Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• STD Treatment Guidelines   at http://www.cdc.gov/STD/treatment

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1993 Sexually Transmitted Diseases Treatment Guidelines

09/24/1993

SUGGESTED CITATION
Centers for Disease Control and Prevention. 1993 Sexually
transmitted diseases treatment guidelines. MMWR 1993;42(No. RR-14):
{inclusive page numbers}.

CIO Responsible for this publication:
National Center for Prevention Services,
Division of Sexually Transmitted Diseases and HIV Prevention

Genital Herpes Simplex Virus Infections
     
     Genital herpes is a viral disease that may be recurrent and
has no cure. Two serotypes of HSV have been identified: HSV-1 and
HSV-2; most cases of genital herpes are caused by HSV-2. On the
basis of serologic studies, approximately 30 million persons in the
United States may have genital HSV infection.

     Most infected persons never recognize signs suggestive of
genital herpes; some will have symptoms shortly after infection and
then never again. A minority of the total infected U.S. population
will have recurrent episodes of genital lesions. Some cases of
first clinical episode genital herpes are manifested by extensive
disease that requires hospitalization. Many cases of genital herpes
are acquired from persons who do not know that they have a genital
infection with HSV or who were asymptomatic at the time of the
sexual contact.

     Randomized trials show that systemic acyclovir provides
partial control of the symptoms and signs of herpes episodes when
used to treat first clinical episodes, or when used as suppressive
therapy. However, acyclovir neither eradicates latent virus nor
affects subsequent risk, frequency, or severity of recurrences
after administration of the drug is discontinued. Topical therapy
with acyclovir is substantially less effective than the oral drug
and its use is discouraged. Episodes of HSV infection among
HIV-infected patients may require more aggressive therapy.
Immunocompromised persons may have prolonged episodes with
extensive disease. For these persons, infections caused by
acyclovir-resistant strains require selection of alternate
antiviral agents.

First Clinical Episode of Genital Herpes

Recommended Regimen -
     Acyclovir 200 mg orally 5 times a day for 7-10 days or until
     clinical resolution is attained.

First Clinical Episode of Herpes Proctitis

Recommended Regimen -
     Acyclovir 400 mg orally 5 times a day for 10 days or until
     clinical resolution is attained.

Recurrent Episodes
     When treatment is instituted during the prodrome or within 2
days of onset of lesions, some patients with recurrent disease
experience limited benefit from therapy. However, since early
treatment can seldom be administered, most immunocompetent patients
with recurrent disease do not benefit from acyclovir treatment, and
it is not generally recommended.

Recommended Regimen -
     Acyclovir 200 mg orally 5 times a day for 5 days,
                         or
     Acyclovir 400 mg orally 3 times a day for 5 days,
                         or
     Acyclovir 800 mg orally 2 times a day for 5 days.

Daily Suppressive Therapy
     Daily suppressive therapy reduces the frequency of HSV
recurrences by at least 75% among patients with frequent
recurrences (i.e., <M>six or more recurrences per year).
Suppressive treatment with oral acyclovir does not totally
eliminate symptomatic or asymptomatic viral shedding or the
potential for transmission. Safety and efficacy have been
documented among persons receiving daily therapy for as long as 5
years. Acyclovir-resistant strains of HSV have been isolated from
some persons receiving suppressive therapy, but these strains have
not been associated with treatment failure among immunocompetent
patients. After 1 year of continuous suppressive therapy, acyclovir
should be discontinued to allow assessment of the patient's rate of
recurrent episodes.

Recommended Regimen -
     Acyclovir 400 mg orally 2 times a day.

Alternative Regimen -
     Acyclovir 200 mg orally 3-5 times a day.

     The goal of the alternative regimen is to identify for each
patient the lowest dose that provides relief from frequently
recurring symptoms.

Severe Disease
     Intravenous (IV) therapy should be provided for patients with
severe disease or complications necessitating hospitalization
(e.g., disseminated infection that includes encephalitis,
pneumonitis, or hepatitis).

Recommended Regimen -
     Acyclovir 5-10 mg/kg body weight IV every 8 hours for 5-7 days
     or until clinical resolution is attained.

Other Management Considerations
     Other considerations for managing patients with genital HSV
infection are as follows:

--   Patients should be advised to abstain from sexual activity
     while lesions are present.

--   Patients with genital herpes should be told about the natural
     history of the disease, with emphasis on the potential for
     recurrent episodes, asymptomatic viral shedding, and sexual
     transmission. Sexual transmission of HSV has been documented to
     occur during periods without evidence of lesions. Many cases are
     transmitted during such asymptomatic periods.

     The use of condoms should be encouraged during all sexual
exposures. The risk for neonatal infection should be explained to
all patients -- male and female -- with genital herpes. Women of
childbearing age who have genital herpes should be advised to
inform health-care providers who care for them during pregnancy
about their HSV infection.

Management of Sex Partners
     Sex partners of patients who have genital herpes are likely to
benefit from evaluation and counseling. Symptomatic sex partners
should be managed in the same manner as any patient with genital
lesions. However, the majority of persons with genital HSV
infection do not have a history of typical genital lesions. These
asymptomatic persons may benefit from evaluation and counseling;
thus, even asymptomatic partners should be queried about histories
of typical and atypical genital lesions and encouraged to examine
themselves for lesions in the future.

     Commercially available HSV type-specific antibody tests have
not demonstrated adequate performance characteristics; their use is
not currently recommended. Sensitive and specific type-specific
serum antibody assays now utilized in research settings might
contribute to future intervention strategies. Should tests with
adequate sensitivity and specificity become commercially available,
it might be possible to accurately identify asymptomatic persons
infected with HSV-2, to focus counseling on how to detect lesions
by self-examination, and to reduce the risk for transmission to sex
partners.

Special Considerations

Allergy, Intolerance, or Adverse Reactions -
     Effective alternatives to therapy with acyclovir are not
available.

HIV Infection -
     Lesions caused by HSV are relatively common among patients
infected with HIV. Intermittent or suppressive therapy with oral
acyclovir may be needed.

     The acyclovir dosage for HIV-infected persons is
controversial, but experience strongly suggests that
immunocompromised patients benefit from increased dosage. Regimens
such as 400 mg orally 3 to 5 times a day, as used for other
immunocompromised persons, have been found useful. Therapy should
be continued until clinical resolution is attained.

     For severe disease, IV acyclovir therapy may be required. If
lesions persist among patients undergoing acyclovir treatment,
resistance to acyclovir should be suspected. These patients should
be managed in consultation with an expert. For severe disease
because of proven or suspected acyclovir-resistant strains,
hospitalization should be considered. Foscarnet, 40 mg/kg body
weight IV every 8 hours until clinical resolution is attained,
appears to be the best available treatment.

Pregnancy -
     The safety of systemic acyclovir therapy among pregnant women
has not been established. Burroughs Wellcome Co., in cooperation
with CDC, maintains a registry to assess the effects of the use of
acyclovir during pregnancy. Women who receive acyclovir during
pregnancy should be reported to this registry (1-800-722-9292, ext.
58465).

     Current registry findings do not indicate an increase in the
number of birth defects identified among the prospective reports
when compared with those expected in the general population.
Moreover, no consistent pattern of abnormalities emerges among
retrospective reports. These findings provide some assurance in
counseling women who have had inadvertent prenatal exposure to
acyclovir. However, accumulated case histories comprise a sample of
insufficient size for reaching reliable and definitive conclusions
regarding the risks of acyclovir treatment to pregnant women and to
their fetuses.

     In the presence of life-threatening maternal HSV infection
(e.g., disseminated infection that includes encephalitis,
pneumonitis, or hepatitis), acyclovir administered IV is indicated.
Among pregnant women without life-threatening disease, systemic
acyclovir should not be used to treat recurrences nor should it be
used as suppressive therapy near-term (or at other times during
pregnancy) to prevent reactivation.

Perinatal Infections
     Most mothers of infants who acquire neonatal herpes lack
histories of clinically evident genital herpes. The risk for
transmission to the neonate from an infected mother appears highest
among women with first episode genital herpes near the time of
delivery, and is low ( less than or equal to 3%) among women with
recurrent herpes. The results of viral cultures during pregnancy do
not predict viral shedding at the time of delivery, and such
cultures are not routinely indicated.

     At the onset of labor, all women should be carefully
questioned about symptoms of genital herpes and should be examined.
Women without symptoms or signs of genital herpes infection (or
prodrome) may deliver their babies vaginally. Among women who have
a history of genital herpes, or who have a sex partner with genital
herpes, cultures of the birth canal at delivery may aid in
decisions relating to neonatal management.

     Infants delivered through an infected birth canal (proven by
virus isolation or presumed by observation of lesions) should be
followed carefully, including virus cultures obtained 24-48 hours
after birth. Available data do not support the routine use of
acyclovir as anticipatory treatment for asymptomatic infants
delivered through an infected birth canal. Treatment should be
reserved for infants who develop evidence of clinical disease and
for those with positive postpartum cultures.

     All infants with evidence of neonatal herpes should be treated
with systemic acyclovir or vidarabine; refer to the Report of the
Committee on Infectious Diseases, American Academy of Pediatrics
(13). For ease of administration and to lower toxicity, acyclovir
(30 mg/kg/day for 10-14 days) is the preferred drug. The care of
these infants should be managed in consultation with an expert.

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