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

BACKGROUND: 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 (i.v.) followed by oral (p.o) acyclovir in a cohort of immunocompromised children. METHODS: The cohort consisted of 26 immunocompromised children between the ages of 1.5 and 12.7 years (mean, 6.3). Therapy was commenced with i.v. acyclovir (1500 mg/m2/day in 3 divided doses). Concurrent management included holding or reducing immunosuppressive therapy (by 50%) and administering varicella-zoster immunoglobulin in 69% (11 of 16) of cases where exposure to chickenpox was recognized. Patients were eligible to switch to p.o therapy after receiving a minimum of 48 h of i.v. 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 (i.v. plus p.o). RESULTS: Of the 26 patients 25 were successfully switched from i.v. to p.o 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 p.o therapy had resolution of their disease and no patient required resumption of i.v. therapy. CONCLUSIONS: The sequential use of i.v. followed by p.o acyclovir is feasible in the treatment of varicella in immunocompromised children and results in a reduction in duration of intravenous therapy and hospitalization.