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. Author manuscript; available in PMC: 2010 Dec 1.
Published in final edited form as: Am J Transplant. 2009 Dec;9(Suppl 4):S108–S115. doi: 10.1111/j.1600-6143.2009.02901.x

Table 2.

Recommendations for VZV Prevention in Solid Organ Transplant Recipients

Strategy Pre-Transplant Post-Transplant Dosing Comments
Primary Prevention
Antiviral Prophylaxis

  • Dosing based on HSV prevention. Evidence in other populations for effectiveness against VZV, however limited data in SOT recipients.

  • IV acyclovir is recommended in children <2 yrs of age [5 mg/kg IV every 8 hours] or those who cannot tolerate oral therapy

  • Alternate less frequent dosing (BID) for acyclovir has been described but has not been evaluated in SOT populations

  • Lifelong risk of HZ limits use of these agents for long-term prevention.

  • Patients receiving CMV prophylaxis generally should be protected from VZV reactivation

  • Valacyclovir is only recommended for children 2 to <18 years of age and has not been studied as a prophylactic agent in children post-SOT
  Acyclovir (and pro-drugs) N/A Consider, short term
prophylaxis if patients
not receiving CMV
prophylaxis
(Evidence III)		 Acyclovir
600-1000 mg/day PO in 3-5 divided doses
(adults and children ≥ 2 yrs)
Max dose in children is 80 mg/kg/day not to
exceed 1000 mg

OR

Valacyclovir
500 mg PO twice daily (adults only)§
Vaccination

  • Vaccination has been shown to be safe in ESRD and ESLD patients

  • Seroconversion rate reduced in immunosuppressed individuals

  • Caution should be used in post-transplant patients since live virus vaccine

  • Second dose can be given 4 weeks after first (see package insert for administration)
 Varicella Vaccine (Varivax®) YES, if seronegative
(Evidence II-1)		 Consider if susceptible
in select populations
(Evidence III)		 Varivax®
0.5 mL administered SQ
 Zoster Vaccine (Zostavax®) No for most transplant
recipients (Evidence III),
unless patient meets
label indications
(Evidence I)		 No
(Evidence III)		 N/A

  • Follow label indications, as no evidence that vaccine is safe in severe organ dysfunction or post-transplant

  • If patient meets label indications can be considered, but should be given at least 3-4 weeks prior to transplant.
Secondary Prevention (Post-exposure)
Immunoprophylaxis

  • VariZIG is only available through IND protocol†

  • Must be given as soon as possible – no efficacy if given more than 96 hours post-exposure

  • Not 100% effective in clinical studies of preventing VZV, so close observation is suggested

  • If varicella develops, patient should be treated with antiviral therapy
 VZV immunoglobulin (VZIG, VariZIG™) YES, if seronegative
(Evidence II-1)		 YES, if susceptible
(Evidence II-1)		 VariZIG
125 units/10 kg body weight in single IM dose
(Max dose is 625 units, min 125 units)
 IV immunoglobulin (non-specific IVIG) Consider, if VZIG or
VariZIG not available
(Evidence III)		 Consider, if VZIG or
VariZIG not available
(Evidence III)		 IVIG
400 mg/kg IV single dose

  • Amount of anti-VZV antibodies in IVIG is variable, and should only be considered if VZV specific immunoglobulin therapy is not available
Antiviral Prophylaxis

  • Given 7-10 days after exposure for 7 days

  • Alternatively, some experts recommend dosing being given days 3-22 after exposure (or till day 28 if given immunoprophylaxis)

  • Caution with patients with underlying renal dysfunction as dosing may need to be reduced

  • IV acyclovir is recommended in children <2 yrs of age [10 mg/kg IV every 8 hours] or those who cannot tolerate oral therapy

  • Valacyclovir is only recommended for children 2 to <18 years of age and has not been studied as a prophylactic agent in children post-SOT
  Acyclovir‡ (and pro-drugs) Consider, if VZIG or
VariZIG not available or
in addition to
immunoprophylaxis
(Evidence III)		 Consider, if VZIG or
VariZIG not available
or in addition to
immunoprophylaxis
(Evidence III)		 Acyclovir
800 mg PO four times daily( adults)
20 mg/kg PO four times daily
(maximum 800 mg four times a day, ≥ 2 yrs
of age)

OR

Valacyclovir
1 gram PO three times daily (adults)

VZV= Varicella zoster virus, HSV = Herpes simplex virus, SOT = Solid organ transplant, ESRD= End-stage renal disease, ESLD=End-stage liver disease

†

Contact information for VariZIG is available online at: (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55e224a1.htm)

‡

Valacyclovir is preferred as oral acyclovir may have poor bioavailability and unpredictable absorption