Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

potential exposure

1st line – cleansing exposed area

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INITIAL
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potential exposure
1st line – 

cleansing exposed area

If a potential B virus exposure occurs, the immediate response should aim at preventing exposure from progressing to infection. Thus, the critical first step is immediate and thorough cleansing of the exposed area. The area should be cleansed on presentation for medical evaluation regardless of whether or not it was previously cleansed. The exposed area should be thoroughly washed and gently scrubbed with soap, povidone-iodine, or detergent for 15 minutes, followed by irrigating the area with running water for 15 to 20 minutes.[42] Mucosal exposure (nose, eyes, mouth) should be flushed with sterile saline solution or water for 15 minutes.

The cleansed exposure area should be evaluated by a third party for adequacy of washing, and repeated if necessary. The date, time, location, nature, and site of injury, and the type of fluid or tissue exposure should also be recorded. The first few minutes after an exposure are considered the most critical period for reducing the risk of infection.

Plus – infection control measures

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INITIAL
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potential exposure
Plus – 

infection control measures

Treatment recommended for ALL patients in selected patient group

Infection control is critical for the management of all patients with suspected B virus infection. Anyone treating or attending to patients with suspected infection must follow standard blood and body fluid precautions.[53] Infection control practitioners should be consulted for further instruction.

Infection control measures should be carried out regardless of whether the patient is receiving antiviral treatment. B virus has been isolated from skin lesions and buccal mucosa of patients actively receiving high-dose intravenous aciclovir.[34]

Plus – consider high-dose oral antiviral prophylaxis

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INITIAL
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potential exposure
Plus – 

consider high-dose oral antiviral prophylaxis

Treatment recommended for ALL patients in selected patient group

Post-exposure prophylaxis (PEP) should be considered if B virus exposure is suspected based on history and physical examination, and the patient presents within 5 days of potential exposure. It is not recommended for patients who present more than 5 days after potential exposure.

The recommended first-line antiviral is high-dose oral valaciclovir. The alternative is high-dose oral aciclovir.[4]

All patients who have experienced B virus exposure should be monitored for changes in serological titres and onset of clinical signs and symptoms suggestive of B virus infection. Patients who present more than 5 days after exposure should be followed with monitoring alone.

PEP should be administered while diagnostic tests are being carried out to confirm infection. Prophylaxis should continue for 14 days or until B virus infection can be excluded.

In women of childbearing age who present with suspected B virus exposure, a pregnancy test should be carried out to aid in the decision of which antiviral to choose. Extensive clinical experience suggests that administering aciclovir during pregnancy is reasonably safe. A registry of women who received the drug during pregnancy showed no increase in congenital abnormalities, although numbers were limited and insufficiently powered to detect low-incidence adverse outcomes.[54][55][56] 

In children exposed to B virus, oral valaciclovir may be considered for prophylaxis owing to its recommended use in treating varicella infection in children aged 2 to 18 years. Furthermore, studies investigating the pharmacokinetics and safety of valaciclovir oral suspension have shown it to be well tolerated and safe in children aged 3 months and older.[57] There are no specific recommendations for treating B virus exposures and disease in children; therefore, an infectious disease specialist should be consulted for advice on adaptation of existing guidelines in adults and antiviral dosing in children.

Primary options

valaciclovir: children: consult specialist for guidance on dose; adults: 1 g orally every 8 hours for 14 days

OR

aciclovir: children: consult specialist for guidance on dose; adults: 800 mg orally five times daily for 14 days

Plus – consider prophylaxis for potential co-infections

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INITIAL
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potential exposure
Plus – 

consider prophylaxis for potential co-infections

Treatment recommended for ALL patients in selected patient group

Exposure from the bite or scratch from monkeys may lead to co-infections such as tetanus, rabies, or bacterial infections.

Reviewing the vaccine history of a patient may be useful to determine whether further vaccinations are required.

Antibacterial treatment of bites should be considered. Prophylactic administration of antibiotics or rabies vaccine and rabies immune globulin may also be considered depending on the cause and severity of exposure and the risk that exposure presents for infections other than B virus.

If the animal associated with exposure has been used in research, specific infections that may have occurred during the research history may be clinically relevant (e.g., simian immunodeficiency virus [SIV] or HIV) and should be investigated.

ACUTE

confirmed infection and/or symptomatic

1st line – high-dose intravenous antiviral therapy

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ACUTE
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confirmed infection and/or symptomatic
1st line – 

high-dose intravenous antiviral therapy

Patients with confirmed B virus infection or who develop signs and/or symptoms consistent with B virus disease after exposure should be treated with intravenous antiviral therapy. Higher antiviral doses than those used to treat HSV infection are required to ensure effectiveness against B virus.

If central nervous system (CNS) disease is present, high-dose intravenous ganciclovir is the recommended first-line treatment.[4] High-dose intravenous aciclovir is the recommended first-line treatment for B virus disease in the absence of CNS disease. High-dose intravenous ganciclovir can be used as an alternative to aciclovir, and should be preferred in any patient who appears to progress on aciclovir or who develops signs and symptoms of CNS disease.[4]

Patients already receiving an oral antiviral as PEP who have onset of symptomatic disease compatible with B virus should be switched to high-dose intravenous antiviral therapy immediately. Treatment should continue until B virus infection has resolved.

Patients receiving aciclovir should be well hydrated to prevent precipitation of the drug in the renal tubules and renal insufficiency. Creatinine levels also need to be monitored, and dosage adjusted accordingly. If patients develop additional symptoms while being treated with aciclovir, clinical evaluation is needed to consider whether treatment should be switched to ganciclovir. As is the case with aciclovir, the dosage of ganciclovir needs to be adjusted for renal insufficiency. White blood cell and platelet counts should be monitored closely due to the myelosuppressive effects of ganciclovir.

In women of childbearing age with confirmed B virus infection, a pregnancy test should be carried out to aid in the decision of which antiviral to choose. Extensive clinical experience suggests that administering aciclovir during pregnancy is reasonably safe. A registry of women who received the drug during pregnancy showed no increase in congenital abnormalities, although numbers were limited and insufficiently powered to detect low-incidence adverse outcomes.[54][55][56] However, the theoretical risk of ganciclovir to the fetus must be weighed against the documented risk of B virus encephalitis for the mother during clinical decision making. Ganciclovir is indicated in any CNS infection.

There are no specific recommendations for treating B virus infection in children; therefore, an infectious disease specialist should be consulted for advice on adaptation of existing guidelines in adults and antiviral dosing in children.

Primary options

aciclovir: children: consult specialist for guidance on dose; adults: 12.5 to 15 mg/kg intravenously every 8 hours

OR

ganciclovir: children: consult specialist for guidance on dose; adults: 5 mg/kg intravenously every 12 hours

Plus – infection control measures

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ACUTE
|
confirmed infection and/or symptomatic
Plus – 

infection control measures

Treatment recommended for ALL patients in selected patient group

Infection control is critical for management of all patients with confirmed B virus infection, and/or those who have symptoms suggesting B virus infection. There has been no documented case of asymptomatic human B virus infection.

Anyone treating or attending to patients with confirmed infection must follow standard blood and body fluid precautions.[53] Infection control practitioners should be consulted for further instruction.

Infection control measures should be carried out regardless of whether the patient is receiving antiviral treatment. B virus has been isolated from skin lesions and buccal mucosa of patients actively receiving high-dose intravenous aciclovir.[34]

Plus – supportive care

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ACUTE
|
confirmed infection and/or symptomatic
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Beyond the described recommendations for antiviral therapy and diagnostic testing, management of B virus-infected people is largely supportive.

Adequate hydration, use of antipyretics for fever, anti-emetics for vomiting, and analgesia for headaches may be instituted in symptomatic patients.

Management decisions must be made at the bedside based on clinical judgement of the treating physician in association with engaged infectious disease specialists.

Plus – intensive care unit care

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ACUTE
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confirmed infection and/or symptomatic
|
with encephalitis
Plus – 

intensive care unit care

Treatment recommended for ALL patients in selected patient group

Usually indicated for patients with encephalitis. Death is often associated with respiratory failure. Management decisions must be made at the bedside based on clinical judgement of the treating physician in association with engaged infectious disease specialists.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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