MUCH LESS = MORE WITH ANTIVIRUS

Much less = more with antivirus

Much less = more with antivirus

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Episodic treatment of recurrent herpes is most effective if therapy is initiated within 1 day of lesion onset or during the prodrome that precedes some outbreaks. The patient should be provided with a supply of drug or a prescription for the medication with instructions to initiate treatment immediately when symptoms begin. Acyclovir, famciclovir, and valacyclovir appear equally effective for episodic treatment of genital herpes (466–470).

Recommended Regimens for Episodic Therapy for Recurrent HSV-2 Genital Herpes*
Acyclovir 800 mg orally 2 times/day for 5 days
OR

Acyclovir 800 mg orally 3 times/day for 2 days
OR

Famciclovir 1 gm orally 2 times/day for 1 day
OR

Famciclovir 500 mg once, followed by 250 mg 2 times/day for 2 days
OR

Famciclovir 125 mg 2 times/day for 5 days
OR

Valacyclovir 500 mg orally 2 times/day for 3 days
OR

Valacyclovir 1 gm orally once daily for 5 days

*Acyclovir 400 mg orally 3 times/day is also effective, but are not recommended because of frequency of dosing.

Severe Disease
Intravenous (IV) acyclovir therapy (5–10 mg/kg body weight IV every 8 hours) should be provided for patients who have severe HSV disease or complications that necessitate hospitalization (e.g., disseminated infection, pneumonitis, or macrobid 50 mg canada hepatitis) or CNS complications (e.g., meningitis or encephalitis). HSV-2 meningitis is a rare complication of HSV-2 genital herpes infection that affects women more than men (480). IV therapy should be considered until clinical improvement followed by oral antiviral therapy to complete >10 days of total therapy. Longer duration is recommended for CNS complications. HSV-2 meningitis is characterized clinically by signs of headache, photophobia, fever, meningismus, and cerebrospinal fluid (CSF) lymphocytic pleocytosis, accompanied by mildly elevated protein and normal glucose (481). Optimal therapies for HSV-2 meningitis have not been well studied (482); however, acyclovir 5–10 mg/kg body weight IV every 8 hours until clinical improvement is observed, followed by high-dose allegra 120mg generic oral antiviral therapy (valacyclovir 1 g 3 times/day) to complete a 10- to 14-day course of total therapy, is recommended. For patients with previous episodes of documented HSV-2 meningitis, oral valacyclovir may be used for the entire course during episodes of recurrent HSV-2 meningitis. A randomized clinical trial indicated that suppressive therapy (valacyclovir 500 mg 2 times/day) did not prevent recurrent HSV-2 meningitis episodes; however, the dose might not have been sufficient for CNS penetration (483). Valacyclovir 500 mg 2 times/day is not recommended for suppression of HSV-2 meningitis; higher doses have not been studied in clinical trials. HSV meningitis should be distinguished from encephalitis, which requires a longer course (14–21 days) of IV therapy. Impaired renal function warrants an adjustment in acyclovir dosage.

Hepatitis
Hepatitis is a rare manifestation of disseminated HSV infection, often reported among pregnant women who acquire HSV during pregnancy (484). Pregnant women in any trimester can present with fever and hepatitis (markedly elevated transaminases) but might not have any genital or skin lesions. HSV hepatitis is associated with fulminant liver failure and high mortality (25%). Therefore, a high index of suspicion for HSV is necessary, with a confirmatory diagnosis by HSV PCR from blood (485). Among pregnant women with fever and unexplained severe hepatitis, disseminated HSV infection should be considered, and empiric IV acyclovir should be initiated pending confirmation (484).

Prevention
Consistent and correct condom use has been reported in multiple studies to decrease, but not eliminate, the risk for HSV-2 transmission from men to women (486–488). Condoms are less effective for preventing transmission from women to men (489). Two randomized clinical trials of medical male circumcision (MMC) demonstrated a decreased risk for HSV-2 acquisition among men in Uganda and South Africa (66,68). Results from a third trial conducted in Kenya did not demonstrate a substantial difference in HSV-2 acquisition among men who received MMC (490). A systematic review indicated high consistency for decreased risk for HSV-2 acquisition among women with a male partner who underwent MMC (491). These data indicate that MMC can be associated with decreased risk for HSV-2 acquisition among adult heterosexual men and with decreased risk macrobid 100mg online for HSV-2 transmission from male to female partners.

Randomized clinical trials have demonstrated that PrEP with daily oral TDF/FTC decreases the risk for HSV-2 acquisition by 30% in heterosexual partnerships (492). Pericoital intravaginal tenofovir 1% gel also decreases the risk for HSV-2 acquisition among heterosexual women (493). Among MSM and transgender women, daily oral TDF/FTC decreases the risk for severe ulcers with symptomatic genital HSV-2 infection but not for HSV-2 acquisition (494). Insufficient evidence exists that TDF/FTC use among those who are not at risk for HIV acquisition will prevent HSV-2 infection, and it should not be used for that sole purpose. Oral TDF does not prevent HSV-2 acquisition among persons with HIV infection who are taking TDF as part of their ART regimen (495). No data indicate that antivirals (acyclovir, valacyclovir, or famciclovir) can be taken as PrEP by persons without HSV-2 to prevent its acquisition.


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