Management strategies depend on disease severity and focus on the following principles:
Infection prevention and control
Symptomatic treatment
Optimized supportive care
Management of skin lesions and wound care
Management of complications
Antiviral therapy.
Patients benefit from supportive care and pain control that is implemented early in the disease course. However, this may not be adequate in some patients (e.g., immunocompromised patients), and antiviral therapy may be required.[136]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of mpox. Jul 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
There is a lack of high-quality evidence-based clinical management guidelines to guide clinical decision-making. Recommendations across guidelines vary, and there are limited recommendations for different risk groups and complications.[248]Webb E, Rigby I, Michelen M, et al. Availability, scope and quality of monkeypox clinical management guidelines globally: a systematic review. BMJ Glob Health. 2022 Aug;7(8):e009838.
https://gh.bmj.com/content/7/8/e009838
http://www.ncbi.nlm.nih.gov/pubmed/35973747?tool=bestpractice.com
The recommendations in this section are mainly based on guidelines from the World Health Organization (WHO) and apply to patients with suspected or confirmed infection.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Consider consultation with specialists in infectious diseases, dermatology, wound care, gastroenterology, neurology, ophthalmology, urology, critical care, and surgery as appropriate.
Infection prevention and control
Immediately contact your regional infectious disease unit if there is a clinical suspicion of infection.
This will trigger procedures to be activated for the safe transfer of the patient to a negative-pressure isolation facility and the notification of the public health team.
It is important to keep records of everyone who has been in close contact with the symptomatic patient (e.g., household contacts, paramedical and medical staff) and whether there are any potential animal carriers present.
All suspected or confirmed cases should be managed by experts, including public health officials, to prevent a potential emergency situation.
Follow your local infection prevention and control protocols.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Standard, contact, and droplet precautions are recommended.
Airborne precautions are recommended when caring for suspected cases of mpox if chickenpox is suspected and until it is excluded. Respirators are recommended when caring for patients with confirmed mpox. Airborne precautions are recommended if aerosol-generating procedures are performed.
Treat all contaminated materials (e.g., linens, hospital gowns) and body fluids/solid waste of patients as potentially infectious.
Ideally all personnel likely to be in contact with the patient, bodily fluids, or fomites should have been vaccinated with the smallpox vaccine.
Postexposure vaccination may be recommended for unvaccinated contacts (see Prevention).
Healthcare workers who are pregnant or severely immunocompromised should not assess or care for patients with suspected or confirmed infection, where possible.[179]UK Health Security Agency; Public Health Wales; Public Health Agency (Northern Ireland). Principles for control of non-HCID mpox in the UK: 4 nations consensus statement. Jan 2023 [internet publication].
https://www.gov.uk/government/publications/principles-for-monkeypox-control-in-the-uk-4-nations-consensus-statement
Mild or uncomplicated disease
Most cases are mild and self-limited and patients recover generally within 2 to 4 weeks.[26]World Health Organization. Mpox (monkeypox): fact sheet. Apr 2023 [internet publication].
https://www.who.int/en/news-room/fact-sheets/detail/monkeypox
Patients with suspected or confirmed infection and with mild or uncomplicated disease and who are not at high risk for severe or complicated disease may be isolated at home for the duration of the infectious period, provided that a home assessment determines that infection prevention and control conditions can be met in the home setting.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Make decisions on a case-by-case basis. Base decisions on factors such as clinical severity, presence of complications, patient care needs, nutrition and hydration status, risk factors for severe disease, and access to medical care if condition deteriorates. Patients should be ambulatory, have good water and food intake, and be able to manage their self-care.
Consider admission to a health facility for patients who are at higher risk of severe disease (e.g., children, pregnant women, immunocompromised people, people with skin conditions) for closer monitoring. Also consider admitting patients who live with vulnerable populations where adequate infection prevention and control precautions cannot be met.
Follow-up should be conducted using telemedicine or telephone where possible.
It is important that the patient follows their regional home self-isolation guidelines. See Patient discussions.
In the UK, the UK Health Security Agency (UKHSA) recommends that possible or probable cases may self-isolate at home, based on an assessment by the clinician and following UKHSA guidance. Possible or probable cases with a travel history to West or Central Africa may need to be managed as having a high consequence infectious disease (HCID); discuss with the Imported Fever Service.[180]UK Health Security Agency. Mpox (monkeypox): case definitions. January 2023 [internet publication].
https://www.gov.uk/guidance/monkeypox-case-definitions
Assess all confirmed (or highly probable) cases for the need for admission based on either clinical or self-isolation requirements, and notify the local health protection team.
Admit patients who require hospital admission for clinical reasons, or those for whom self-isolation is not possible for social or medical reasons following clinical assessment, to a single room at a negative or neutral pressure at a local hospital site with respiratory protective equipment and personal protective equipment (with appropriate infection prevention and control).
NHS England recommends using a risk-stratified clinical approach to aid these decisions.[213]NHS England. Management of laboratory confirmed mpox infections. February 2023 [internet publication].
https://www.england.nhs.uk/publication/management-of-laboratory-confirmed-mpox-infections
All clade II (clade IIa and clade IIb) virus infections are not classified as an HCID in the UK. However, infections caused by the clade I virus are considered to be an HCID.[249]UK Health Security Agency. HCID status of mpox (monkeypox). January 2023 [internet publication].
https://www.gov.uk/guidance/hcid-status-of-monkeypox
There is an increased risk of unrecognized HCID infections circulating on the background of clade II infections, following a cluster of sexually transmitted clade I infections identified in 2023.[215]UK Health Security Agency. Mpox (monkeypox): diagnostic testing. Jan 2024 [internet publication].
https://www.gov.uk/guidance/monkeypox-diagnostic-testing
Appropriate symptomatic treatment (with attention to pain control) and supportive care are recommended.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Treatment should be started early in the disease course.
Pain
Pain management is an important part of treatment as pain is common and may be severe (e.g., rectal pain/proctitis, pain from lesions, pain from mucosal lesions not evident on physical exam, pain from lymphadenopathy, headache, muscle aches).
A multimodal approach including nonpharmacologic and pharmacologic therapies is recommended. Topical and/or systemic therapies may be required. Pain management strategies should be individualized, patient-centered, and tailored to the needs and context of an individual patient. Assess pain initially, and then regularly assess pain control and adjust pain management as required. Consultation with a pain specialist may be required for refractory cases. Prolonged follow-up is recommended to quickly diagnose prolonged nociceptive syndromes.[250]Centers for Disease Control and Prevention. Clinical considerations for pain management of mpox. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pain-management.html
[251]Hans GH, Wildemeersch D, Meeus I. Integrated analgesic care in the current human monkeypox outbreak: perspectives on an integrated and holistic approach combining old allies with innovative technologies. Medicina (Kaunas). 2022 Oct 15;58(10):1454.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9612138
http://www.ncbi.nlm.nih.gov/pubmed/36295614?tool=bestpractice.com
Over-the-counter medications such as acetaminophen or ibuprofen are recommended for mild pain.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[250]Centers for Disease Control and Prevention. Clinical considerations for pain management of mpox. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pain-management.html
Opioids such as tramadol or morphine are recommended for the short-term management of severe pain (e.g., severe rectal pain due to proctitis) after an assessment of the benefits and risks associated with opioid use (e.g., constipation, opioid use disorder with long-term use).[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[250]Centers for Disease Control and Prevention. Clinical considerations for pain management of mpox. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pain-management.html
Neuropathic pain agents (e.g., gabapentin) have been used for the short-term management of pain in some circumstances (e.g., severe proctitis) based on anecdotal reports.[250]Centers for Disease Control and Prevention. Clinical considerations for pain management of mpox. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pain-management.html
Salt water rinses, antiseptic mouthwashes (e.g., chlorhexidine), and local anesthetics (e.g., viscous lidocaine) are recommended for oral lesions.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[250]Centers for Disease Control and Prevention. Clinical considerations for pain management of mpox. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pain-management.html
Warm sitz baths and/or topical lidocaine are recommended for genital or anorectal lesions. Topical corticosteroids may also be used for genital lesions; however, the risks and benefits of using these agents on active lesions must be considered.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[250]Centers for Disease Control and Prevention. Clinical considerations for pain management of mpox. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pain-management.html
Early treatment with the antiviral tecovirimat (see Antiviral therapy below) may help with pain control in patients with severe proctitis, based on case reports.[252]Lucar J, Roberts A, Saardi KM, et al. Monkeypox virus-associated severe proctitis treated with oral tecovirimat: a report of two cases. Ann Intern Med. 2022 Aug 18 [Epub ahead of print].
https://www.acpjournals.org/doi/10.7326/L22-0300
http://www.ncbi.nlm.nih.gov/pubmed/35981225?tool=bestpractice.com
However, there is no evidence to support this.
Despite pain management being a key consideration of management (over half of patients report some degree of pain), there is currently no high-quality evidence to guide clinical decision-making. There is a lack of randomized controlled trials and paucity of research in this area to help standardize a pain control plan.[253]Hallo-Carrasco A, Hunt CL, Prusinski CC, et al. Pain associated with monkeypox virus: a rapid review. Cureus. 2023 Feb;15(2):e34697.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9995223
http://www.ncbi.nlm.nih.gov/pubmed/36909034?tool=bestpractice.com
Proctitis
Pain may be severe and require appropriate pain management (see above).
Corticosteroid/local anesthetic suppositories or topical lidocaine gel may be used to relieve pain, spasm, and inflammation.[250]Centers for Disease Control and Prevention. Clinical considerations for pain management of mpox. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pain-management.html
[254]British Association for Sexual Health and HIV. Monkeypox management recommendations (proctitis). June 2022 [internet publication].
https://www.bashh.org/news/monkeypox-resources
Stool softeners may be considered to reduce pain associated with bowel movements (particularly if the patient is on opioid analgesia).[250]Centers for Disease Control and Prevention. Clinical considerations for pain management of mpox. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pain-management.html
[254]British Association for Sexual Health and HIV. Monkeypox management recommendations (proctitis). June 2022 [internet publication].
https://www.bashh.org/news/monkeypox-resources
Specialist referral is recommended for complications of proctitis (e.g., acute prostatitis, prostate abscess) as antibiotics may be required.[254]British Association for Sexual Health and HIV. Monkeypox management recommendations (proctitis). June 2022 [internet publication].
https://www.bashh.org/news/monkeypox-resources
Fever
Acetaminophen is recommended for the management of fever.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Pruritus
An antihistamine (e.g., loratadine) is recommended for the management of rash-associated pruritus. Topical agents such as calamine lotion, petroleum jelly, or colloidal oatmeal may also be considered.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[250]Centers for Disease Control and Prevention. Clinical considerations for pain management of mpox. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pain-management.html
Nausea/vomiting
May be treated with antiemetics (e.g., ondansetron, promethazine).[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Diarrhea
Manage conservatively; antimotility agents are generally not recommended.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Dyspepsia
May be treated with a proton-pump inhibitor (e.g., omeprazole).[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Nutrition
Nutrition and hydration status may be compromised due to oropharyngeal lesions or painful cervical lymphadenopathy.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Advise patients to eat a soft diet and ensure adequate oral hydration. Intravenous hydration may be required in cases of severe odynophagia.[255]Maredia H, Sartori-Valinotti JC, Ranganath N, et al. Supportive care management recommendations for mucocutaneous manifestations of monkeypox infection. Mayo Clin Proc. 2023 Apr 29 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10148669
http://www.ncbi.nlm.nih.gov/pubmed/37125977?tool=bestpractice.com
Advise patients to maintain adequate hydration and nutrition. If this is not possible, evaluate the reason why (e.g., pain, nausea, weakness) and manage appropriately (e.g., analgesia, antiemetic).[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Provide vitamin A supplementation according to standard recommendations as it aids wound healing and eye health.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Mental health care
Promptly identify and assess for anxiety and depressive symptoms in order to initiate basic psychosocial support strategies and first-line interventions for the management of new anxiety and depressive symptoms (e.g., self-management strategies, psychological or pharmacologic therapies).[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Psychosocial support strategies are recommended for the management of sleep issues (e.g., sleep hygiene advice).
A conservative approach to the management of skin lesions is recommended, with the aim to relieve discomfort, speed healing, and prevent complications. However, the optimal management of skin lesions is uncertain.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Advise patients not to scratch the skin, and to keep the skin lesions clean (i.e., with sterile water or antiseptic solution) and dry. The rash should not be covered. Avoid the use of plasters.
Monitor lesions for secondary bacterial infection (e.g., erythema, warmth, induration, worsening pain, purulent or malodorous discharge, recurrence of fever) and, if present, treat with appropriate oral antibiotic therapy.
The decision to initiate antibiotic therapy and choice of antibiotic should be based on individual clinical assessment and local antimicrobial resistance patterns. Follow your local protocols.
Prophylactic antibiotics are not recommended. Evidence on use of antibiotics for prophylaxis against secondary skin infections is anecdotal and limited.[5]Beer EM, Rao VB. A systematic review of the epidemiology of human monkeypox outbreaks and implications for outbreak strategy. PLoS Negl Trop Dis. 2019 Oct;13(10):e0007791.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816577
http://www.ncbi.nlm.nih.gov/pubmed/31618206?tool=bestpractice.com
Despite this, some centers may use topical antibiotics for prophylaxis in select patients (e.g., lesions on anogenital region, immunocompromised).[256]de Sousa D, Frade J, Patrocínio J, et al. Monkeypox infection and bacterial cellulitis: a complication to look for. Int J Infect Dis. 2022 Oct;123:180-2.
https://www.ijidonline.com/article/S1201-9712(22)00494-5/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/36055636?tool=bestpractice.com
Hospital admission may be required for a small proportion of patients with painful or infected skin or mucosal lesions for pain management and/or antibiotic therapy.[196]Girometti N, Byrne R, Bracchi M, et al. Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: an observational analysis. Lancet Infect Dis. 2022 Sep;22(9):1321-8.
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00411-X/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/35785793?tool=bestpractice.com
See section below.
Appropriate wound care is recommended and should include the following general principles:[257]American Academy of Dermatology Association. Mpox: treating severe lesions [internet publication].
https://www.aad.org/member/clinical-quality/clinical-care/mpox/severe-lesions
Cleanse wounds with gentle soap and water
Create a moist wound healing environment (e.g., apply topical petrolatum and/or occlusive nonstick dressings)
Protect skin at the borders of a large wound (e.g., apply a protective coating of white petrolatum, zinc oxide paste, or silicone film).
Consider specialist referral if there is suspicion of exfoliation or deeper soft-tissue infection.
Monitor patients for deterioration of their clinical condition.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Advise patients about signs and symptoms of complications that should prompt urgent care (e.g., lesions get worse or increase in quantity, worsening pain, persistent fever, decreased oral intake, visual symptoms, difficult breathing, dizziness, confusion).
Severe or complicated disease or patients at high risk of severe disease
Patients with severe disease, or those who are at increased risk of severe disease, typically require hospitalization, supportive care, and antiviral therapy.
The patient will be transferred to a specialized center for further care if hospitalization is required.
For more information on patients who meet criteria for severe or complicated disease, or those who are at increased risk of severe disease, see Diagnosis approach.
Patients may require hospital admission for the management of pain and swelling, difficulty swallowing (odynophagia), eye lesions, or complications (e.g., bacterial superinfection).[97]Thornhill JP, Barkati S, Walmsley S, et al. Monkeypox virus infection in humans across 16 countries: April–June 2022. N Engl J Med. 2022 Aug 25;387(8):679-91.
https://www.nejm.org/doi/full/10.1056/NEJMoa2207323
http://www.ncbi.nlm.nih.gov/pubmed/35866746?tool=bestpractice.com
[186]Patel A, Bilinska J, Tam JCH, et al. Clinical features and novel presentations of human monkeypox in a central London centre during the 2022 outbreak: descriptive case series. BMJ. 2022 Jul 28;378:e072410.
https://www.bmj.com/content/378/bmj-2022-072410
http://www.ncbi.nlm.nih.gov/pubmed/35902115?tool=bestpractice.com
[187]World Health Organization. Update 79: Monkeypox outbreak update: situation - transmission - countermeasures. August 2022 [internet publication].
https://www.who.int/publications/m/item/update-79-monkeypox-outbreak-update
[192]Tarín-Vicente EJ, Alemany A, Agud-Dios M, et al. Clinical presentation and virological assessment of confirmed human monkeypox virus cases in Spain: a prospective observational cohort study. Lancet. 2022 Aug 27;400(10353):661-9.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01436-2/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/35952705?tool=bestpractice.com
[211]Gomez-Garberi M, Sarrio-Sanz P, Martinez-Cayuelas L, et al. Genitourinary lesions due to monkeypox. Eur Urol. 2022 Dec;82(6):625-30.
https://www.sciencedirect.com/science/article/pii/S0302283822026252
http://www.ncbi.nlm.nih.gov/pubmed/36096858?tool=bestpractice.com
[213]NHS England. Management of laboratory confirmed mpox infections. February 2023 [internet publication].
https://www.england.nhs.uk/publication/management-of-laboratory-confirmed-mpox-infections
[258]Reda A, Hemmeda L, Brakat AM, et al. The clinical manifestations and severity of the 2022 monkeypox outbreak among 4080 patients. Travel Med Infect Dis. 2022 Sep 15 [Epub ahead of print].
https://www.sciencedirect.com/science/article/pii/S1477893922002022
http://www.ncbi.nlm.nih.gov/pubmed/36116767?tool=bestpractice.com
[259]Fink DL, Callaby H, Luintel A, et al. Clinical features and management of individuals admitted to hospital with monkeypox and associated complications across the UK: a retrospective cohort study. Lancet Infect Dis. 2022 Dec 22 [Epub ahead of print].
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00806-4/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/36566771?tool=bestpractice.com
Data from the 2022 global outbreak indicate that approximately 7% to 13% of cases required hospital admission. A meta-analysis of over 7000 cases found the hospitalization rate to be 14.1%; however, this analysis included cases prior to the 2022 outbreak. The hospitalization rate has decreased from 49.8% for pre-2017 outbreaks to 5.8% during the 2022 outbreak.[260]DeWitt ME, Polk C, Williamson J, et al. Global monkeypox case hospitalisation rates: a rapid systematic review and meta-analysis. EClinicalMedicine. 2022 Dec;54:101710.
https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00440-0/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/36345526?tool=bestpractice.com
Clinical reasons for admission include severe pain including anorectal pain and proctitis, severe penile edema, constipation or urinary retention, soft-tissue superinfection, pharyngitis limiting oral intake, coinfections with sexually transmitted diseases, lesions that require surgical intervention, or eye lesions.
The most common reasons for hospitalization are:[261]de Oliveira-Júnior JM, Tenório MDL, Dos Santos Caduda S, et al. Reasons for hospitalization of patients with monkeypox: a quantitative evidence synthesis. Infection. 2022 Oct 18 [Epub ahead of print].
https://link.springer.com/article/10.1007/s15010-022-01937-1
http://www.ncbi.nlm.nih.gov/pubmed/36258119?tool=bestpractice.com
Bacterial cellulitis or abscess with severe pain, especially in the tonsillar or anogenital regions (55.8%)
Oral ulcers (14.3%)
Proctitis (11.7%)
Dysphagia, ocular involvement, urethritis, colitis, and respiratory complications (18.2%).
No serious complications were reported in the majority of those admitted. However, rare complications such as epiglottitis, tonsillitis, peritonsillar cellulitis, tonsillar/peritonsillar abscess, paraphimosis/phimosis, balanitis, perianal/groin abscess, rectal perforation, urethritis, encephalitis, pneumonitis, and myocarditis have been observed. See Complications.
Admit patients with severe or complicated disease, or those who are at high risk for severe disease or complications, to hospital for closer monitoring and clinical care. Follow your local protocols.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Monitor vital signs, neurologic status, volume status, respiratory system, and signs of perfusion.
Monitor laboratory values including complete blood count, urea and electrolytes, and liver function.
Assess pain, general condition, nutrition status, and rash characteristics (i.e., stage, location, number of lesions, presence of exfoliation or secondary bacterial infections).
Provide symptomatic treatment as necessary (see Mild or uncomplicated disease above).
Manage patients with optimized supportive care interventions. Follow your local protocols.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Pay attention to fluid balance, oxygenation, nutrition, symptom relief (see Mild or uncomplicated disease above), prompt treatment of additional secondary bacterial infections, and management of complications and prevention of long-term sequelae.
Intravenous or intraosseous fluids, given as one or multiple boluses with close monitoring of fluid responsiveness, are recommended for the management of severe dehydration caused by intravascular volume loss.
Enteral nutrition may be required if the patient is unable to tolerate oral nutrition.
Pharmacologic treatment may be required if the patient is agitated and becomes a danger to themself, other patients, or healthcare workers.
For specific information on how to manage complications, see Complications.
Consider antiviral therapy in patients who are at risk for severe disease or those who present with, or develop, severe disease.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[136]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of mpox. Jul 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
Antiviral therapy
Antiviral agents developed for the treatment of smallpox (e.g., tecovirimat, brincidofovir, cidofovir) have activity against mpox and may be beneficial.[229]Titanji BK, Tegomoh B, Nematollahi S, et al. Monkeypox: a contemporary review for healthcare professionals. Open Forum Infect Dis. 2022 Jul;9(7):ofac310.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9307103
http://www.ncbi.nlm.nih.gov/pubmed/35891689?tool=bestpractice.com
[262]Siegrist EA, Sassine J. Antivirals with activity against monkeypox: a clinically oriented review. Clin Infect Dis. 2022 Jul 29 [Epub ahead of print].
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciac622/6651596
http://www.ncbi.nlm.nih.gov/pubmed/35904001?tool=bestpractice.com
[263]Shamim MA, Padhi BK, Satapathy P, et al. The use of antivirals in the treatment of human monkeypox outbreaks: a systematic review. Int J Infect Dis. 2023 Feb;127:150-61.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9719850
http://www.ncbi.nlm.nih.gov/pubmed/36470502?tool=bestpractice.com
Antiviral therapy is recommended in patients with severe disease, those who are at high risk of severe disease, those who have involvement of anatomic areas that might result in serious sequelae that include scarring or strictures (e.g., pharynx, penile foreskin, vulva, vagina, urethra, rectum, anus), or those who have severe infections (especially those that require surgical intervention such as debridement). Treatment should be started early in the disease course. However, there are no safety and efficacy data in humans to support the use of antiviral therapy for this indication.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
[136]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of mpox. Jul 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
The CDC have developed a management algorithm outlining the approach to patients with suspected, probable, or confirmed mpox, to aid decision-making regarding the use of therapeutics.[264]Centers for Disease Control and Prevention. Interim clinical treatment considerations for severe manifestations of Mpox — United States, February 2023. Mar 2023 [internet publication].
https://www.cdc.gov/mmwr/volumes/72/wr/mm7209a4.htm?s_cid=mm7209a4_x
Tecovirimat (an inhibitor of the Orthopoxvirus VP37 envelope wrapping protein) is generally recommended as the first-line treatment.[136]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of mpox. Jul 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
It is approved in the UK and Europe for the treatment of mpox. In the UK, it may be offered to symptomatic patients who have been admitted to hospital with severe or complicated infection. Supply is being managed via specialist regional adult infectious diseases centers.[265]Medicines and Healthcare products Regulatory Agency. Tecovirimat as a treatment for patients hospitalised due to monkeypox viral infection. September 2022 [internet publication].
https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103213
It is approved in the US for smallpox, but may be used under an expanded access investigational new drug protocol for the treatment of mpox during an outbreak.
Alternative antivirals that may be approved or recommended for smallpox include brincidofovir (an Orthopoxvirus nucleotide analog DNA polymerase inhibitor and prodrug of cidofovir), cidofovir (a nucleotide analog antiviral with activity against poxviruses), or vaccinia immune globulin (see Emerging).
Brincidofovir has orphan-drug designation for the treatment of smallpox in Europe. It is approved in the US for smallpox, but is also available for the treatment of mpox in select patients under a Food and Drug Administration-authorized single-patient emergency-use expanded access investigational new drug protocol.[136]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of mpox. Jul 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
Cidofovir is approved in the US for cytomegalovirus retinitis in patients with AIDS, but it may be considered for use in patients with severe mpox off-label.[136]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of mpox. Jul 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
These alternative agents may be used off-label for mpox in some countries according to guidance from local public health authorities.
The Centers for Disease Control and Prevention recommends that these treatments can be considered as additive or alternative therapies for:[136]Centers for Disease Control and Prevention. Interim clinical guidance for the treatment of mpox. Jul 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html
Patients with severe disease, or who are at high risk for progression to severe disease, at initial presentation
Patients experiencing clinically significant disease progression on tecovirimat, or who develop recrudescence after an initial period of improvement on tecovirimat
Patients with severe immunocompromise
Patients for whom there is a concern of the development of tecovirimat resistance
Patients who are allergic to tecovirimat, or who are otherwise unable to receive tecovirimat.
Decisions should be made on a case-by-case basis and based on clinical and other parameters.
Cases of laboratory-confirmed tecovirimat resistance have been reported in immunocompromised patients, particularly those on multiple or long courses of tecovirimat.[266]Smith TG, Gigante CM, Wynn NT, et al. Tecovirimat resistance in mpox patients, United States, 2022-2023. Emerg Infect Dis. 2023 Oct 19;29(12).
https://wwwnc.cdc.gov/eid/article/29/12/23-1146_article
http://www.ncbi.nlm.nih.gov/pubmed/37856204?tool=bestpractice.com
[267]Mertes H, Rezende AM, Brosius I, et al. Tecovirimat resistance in an immunocompromised patient with mpox and prolonged viral shedding. Ann Intern Med. 2023 Aug;176(8):1141-3.
https://www.acpjournals.org/doi/10.7326/L23-0131
Consider testing lesion swab specimens for tecovirimat resistance and plasma pharmacokinetic sample collection (to see if drug levels are below target concentrations) for any patient who experiences persistent or newly emerging lesions after completing 14 days of treatment.[268]Centers for Disease Control and Prevention. Update on managing monkeypox in patients receiving therapeutics. November 2022 [internet publication].
https://emergency.cdc.gov/han/2022/han00481.asp
Post-treatment lesions have been reported after the administration of tecovirimat (i.e., occurrence of new skin or mucosal lesions in a patient with probable or confirmed mpox emerging ≤30 days after completing the recommended 14-day treatment course and after improvement or resolution of initial lesions). Further research is required to understand the etiology of these new lesions.[269]Seifu L, Garcia E, McPherson TD, et al. Notes from the field: posttreatment lesions after tecovirimat treatment for Mpox - New York City, August-September 2022. MMWR Morb Mortal Wkly Rep. 2023 Apr 28;72(17):471-2.
https://www.cdc.gov/mmwr/volumes/72/wr/mm7217a5.htm?s_cid=mm7217a5_w
http://www.ncbi.nlm.nih.gov/pubmed/37104293?tool=bestpractice.com
Evidence to support the use of antiviral therapy is limited. There are no randomized controlled trial data available to support the use of antivirals. One Cochrane review found no evidence from randomized controlled trials concerning the safety and efficacy of these drugs, although trials are ongoing for tecovirimat in both adults and children.[270]Fox T, Gould S, Princy N, et al. Therapeutics for treating mpox in humans. Cochrane Database Syst Rev. 2023 Mar 14;(3):CD015769.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015769/full
http://www.ncbi.nlm.nih.gov/pubmed/36916727?tool=bestpractice.com
Tecovirimat
Efficacy has been confirmed in two animal model studies using orthopoxviruses, and safety has been confirmed in a phase 3 trial of 359 healthy human volunteers.[271]ClinicalTrials.gov. A trial to assess the safety, tolerability, and pharmacokinetics of the anti-orthopoxvirus compound tecovirimat (SIGA246-008). November 2017 [internet publication].
https://clinicaltrials.gov/ct2/show/NCT02474589
[272]Grosenbach DW, Honeychurch K, Rose EA, et al. Oral tecovirimat for the treatment of smallpox. N Engl J Med. 2018 Jul 5;379(1):44-53.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6086581
http://www.ncbi.nlm.nih.gov/pubmed/29972742?tool=bestpractice.com
Efficacy for mpox in humans is limited to case reports and case studies.[273]Adler H, Gould S, Hine P, et al. Clinical features and management of human monkeypox: a retrospective observational study in the UK. Lancet Infect Dis. 2022 Aug;22(8):1153-62.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9300470
http://www.ncbi.nlm.nih.gov/pubmed/35623380?tool=bestpractice.com
[274]Matias WR, Koshy JM, Nagami EH, et al. Tecovirimat for the treatment of human monkeypox: an initial series from Massachusetts, United States. Open Forum Infect Dis. 2022 Aug;9(8):ofac377.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9356679
http://www.ncbi.nlm.nih.gov/pubmed/35949403?tool=bestpractice.com
[275]Desai AN, Thompson GR 3rd, Neumeister SM, et al. Compassionate use of tecovirimat for the treatment of monkeypox infection. JAMA. 2022 Oct 4;328(13):1348-150.
https://jamanetwork.com/journals/jama/fullarticle/2795743
http://www.ncbi.nlm.nih.gov/pubmed/35994281?tool=bestpractice.com
[276]O'Laughlin K, Tobolowsky FA, Elmor R, et al. Clinical use of tecovirimat (Tpoxx) for treatment of monkeypox under an investigational new drug protocol: United States, May - August 2022. MMWR Morb Mortal Wkly Rep. 2022 Sep 16;71(37):1190-5.
https://www.cdc.gov/mmwr/volumes/71/wr/mm7137e1.htm
http://www.ncbi.nlm.nih.gov/pubmed/36107794?tool=bestpractice.com
[277]Viguier C, de Kermel T, Boumaza X, et al. A severe monkeypox infection in a patient with an advanced HIV infection treated with tecovirimat: clinical and virological outcome. Int J Infect Dis. 2022 Oct 29;125:135-7.
https://www.ijidonline.com/article/S1201-9712(22)00568-9/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/36397606?tool=bestpractice.com
[278]Mbrenga F, Nakouné E, Malaka C, et al. Tecovirimat for monkeypox in Central African Republic under expanded access. N Engl J Med. 2022 Dec 15;387(24):2294-5.
https://www.nejm.org/doi/10.1056/NEJMc2210015
http://www.ncbi.nlm.nih.gov/pubmed/36449745?tool=bestpractice.com
[279]Wu EL, Osborn RL, Bertram CM, et al. Tecovirimat use in ambulatory and hospitalized patients with monkeypox virus infection. Sex Transm Dis. 2022 Dec 2 [Epub ahead of print].
http://www.ncbi.nlm.nih.gov/pubmed/36455293?tool=bestpractice.com
[280]Hermanussen L, Brehm TT, Wolf T, et al. Tecovirimat for the treatment of severe mpox in Germany. Infection. 2023 Oct;51(5):1563-8.
https://link.springer.com/article/10.1007/s15010-023-02049-0
http://www.ncbi.nlm.nih.gov/pubmed/37273167?tool=bestpractice.com
Safety and efficacy data for pregnant or breastfeeding women and children are lacking. The recommendation to use tecovirimat in pregnant women is based on animal studies where no embryo-fetal developmental toxicity was observed.[117]Centers for Disease Control and Prevention. Clinical considerations for mpox in children and adolescents. Sep 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pediatric.html
[120]Centers for Disease Control and Prevention. Clinical considerations for mpox in people who are pregnant or breastfeeding. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html
Early treatment with tecovirimat may help with pain control in patients with severe proctitis, based on case reports.[252]Lucar J, Roberts A, Saardi KM, et al. Monkeypox virus-associated severe proctitis treated with oral tecovirimat: a report of two cases. Ann Intern Med. 2022 Aug 18 [Epub ahead of print].
https://www.acpjournals.org/doi/10.7326/L22-0300
http://www.ncbi.nlm.nih.gov/pubmed/35981225?tool=bestpractice.com
However, there is no evidence to support this.
Randomized controlled trials are in development or ongoing (e.g., the National Institutes of Health-funded STOMP trial), and patients should be encouraged to enroll when trials are available.[281]Rojek A, Dunning J, Olliaro P. Monkeypox: how will we know if the treatments work? Lancet Infect Dis. 2022 Sep;22(9):1269-70.
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00514-X/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/35931096?tool=bestpractice.com
[282]National Institute for Health and Care Research. Efficacy of tecovirimat for the treatment of non-hospitalised patients with confirmed monkeypox: research brief. May 2022 [internet publication].
https://www.nihr.ac.uk/documents/efficacy-of-tecovirimat-for-the-treatment-of-non-hospitalised-patients-with-confirmed-monkeypox-research-brief/30705
[283]University of Oxford. PLATINUM: placebo-controlled randomised trial of tecovirimat in non-hospitalised monkeypox patients. 2022 [internet publication].
https://www.platinumtrial.ox.ac.uk
[284]National Institutes of Health. STOMP: study of tecovirimat for human monkeypox virus. 2022 [internet publication].
https://www.stomptpoxx.org/main
HIV status does not appear to affect treatment outcomes with tecovirimat.[285]McLean J, Stoeckle K, Huang S, et al. Tecovirimat Treatment of People With HIV During the 2022 Mpox Outbreak : A Retrospective Cohort Study. Ann Intern Med. 2023 May 2 [Epub ahead of print].
https://www.acpjournals.org/doi/10.7326/M22-3132
http://www.ncbi.nlm.nih.gov/pubmed/37126820?tool=bestpractice.com
[286]Aldred B, Lyles RH, Scott JY, et al. Early tecovirimat treatment for mpox disease among people with HIV. JAMA Intern Med. 2024 Mar 1;184(3):275-9.
http://www.ncbi.nlm.nih.gov/pubmed/38190312?tool=bestpractice.com
One Cochrane review found very-low certainty evidence from nonrandomized studies that indicated no serious safety signals with tecovirimat.[270]Fox T, Gould S, Princy N, et al. Therapeutics for treating mpox in humans. Cochrane Database Syst Rev. 2023 Mar 14;(3):CD015769.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015769/full
http://www.ncbi.nlm.nih.gov/pubmed/36916727?tool=bestpractice.com
Brincidofovir
There are no data available on the efficacy of brincidofovir in treating human cases of mpox.
One Cochrane review found very-low certainty evidence that suggests a safety signal of liver injury with brincidofovir.[270]Fox T, Gould S, Princy N, et al. Therapeutics for treating mpox in humans. Cochrane Database Syst Rev. 2023 Mar 14;(3):CD015769.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD015769/full
http://www.ncbi.nlm.nih.gov/pubmed/36916727?tool=bestpractice.com
Cidofovir
In vitro and macaque challenge studies suggest that cidofovir may be beneficial in mpox.[287]Stittelaar KJ, Neyts J, Naesens L, et al. Antiviral treatment is more effective than smallpox vaccination upon lethal monkeypox virus infection. Nature. 2006 Feb 9;439(7077):745-8.
https://www.nature.com/articles/nature04295
http://www.ncbi.nlm.nih.gov/pubmed/16341204?tool=bestpractice.com
[288]Huggins J, Goff A, Hensley L, et al. Nonhuman primates are protected from smallpox virus or monkeypox virus challenges by the antiviral drug ST-246. Antimicrob Agents Chemother. 2009 Jun;53(6):2620-5.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2687232
http://www.ncbi.nlm.nih.gov/pubmed/19349521?tool=bestpractice.com
However, there are very limited data available on the efficacy of cidofovir in treating human cases of mpox.[289]Fabrizio C, Bruno G, Cristiano L, et al. Cidofovir for treating complicated monkeypox in a man with acquired immune deficiency syndrome. Infection. 2022 Nov 10 [Epub ahead of print].
https://link.springer.com/article/10.1007/s15010-022-01949-x
http://www.ncbi.nlm.nih.gov/pubmed/36355271?tool=bestpractice.com
[290]Raccagni AR, Candela C, Bruzzesi E, et al. Real-life use of cidofovir for the treatment of severe monkeypox cases. J Med Virol. 2022 Oct 13 [Epub ahead of print].
https://onlinelibrary.wiley.com/doi/10.1002/jmv.28218
http://www.ncbi.nlm.nih.gov/pubmed/36229902?tool=bestpractice.com
[291]Mondi A, Gagliardini R, Mazzotta V, et al. Clinical experience with use of oral tecovirimat or intravenous cidofovir for the treatment of monkeypox in an Italian reference hospital. J Infect. 2022 Nov 5 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9637020
http://www.ncbi.nlm.nih.gov/pubmed/36347428?tool=bestpractice.com
[292]Labate L, Brucci G, Ciccarese G, et al. Nasal monkeypox virus infection successfully treated with cidofovir in a patient newly diagnosed with HIV. Int J STD AIDS. 2022 Dec 15 [Epub ahead of print].
http://www.ncbi.nlm.nih.gov/pubmed/36520997?tool=bestpractice.com
[293]Stafford A, Rimmer S, Gilchrist M, et al. Use of cidofovir in a patient with severe mpox and uncontrolled HIV infection. Lancet Infect Dis. 2023 Feb 8 [Epub ahead of print].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9908088
http://www.ncbi.nlm.nih.gov/pubmed/36773621?tool=bestpractice.com
These drugs may be stockpiled in some countries, but are not yet widely available.
It is preferable to use antivirals under randomized clinical trials with collection of standardized clinical and outcome data. If this is not possible, antivirals may be used under expanded access protocols.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Consult your local public health authority for guidance on the use of antiviral therapy.
Discontinuation of isolation precautions and discharge
Decisions regarding discontinuation of isolation precautions depend on whether the patient is hospitalized or self-isolating in a household setting, and should be made in consultation with the local public health authority.[244]Centers for Disease Control and Prevention. Infection prevention and control of mpox in healthcare settings. Oct 2022 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/infection-control-healthcare.html
In general, precautions should be continued until all lesions have resolved and a fresh layer of skin has formed.
Prolonged upper respiratory tract viral shedding and viremia after skin lesion resolution has been reported in a small number of patients, leading to extended isolation in hospital.[273]Adler H, Gould S, Hine P, et al. Clinical features and management of human monkeypox: a retrospective observational study in the UK. Lancet Infect Dis. 2022 Aug;22(8):1153-62.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9300470
http://www.ncbi.nlm.nih.gov/pubmed/35623380?tool=bestpractice.com
In hospitalized patients, the UKHSA recommends that isolation precautions may end when the following criteria are met:[294]UK Health Security Agency. De-isolation and discharge of mpox-infected patients: interim guidance. September 2022 [internet publication].
https://www.gov.uk/guidance/de-isolation-and-discharge-of-monkeypox-infected-patients-interim-guidance
Clinical criteria: the patient is judged to be clinically well enough for safe de-isolation as judged by the clinical team managing the patient
Laboratory criteria: the patient tests negative on polymerase chain reaction for all three of the following samples:
Lesion criteria: there have been no new lesions for 48 hours; there are no mucous membrane lesions; and all lesions have crusted over, scabs have dropped off, and intact skin remains underneath.
Patients can be discharged from an isolation facility/floor to another hospital floor, a different inpatient facility, or a residential facility (e.g., care home) only when all of the above clinical, laboratory, and lesion criteria are met. Patients can be discharged to their home, without the need for ongoing isolation, if all of the above criteria are met. Patients who meet the clinical criteria, but who do not meet either the laboratory or lesion criteria, may be discharged to continue isolation at home (according to current public health regulations) where it is safe to do so as assessed by the treating clinician.
In household settings, the UKHSA recommends that patients are able to end self-isolation at home once the following criteria are met:[294]UK Health Security Agency. De-isolation and discharge of mpox-infected patients: interim guidance. September 2022 [internet publication].
https://www.gov.uk/guidance/de-isolation-and-discharge-of-monkeypox-infected-patients-interim-guidance
Clinical criteria: the patient has been assessed by telephone or video call and has been afebrile for 72 hours and is considered systemically well
Lesion criteria: there have been no new lesions for 48 hours; there are no oral mucous membrane lesions; all lesions have crusted over; all lesions on exposed skin (including face, arms, and hands) have scabbed over, the scabs have dropped off, and a fresh layer of skin has formed underneath; and lesions in other areas can remain covered throughout the patient’s time outside of their home or when in contact with other people.
The patient can resume full normal activities with no restrictions (full de-isolation) when they meet the clinical criteria above and the following lesion criteria:[294]UK Health Security Agency. De-isolation and discharge of mpox-infected patients: interim guidance. September 2022 [internet publication].
https://www.gov.uk/guidance/de-isolation-and-discharge-of-monkeypox-infected-patients-interim-guidance
No new lesions for 48 hours
No mucous membrane lesions
All lesions (for both exposed and unexposed areas) have crusted over, all scabs have dropped off, and intact skin remains underneath.
Advise patients to avoid close contact with immunocompromised people, pregnant women, and children <12 years of age until they meet full de-isolation criteria above (this may include exclusion from work if their work requires close contact with any of these groups).
Children and adolescents
Consider treatment on a case-by-base case in children and adolescents with suspected or confirmed mpox who are at risk of severe disease or who develop complications. Antiviral treatment may be considered in children ages <6 months (in consult with your local public health authority), as it is unclear whether younger children can develop more severe illness. Management is generally the same as for adults, with a few exceptions.[117]Centers for Disease Control and Prevention. Clinical considerations for mpox in children and adolescents. Sep 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pediatric.html
Take the child’s age, caregiving needs, and family and caregiver preferences into consideration for isolation and infection control in children who require hospitalization. Limit the number of caregivers to one person, when possible, regardless of whether the child is in hospital or at home.
Pay particular attention to keeping skin lesions covered and preventing children from scratching lesions or touching their eyes in order to prevent autoinoculation and more severe disease.
Tecovirimat is also the recommended first-line antiviral agent in children and adolescents, if treatment is indicated. However, safety and efficacy data are lacking and no clinical studies have been performed in pediatric populations. Alternative antiviral agents (e.g., cidofovir, brincidofovir) are reserved for unusual circumstances (e.g., very severe infections, disease progression despite tecovirimat treatment, tecovirimat is contraindicated or unavailable) due to their potential toxicity.
Pregnant and breastfeeding women
Prioritize pregnant (or recently pregnant) and breastfeeding women for treatment due to the probable increased risk for severe disease during pregnancy and the risk of transmission to the fetus or newborn baby.[120]Centers for Disease Control and Prevention. Clinical considerations for mpox in people who are pregnant or breastfeeding. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html
Discuss the risks and benefits of treatment with the patient using shared decision-making.
Closely monitor the patient for severe disease and pregnancy complications.
Direct contact between a patient in isolation and their newborn is not advised. Separation is advised; however, if the patient chooses to have contact with the newborn during the infectious period, strict precautions should be taken (e.g., no skin-to-skin contact; wearing gloves, gown, and mask).
It is unknown whether monkeypox virus is present in breast milk. However, mpox is spread via close contact and breastfeeding should therefore be delayed until criteria for discontinuing isolation are met.
Pregnant (or recently pregnant) women with mild or uncomplicated disease may not require hospitalization; however, close monitoring in a health facility may be preferred. Admit pregnant women with severe or complicated disease to a health facility for optimized supportive care and/or interventions to improve maternal and fetal survival.[1]World Health Organization. Clinical management and infection prevention and control for monkeypox: interim rapid response guidance, 10 June 2022. Jun 2022 [internet publication].
https://www.who.int/publications/i/item/WHO-MPX-Clinical-and-IPC-2022.1
Method of delivery should be individualized, based on obstetric indications and the woman’s preferences. Induction of labor and cesarean section should only be undertaken when medically justified and based on maternal and fetal condition.
Monitor newborn infants closely for evidence of potential congenital or perinatal exposure or infection.
It is currently unknown whether the virus or antibodies are present in the breast milk of an infected mother. Infant feeding practices should be assessed on a case-by-case basis, taking the mother’s physical status and severity of disease into consideration.
General infection prevention and control measures are recommended for mothers when handling and feeding their infants (e.g., hand hygiene, wearing a mask if possible, covering any lesions that have direct contact with the infant).
Antiviral therapies should be used with caution in pregnant (or recently pregnant) and breastfeeding women, and only under the guidance of a local public health authority due to limited data in this population.
Tecovirimat is recommended first line in pregnant (or recently pregnant) and breastfeeding women, if treatment is indicated. However, there are limited data on human use during pregnancy or breastfeeding and the recommendation is based on animal studies (no embryo-fetal developmental toxicity was observed in animal studies).[120]Centers for Disease Control and Prevention. Clinical considerations for mpox in people who are pregnant or breastfeeding. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html
A case of a pregnant woman receiving tecovirimat in the third trimester has been reported. No maternal or neonatal complications were reported, and there was no evidence of neonatal infection.[295]Sampson MM, Magee G, Schrader EA, et al. Mpox (Monkeypox) infection during pregnancy. Obstet Gynecol. 2023 May 1;141(5):1007-10.
http://www.ncbi.nlm.nih.gov/pubmed/36928418?tool=bestpractice.com
Cidofovir and brincidofovir have shown evidence of teratogenicity in animal studies and should not be used during the first trimester of pregnancy or in breastfeeding women.[120]Centers for Disease Control and Prevention. Clinical considerations for mpox in people who are pregnant or breastfeeding. Mar 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/pregnancy.html
Further guidelines for the management of pregnant women have been proposed.[296]Dashraath P, Nielsen-Saines K, Mattar C, et al. Guidelines for pregnant individuals with monkeypox virus exposure. Lancet. 2022 Jul 2;400(10345):21-2.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01063-7/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/35750071?tool=bestpractice.com
[297]Khalil A, Samara A, O'Brien P, et al. Monkeypox and pregnancy: what do obstetricians need to know? Ultrasound Obstet Gynecol. 2022 Jul;60(1):22-7.
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.24968
http://www.ncbi.nlm.nih.gov/pubmed/35652380?tool=bestpractice.com
Immunocompromised
People with HIV-associated immunosuppression, people with HIV who are not virologically suppressed, and people who are immunocompromised from other conditions or using immunosuppressive agents may be at increased risk of severe prolonged disease (particularly those who are severely immunocompromised, e.g., CD4 count ≤350 cells/microliter). Treatment and close monitoring is a priority in these patients.[31]Centers for Disease Control and Prevention. Clinical considerations for treatment and prophylaxis of mpox infection in people who are immunocompromised. Sep 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/people-with-HIV.html
[32]O'Shea J, Filardo TD, Morris SB, et al. Interim guidance for prevention and treatment of monkeypox in persons with HIV infection: United States, August 2022. MMWR Morb Mortal Wkly Rep. 2022 Aug 12;71(32):1023-8.
https://www.cdc.gov/mmwr/volumes/71/wr/mm7132e4.htm
http://www.ncbi.nlm.nih.gov/pubmed/35951495?tool=bestpractice.com
Severe complications were more common in patients with CD4 counts <100 cells/microliter compared with patients with CD4 counts <300 cells/microliter, and included necrotizing skin lesions, lung dysfunction, secondary infections, and sepsis. All deaths were among patients with CD4 counts <200 cells/microliter, and most occurred in those with a high HIV viral load.[133]Mitjà O, Alemany A, Marks M, et al. Mpox in people with advanced HIV infection: a global case series. Lancet. 2023 Mar 18;401(10380):939-49.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00273-8/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/36828001?tool=bestpractice.com
Optimizing immune function is important in immunocompromised patients. Defer chemotherapy or immunotherapy during treatment, if possible. There is no high-quality evidence to either support or refute the use of immunomodulators in patients with mpox. However, models suggest corticosteroids are associated with severe illness and possibly death in orthopoxvirus-infected animals. Use systemic immunomodulators (including corticosteroids) with caution, or reduce their use if feasible, weighing the risks and benefits of their use.[264]Centers for Disease Control and Prevention. Interim clinical treatment considerations for severe manifestations of Mpox — United States, February 2023. Mar 2023 [internet publication].
https://www.cdc.gov/mmwr/volumes/72/wr/mm7209a4.htm?s_cid=mm7209a4_x
In patients with HIV:[31]Centers for Disease Control and Prevention. Clinical considerations for treatment and prophylaxis of mpox infection in people who are immunocompromised. Sep 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/people-with-HIV.html
[32]O'Shea J, Filardo TD, Morris SB, et al. Interim guidance for prevention and treatment of monkeypox in persons with HIV infection: United States, August 2022. MMWR Morb Mortal Wkly Rep. 2022 Aug 12;71(32):1023-8.
https://www.cdc.gov/mmwr/volumes/71/wr/mm7132e4.htm
http://www.ncbi.nlm.nih.gov/pubmed/35951495?tool=bestpractice.com
Continue (or start/restart) antiretroviral therapy and opportunistic infection prophylaxis while managing mpox, as treatment interruption could lead to rebound viremia, which could complicate the disease course. People taking antiretroviral therapy for pre- or postexposure prophylaxis should continue to do so.
Always check for drug-drug interactions between antivirals used for the treatment of mpox and antiretroviral therapy (or other treatments) for HIV infection.
Monitor viral load and CD4 count during treatment and follow-up. Case series have shown alterations in these parameters are possible during infection.[298]Raccagni AR, Mileto D, Galli L, et al. HIV viral load monitoring during monkeypox virus infection among PLWH. AIDS. 2023 Jan 9 [Epub ahead of print].
http://www.ncbi.nlm.nih.gov/pubmed/36689645?tool=bestpractice.com
Tecovirimat is recommended first line in immunocompromised patients, if treatment is indicated (e.g., advanced or poorly controlled HIV). Start treatment as soon as possible, and consider extending the treatment course beyond the standard 14-day course on a day-by-day basis. Addition of other therapeutics (e.g., cidofovir, brincidofovir, vaccinia immune globulin) may be considered for those not improving or those progressing while on tecovirimat.[31]Centers for Disease Control and Prevention. Clinical considerations for treatment and prophylaxis of mpox infection in people who are immunocompromised. Sep 2023 [internet publication].
https://www.cdc.gov/poxvirus/monkeypox/clinicians/people-with-HIV.html
[32]O'Shea J, Filardo TD, Morris SB, et al. Interim guidance for prevention and treatment of monkeypox in persons with HIV infection: United States, August 2022. MMWR Morb Mortal Wkly Rep. 2022 Aug 12;71(32):1023-8.
https://www.cdc.gov/mmwr/volumes/71/wr/mm7132e4.htm
http://www.ncbi.nlm.nih.gov/pubmed/35951495?tool=bestpractice.com
[299]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: mpox. Jul 2023 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/mpox?view=full
Combination therapy may be considered for severe disease at the first medical encounter (in consult with your local public health authority or an expert in the management of mpox).[299]National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. Panel on guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: mpox. Jul 2023 [internet publication].
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-opportunistic-infections/mpox?view=full
The British HIV Association does not currently recommend any specific actions for people with HIV infection beyond vigilance about clinical presentation and history of exposure (except vaccine considerations). People with a CD4 count <200 cells/microliter, persistent viremia (e.g., >200 copies/mL), recent HIV-related illness, or concomitant conditions or treatments that may cause immunosuppression may be at higher risk for infection and complications, and should be prioritized for specialist review.[156]British HIV Association. BHIVA rapid guidance on monkeypox virus. October 2022 [internet publication].
https://www.bhiva.org/rapid-guidance-on-monkeypox-virus