family; excellent materials on CDC website
• Cultural concerns
• Materials in their language
• Address LTBI management in US vs. their country of origin
• Remembering to take the medication
• Review adherence strategies; consider directly observed therapy
• Duration of therapy
• Consider alternative regimens
• Cost
• DPH supervised therapy if available
• Concern about adverse events
• Review indications to stop therapy, monthly checks

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258

Addressing Barriers to Adherence

• Side effects the patient is experiencing
• Abdominal pain right away after INH  Take with food to

decrease gastric irritation

• Abdominal pain hours after INH or RIF, or associated with

vomiting or signs of jaundice  Stop medication immediately and contact medical provider

• Diarrhea on INH liquid  Change to crushed tablets
• Numbness/tingling in hands/feet on INH  B6

supplementation

• Joint pain on PZA  Check uric acid; if high, stop PZA
• Rash  Depends on presence of other signs of type-1

hypersensitivity reaction

• Headache  nonspecific; usually not attributable to TB

meds

Cruz & Starke, J Ped Inf Dis Soc 2013;(2):248-258

Curbside Question

How do I manage this patient who has been exposed to zoster? Would it be different if they were exposed to someone with primary varicella (chickenpox)?

www.cdc.gov/vaccines

Varicella Zoster Virus

• Herpesvirus
• Incubation period usually 2 weeks (range 10-21 days)
• Chickenpox / varicella  latency in sensory nerve

ganglia potential for shingles / zoster

• Varicella: 1-2 day prodrome (fever, malaise) with

itchy rash (crops of macules, papules, vesicles)

• ~250-500 lesions appearing in waves and then crusting over
• Complications: secondary bacterial infections, pneumonia,

cerebellar ataxia, encephalitis, hemorrhagic conditons

• 1/40,000 cases result in death
• Modified varicella (“breakthrough” varicella)
• Usually mild; <50 lesions, may be afebrile, rash shorter and may

have maculopapular lesions with fewer/less obvious vesicles

• Contagious, but less so

http://www.cdc.gov/chickenpox/about/photos.html:

Varicella Zoster Virus

Varicella in unvaccinated patient Breakthrough varicella in vaccinated patient

www.cdc.gov/vaccines

Varicella Zoster Virus

• Vaccine impact
• HUGE!!!
• Vaccine introduced in 1995
• 1 dose is 85% effective (any form of varicella) and almost 100%

effective against severe forms

• 2 doses are 98% effective (any form of varicella) and 100%

effective against severe forms

• Post-licensure studies: 2 doses were 88-98% effective

at preventing all varicella

AAP Red Book 2012; http://www.cdc.gov/chickenpox/hcp/healthcare-setting.html

VZV Exposure - Considerations

• Nature of exposure?
• Varicella – highly contagious; direct contact,

aerosolization of skin lesions or respiratory tract secretions

• Infectious from 1-2 days before rash onset until

all lesions are crusted (usually 4-7 days after

• nset of rash)
• Zoster – direct contact with mucous membranes
• Evidence of immunity
• Risk of complications

AAP Red Book 2012; http://www.cdc.gov/chickenpox/hcp/healthcare-setting.html

VZV Exposure - Considerations

• Nature of exposure
• Evidence of immunity?
• Up-to-date for age on vaccines
• Lab evidence of immunity or lab-confirmed

disease

• Varicella or zoster diagnosed by a health care

provider, or verification of history of disease

• Birth in the US prior to 1980 (unless pregnant,

immunocompromised, or health care professional)

• Risk of complications

AAP Red Book 2012; http://www.cdc.gov/chickenpox/hcp/healthcare-setting.html

VZV Exposure - Considerations

• Nature of exposure
• Zoster vs. varicella
• Evidence of immunity
• At risk for complications?
• Pregnant
• Preterm, born to unimmunized women
• Preterm, born before 28 weeks or < 1000 grams,

regardless of maternal status

• Immunocompromised patients

VZV Exposure

• If there is evidence of immunity – no intervention
• If not immune / unknown, your patient may be a

candidate for:

• Active immunization
• Passive immunization
• Chemoprophylaxis with acyclovir or valacyclovir

AAP Red Book 2012:

VZV Exposure

• Active immunization
• If > 12 months of age, give for 1st or 2nd dose of vaccine as

indicated based on vaccine history

• Ideally within 3 days of (but up to 5 days after) exposure
• May get varicella if exposed at same time as index case

MMWR July 19, 2013 / 62(28);574-576

VZV Exposure

• Passive immunoprophylaxis – Varicella-zoster

Immune Globulin

• VariZIG is currently the only preparation available in the

US (VZIG discontinued in 2006)

• Available under an IND protocol through FFF Enterprises,

800-843-7477 (www.fffenterprises.com)

• IVIG can be used if unable to obtain
• In 2012 FDA extended the period for administration from

96 hours to 10 days after exposure

• Ideally given ASAP after exposure
• Given to patients at high risk for severe disease without

evidence of immunity, who cannot receive the VZV vaccine

MMWR July 19, 2013 / 62(28);574-576

VZV Exposure

• Passive immunoprophylaxis candidates
• Immunocompromised patients
• Neonates whose mothers have signs/symptoms of

varicella 5 days before to 2 days after delivery

• No time for transfer of maternal Ab to baby
• Premature infants born at ≥ 28 weeks, exposed during

neonatal period, with mothers who have no evidence of immunity

• Premature infants born at < 28 weeks or with birthweight <

1000 g exposed during the neonatal period, regardless of their mother’s evidence of immunity status

• Pregnant women

AAP Red Book 2012

VZV Exposure

• Chemoprophylaxis
• Acyclovir or valacyclovir x 7 days, starting 7-10 days after

exposure

• Generally not indicated for routine use in healthy

susceptible children and adolescents (vaccination preferred)

• Consider for those who cannot receive vaccine, or who

refuse vaccine

• May prevent or attenuate varicella in healthy children (little

data to support)

• Unclear whether helps in immunocompromised patients,

but should receive prophylaxis if unable to receive immune globulin

Thank You!