Red Book® Online -- Intravenous Acyclovir Shortage Recommendations Table

Red Book^® Online Table – NEW
Intravenous Acyclovir Shortage Recommendations for Pediatrics
Posted March 2009

Antiviral Recommendations for Herpes Simplex Virus (HSV) and Varicella Zoster Virus (VZV) Infections in Hospitalized Pediatric Patients during the Intravenous Acyclovir Shortage

These recommendations should be instituted in consultation with a pediatric infectious disease practitioner.
Until the national shortage is resolved, intravenous (IV) acyclovir should be reserved for the following priority conditions:

Neonates with proven HSV disease (20mg/kg/dose every 8 hours)
Pregnant women
Individuals with herpes simplex encephalitis.

Alternative regimens to intravenous acyclovir (when supplies are depleted) and alternatives for non-priority conditions are outlined below:

Condition	1st line therapy	2nd line therapy
Herpes simplex encephalitis and suspected/proven neonatal HSV disease	IV ganciclovir <90 days old: 6mg/kg every 12hrs >90 days old: 5mg/kg every 12hrs	IV foscarnet 60mg/kg every 12hrs
Skin recurrences following neonatal HSV disease (without CNS involvement at the time) [NOTE: with CNS involvement, see above recommendations for intravenous alternatives*]	Oral/ng tube acyclovir 20 mg/kg/dose four times a day; [max per dose: 800 mg (3200 mg/day)]	**Oral/ng tube valacyclovir 20 mg/kg/dose three times a day; [max per dose: 1000 mg (3000 mg/day)]
HSV gingivostomatitis or HSV infection in an immunocompetent host or Varicella infection in an immunocompetent host	**Oral/ng tube valacyclovir 20 mg/kg/dose three times a day; [max per dose: 1000 mg (3000 mg/day)]	Oral/ng tube acyclovir 20 mg/kg/dose four times a day; [max per dose: 800 mg (3200 mg/day)]
Zoster infection in an immunocompetent host	**Oral/ng tube valacyclovir 20 mg/kg/dose three times a day; [max per dose: 1000 mg (3000 mg/day)]	Oral/ng tube acyclovir 20 mg/kg/dose five times a day; [max per dose: 800 mg (4000 mg/day)]
Treatment of HSV / VZV infection in immunocompromised hosts and those unable to take oral acyclovir or valacyclovir	IV ganciclovir <90 days old: 6mg/kg every 12hrs >90 days old: 5mg/kg every 12hrs	IV foscarnet 60mg/kg every12hrs (may used as first line therapy if concerned about neutropenia and less concerned about renal function)

*Until the national shortage is resolved, IV acyclovir should be reserved for the following priority conditions: 1) Neonates with proven HSV disease (20mg/kg/dose every 8 hours); 2) Pregnant women; 3) Individuals with herpes simplex encephalitis.
**limited data exist in infants <3 months of age.
Drug Side Effect Monitoring:
Ganciclovir – monitor CBC d/p and BMP
Foscarnet - monitor BMP with Ca, Mg, and P

Table compiled by Natasha Halasa, MD, based upon the COID table published in March 2009 AAP News ("Ganciclovir may be used during intravenous acyclovir shortage," David W. Kimberlin, MD, FAAP). Table further modified based upon input by the NIAID Collaborative Antiviral Study Group investigators.