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
suspected or confirmed infection: mild or uncomplicated disease
infection prevention and control
Immediately isolate the patient in a negative-pressure room (with private bathroom facilities) and notify the regional infectious diseases unit. 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. 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 also recommended if aerosol-generating procedures are performed, or clade I mpox is suspected or confirmed. Treat all contaminated materials (e.g., linens, hospital gowns) and body fluids/solid waste of patients as potentially infectious.[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
Ideally all personnel likely to be in contact with the patient, bodily fluids, or fomites should have been vaccinated. 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.[194]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. Oct 2024 [internet publication]. https://www.gov.uk/government/publications/principles-for-monkeypox-control-in-the-uk-4-nations-consensus-statement
Consult your local guidelines for detailed guidance on infection prevention and control measures. Recommendations may vary depending on the clade of the virus, with enhanced measures typically recommended for clade I mpox (e.g., airborne precautions).
CDC: mpox infection prevention and control in healthcare settings Opens in new window
consider home isolation
Treatment recommended for ALL patients in selected patient group
Patients with suspected or confirmed infection and with mild or uncomplicated disease 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
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.[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 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.[212]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
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. Follow-up should be conducted using telemedicine or telephone where possible.[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 NHS England: virtual management of confirmed monkeypox cases Opens in new window
In the UK, the UK Health Security Agency (UKHSA) recommends that suspected cases may self-isolate at home, based on an assessment by the clinician and following UKHSA guidance. 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. However, discuss suspected cases who meet the high consequence infectious disease (HCID) case definition for clade I mpox with the local infection team and Imported Fever Service, as they will review the risk assessment and advise on the next steps for investigation and management.[268]UK Health Security Agency. Mpox: guidance on when to suspect a case of mpox. Oct 2024 [internet publication]. https://www.gov.uk/guidance/monkeypox-case-definitions NHS England recommends using a risk-stratified clinical approach to aid these decisions.[230]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.[269]UK Health Security Agency. HCID status of mpox (monkeypox). Oct 2024 [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 first identified in 2023 (due to the newly identified clade Ib variant).[232]UK Health Security Agency. Mpox: diagnostic testing. Sep 2024 [internet publication]. https://www.gov.uk/guidance/monkeypox-diagnostic-testing
Decisions regarding discontinuation of isolation precautions should be made in consultation with the local public health authority. In general, precautions should be continued until all lesions have resolved and a fresh layer of skin has formed.[262]Centers for Disease Control and Prevention. Mpox infection prevention and control in healthcare settings. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/infection-control/healthcare-settings.html The UKHSA recommends that patients are able to end self-isolation at home once: 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 following lesion criteria: no new lesions for 48 hours; no mucous membrane lesions; and 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 (this may include exclusion from work if their work requires close contact with any of these groups).[315]UK Health Security Agency. De-isolation and discharge of mpox-infected patients. Sep 2024 [internet publication]. https://www.gov.uk/guidance/de-isolation-and-discharge-of-monkeypox-infected-patients-interim-guidance
It is important that the patient follows their regional home self-isolation guidelines. For advice, see Patient discussions.
symptomatic treatment and supportive care
Treatment recommended for ALL patients in selected patient group
Symptomatic treatment 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
Pain: pain management is important 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.[270]Centers for Disease Control and Prevention. Clinical considerations for pain management. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pain-management.html [271]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. Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. 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). 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. Salt water rinses, antiseptic mouthwashes (e.g., chlorhexidine), and local anesthetics (e.g., viscous lidocaine) are recommended for oral lesions. 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 [270]Centers for Disease Control and Prevention. Clinical considerations for pain management. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pain-management.html 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.[273]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 pain management (see above). Corticosteroid/local anesthetic suppositories or topical lidocaine gel may be used to relieve pain, spasm, and inflammation. Stool softeners may be considered to reduce pain associated with bowel movements (particularly if the patient is on opioid analgesia). Consider specialist referral for complications (e.g., acute prostatitis, prostate abscess) as antibiotics may be required.[270]Centers for Disease Control and Prevention. Clinical considerations for pain management. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pain-management.html
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 [270]Centers for Disease Control and Prevention. Clinical considerations for pain management. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/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
Skin care: 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.[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 Wound care is recommended.[276]American Academy of Dermatology Association. Mpox: treating severe lesions [internet publication]. https://www.aad.org/member/clinical-quality/clinical-care/mpox/severe-lesions
Nutrition: 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). 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).[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
Primary options
Fever or mild pain
acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
Mild pain
ibuprofen: children ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
Severe pain
tramadol: children: consult specialist for guidance on dose; adults: 50-100 mg orally/intravenously every 4-6 hours when required, maximum 400 mg/day
OR
Severe pain
morphine sulfate: children: consult specialist for guidance on dose; adults: 10 mg orally (immediate-release) every 4 hours when required, maximum 60 mg/day; adults: 1-4 mg intravenously/subcutaneously every 4 hours when required
OR
Severe pain
gabapentin: adults: consult specialist for guidance on dose
OR
Pruritus
loratadine: children body weight >30 kg and adults: 10 mg orally once daily
OR
Nausea/vomiting
ondansetron: children: 0.15 mg/kg orally/intravenously every 12 hours when required, maximum 8 mg/dose; adults: 8 mg orally every 12 hours when required, or 4 mg intravenously every 8 hours when required
OR
Nausea/vomiting
promethazine: adults: 12.5 to 25 mg orally every 4-6 hours when required
OR
Dyspepsia
omeprazole: children body weight 5-10 kg: 5 mg orally/intravenously once daily; children body weight 10-20 kg: 10 mg orally/intravenously once daily; children body weight ≥20 kg: 20 mg orally/intravenously once daily; adults: 40 mg orally/intravenously once daily
monitoring
Treatment recommended for ALL patients in selected patient group
Monitor patients for deterioration of their clinical condition. 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). Also advise patients to monitor for any persistent, new, or changing symptoms, and to seek medical care if this occurs.[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 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. Consider specialist referral if there is suspicion of exfoliation or deeper soft-tissue 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 Follow your local protocols.
suspected or confirmed infection: severe or complicated disease, or at increased risk for severe disease or complications
infection prevention and control
Immediately isolate the patient in a negative-pressure room (with private bathroom facilities) and notify the regional infectious diseases unit. All suspected cases should be managed by experts, including public health officials, to prevent a potential emergency situation.
Follow your local infection prevention and control protocols. 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 also recommended if aerosol-generating procedures are performed, or clade I mpox is suspected or confirmed. Treat all contaminated materials (e.g., linens, hospital gowns) and body fluids/solid waste of patients as potentially infectious.[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
Ideally all personnel likely to be in contact with the patient, bodily fluids, or fomites should have been vaccinated. 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.[194]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. Oct 2024 [internet publication]. https://www.gov.uk/government/publications/principles-for-monkeypox-control-in-the-uk-4-nations-consensus-statement
Consult your local guidelines for detailed guidance on infection prevention and control measures. Recommendations may vary depending on the clade of the virus, with enhanced measures typically recommended for clade I mpox (e.g., airborne precautions).
CDC: mpox infection prevention and control in healthcare settings Opens in new window
hospital admission
Treatment recommended for ALL patients in selected patient group
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.[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 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, difficulty swallowing (odynophagia), or bacterial superinfection. Nearly all patients with perianal or rectal lesions report pain, and hospital admission has been required for patients with severe rectal pain and proctitis.
The patient will be transferred to a specialized center for further care if hospitalization is required.
In the UK, the UK Health Security Agency (UKHSA) recommends assessing all confirmed (or highly probable) cases for the need for admission based on either clinical or self-isolation requirements, and notifying the local health protection team. However, discuss suspected cases who meet the high consequence infectious disease (HCID) case definition for clade I mpox with the local infection team and Imported Fever Service, as they will review the risk assessment and advise on the next steps for investigation and management.[268]UK Health Security Agency. Mpox: guidance on when to suspect a case of mpox. Oct 2024 [internet publication]. https://www.gov.uk/guidance/monkeypox-case-definitions NHS England recommends using a risk-stratified clinical approach to aid these decisions.[230]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 a high consequence infectious disease (HCID) in the UK. However, infections caused by the clade I virus are considered to be an HCID.[269]UK Health Security Agency. HCID status of mpox (monkeypox). Oct 2024 [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 first identified in 2023 (due to the newly identified clade Ib variant).[232]UK Health Security Agency. Mpox: diagnostic testing. Sep 2024 [internet publication]. https://www.gov.uk/guidance/monkeypox-diagnostic-testing
symptomatic treatment
Treatment recommended for ALL patients in selected patient group
Symptomatic treatment is recommended. 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
Pain: pain management is important 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.[270]Centers for Disease Control and Prevention. Clinical considerations for pain management. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pain-management.html [271]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. Ibuprofen should only be taken at the lowest effective dose for the shortest period needed to control symptoms. 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). 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. Salt water rinses, antiseptic mouthwashes (e.g., chlorhexidine), and local anesthetics (e.g., viscous lidocaine) are recommended for oral lesions. 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 [270]Centers for Disease Control and Prevention. Clinical considerations for pain management. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pain-management.html 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.[273]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 pain management (see above). Corticosteroid/local anesthetic suppositories or topical lidocaine gel may be used to relieve pain, spasm, and inflammation. Stool softeners may be considered to reduce pain associated with bowel movements (particularly if the patient is on opioid analgesia). Consider specialist referral for complications (e.g., acute prostatitis, prostate abscess) as antibiotics may be required.[270]Centers for Disease Control and Prevention. Clinical considerations for pain management. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pain-management.html
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 [270]Centers for Disease Control and Prevention. Clinical considerations for pain management. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/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
Primary options
Fever or mild pain
acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day
OR
Mild pain
ibuprofen: children ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 400 mg orally every 4-6 hours when required, maximum 2400 mg/day
OR
Severe pain
tramadol: children: consult specialist for guidance on dose; adults: 50-100 mg orally/intravenously every 4-6 hours when required, maximum 400 mg/day
OR
Severe pain
morphine sulfate: children: consult specialist for guidance on dose; adults: 10 mg orally (immediate-release) every 4 hours when required, maximum 60 mg/day; adults: 1-4 mg intravenously/subcutaneously every 4 hours when required
OR
Severe pain
gabapentin: adults: consult specialist for guidance on dose
OR
Pruritus
loratadine: children body weight >30 kg and adults: 10 mg orally once daily
OR
Nausea/vomiting
ondansetron: children: 0.15 mg/kg orally/intravenously every 12 hours when required, maximum 8 mg/dose; adults: 8 mg orally every 12 hours when required, or 4 mg intravenously every 8 hours when required
OR
Nausea/vomiting
promethazine: adults: 12.5 to 25 mg orally every 4-6 hours when required
OR
Dyspepsia
omeprazole: children body weight 5-10 kg: 5 mg orally/intravenously once daily; children body weight 10-20 kg: 10 mg orally/intravenously once daily; children body weight ≥20 kg: 20 mg orally/intravenously once daily; adults: 40 mg orally/intravenously once daily
supportive care
Treatment recommended for ALL patients in selected patient group
Manage patients with optimized supportive care interventions. Pay attention to fluid balance, oxygenation, nutrition, 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. 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 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. Consider specialist referral if there is suspicion of exfoliation or deeper soft-tissue infection. 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 Wound care is recommended.[276]American Academy of Dermatology Association. Mpox: treating severe lesions [internet publication]. https://www.aad.org/member/clinical-quality/clinical-care/mpox/severe-lesions
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). Psychosocial support strategies are recommended for the management of sleep issues (e.g., sleep hygiene advice).[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
For specific information on how to manage complications, see Complications.
monitoring
Treatment recommended for ALL patients in selected patient group
Monitor vital signs, neurologic status, volume status, respiratory system, and signs of perfusion.[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 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).
Follow your local protocols.
antiviral therapy
Treatment recommended for SOME patients in selected patient group
Consider antiviral therapy in patients with (or at high risk of) severe disease or protracted or life-threatening sickness, including severely immunocompromised patients, people with atopic dermatitis and other conditions that affect skin integrity, children, and pregnant/breast-feeding women. Treatment should be started early in the disease course.[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 [229]Centers for Disease Control and Prevention. Clinical treatment of mpox. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care
Tecovirimat is generally recommended as the first-line treatment if treatment is indicated, including in pregnant or breast-feeding women, children and adolescents, and immunocompromised patients.[40]Centers for Disease Control and Prevention. Clinical considerations for mpox in children and adolescents in the U.S. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pediatric.html [41]Centers for Disease Control and Prevention. Clinical considerations for mpox in immunocompromised people. Oct 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/immunocompromised-people.html [133]Centers for Disease Control and Prevention. Mpox considerations for people who are pregnant or breastfeeding. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pregnancy.html [229]Centers for Disease Control and Prevention. Clinical treatment of mpox. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care The decision to use the oral or intravenous formulation should be individualized based on disease severity, other comorbidities, and ability to eat a full fatty meal (required with the oral formulation). The most frequently reported adverse effects were headache and nausea. CDC: tecovirimat (TPOXX) for treatment of mpox Opens in new window
Other antivirals including brincidofovir and cidofovir may be considered as additive or alternative therapies in: patients with ocular infections; patients with protracted or life-threatening manifestations of mpox because of, for example, severe immunocompromise; patients experiencing clinically significant disease progression on tecovirimat, or who develop recrudescence after an initial period of improvement on tecovirimat; patients for whom there is a concern of the development of tecovirimat resistance; and 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. Nearly all patients treated with brincidofovir or cidofovir are severely immunocompromised and require combination treatment with tecovirimat. Brincidofovir and cidofovir should not be used simultaneously.[229]Centers for Disease Control and Prevention. Clinical treatment of mpox. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care Only use these agents in children and adolescents in unusual circumstances (e.g., very severe infections, disease progression despite tecovirimat treatment, tecovirimat is contraindicated or unavailable).[40]Centers for Disease Control and Prevention. Clinical considerations for mpox in children and adolescents in the U.S. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pediatric.html Brincidofovir may cause increases in serum transaminases and serum bilirubin; perform liver function tests before and during treatment. Nephrotoxicity limits the use of cidofovir (use probenecid and hydration concomitantly). Brincidofovir and cidofovir have shown evidence of teratogenicity in animal studies and should not be used during the first trimester of pregnancy or in breast-feeding women.[133]Centers for Disease Control and Prevention. Mpox considerations for people who are pregnant or breastfeeding. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pregnancy.html
Tecovirimat has the potential to cause resistance to poxviruses and caution is required in immunocompromised patients. Cases and clusters of laboratory-confirmed tecovirimat resistance have been reported in immunocompromised patients, particularly those on multiple or long courses of tecovirimat, as well as people with no documentation of previous tecovirimat treatment (due to the spread of a tecovirimat-resistant variant of the virus).[284]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 [285]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 [286]Gigante CM, Takakuwa J, McGrath D, et al. Notes from the field: mpox cluster caused by tecovirimat-resistant monkeypox virus - five states, October 2023-February 2024. MMWR Morb Mortal Wkly Rep. 2024 Oct 10;73(40):903-5. https://pmc.ncbi.nlm.nih.gov/articles/PMC11466377 http://www.ncbi.nlm.nih.gov/pubmed/39388389?tool=bestpractice.com 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.[287]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 Worsening, nonhealing, recurrent, and new skin lesions have been reported in immunocompromised people with severe manifestations while receiving tecovirimat. Treatment beyond 14 days may be considered in these patients until there is clinical improvement (no more than 90 days).[200]Centers for Disease Control and Prevention. Health alert network (HAN) health advisory: severe manifestations of monkeypox among people who are immunocompromised due to HIV or other conditions. September 2022 [internet publication]. https://emergency.cdc.gov/han/2022/han00475.asp
Post-treatment lesions have been reported after 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 the new lesions.[288]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
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. Very-low certainty evidence from nonrandomized studies indicated no serious safety signals with tecovirimat. Very-low certainty evidence suggests a safety signal of liver injury with brincidofovir.[289]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 See Management approach for more evidence.
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.
Antiviral treatments may interact with HIV antiretroviral therapy (ART) and caution is advised in patients on ART. However, none of the identified drug interactions, so far, should preclude administration of tecovirimat with ART. Consult your local pharmacist for more information.[41]Centers for Disease Control and Prevention. Clinical considerations for mpox in immunocompromised people. Oct 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/immunocompromised-people.html [172]British HIV Association. BHIVA rapid guidance on monkeypox virus. October 2022 [internet publication]. https://www.bhiva.org/rapid-guidance-on-monkeypox-virus
University of Liverpool: HIV drug interactions Opens in new window
Primary options
Oral dose regimen
tecovirimat: children <13 kg body weight: consult specialist for guidance on oral dose; children 13 to <25 kg body weight: 200 mg orally twice daily for 14 days; children 25 to <40 kg body weight: 400 mg orally twice daily for 14 days; children and adults 40 to <120 kg body weight: 600 mg orally twice daily for 14 days; children and adults ≥120 kg body weight: 600 mg orally three times daily for 14 days
More tecovirimatOral tecovirimat must be taken with fatty meals to ensure adequate absorption of the drug and maximize serum drug levels. For those who cannot swallow capsules, the contents of capsules may be administered by mixing them in 30 mL of liquid or soft food.
OR
Intravenous dose regimen
tecovirimat: children 3 to <35 kg body weight: 6 mg/kg intravenously every 12 hours for 14 days; children and adults 35 to <120 kg body weight: 200 mg intravenously every 12 hours for 14 days; children and adults ≥120 kg body weight: 300 mg intravenously every 12 hours for 14 days
More tecovirimatThe intravenous formulation is preferred in children <13 kg because of the challenge of accurate dosing with the oral formulation. The intravenous formulation is contraindicated in patients with severe renal impairment, and should be used with caution in patients with mild to moderate renal impairment and children <2 years of age due to the presence of hydroxypropyl-beta-cyclodextrin (an excipient). Monitor renal function during treatment.[40]Centers for Disease Control and Prevention. Clinical considerations for mpox in children and adolescents in the U.S. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/clinical-care/pediatric.html Switch to the oral formulation to complete the treatment course as soon as oral therapy can be tolerated.
Secondary options
brincidofovir: children <10 kg body weight: 6 mg/kg orally once weekly for 2 doses; children and adults 10 to <48 kg body weight: 4 mg/kg orally once weekly for 2 doses; children and adults ≥48 kg body weight: 200 mg orally once weekly for 2 doses
Tertiary options
cidofovir: children and adults: consult specialist for guidance on dose
discontinuation of isolation precautions and discharge
Treatment recommended for SOME patients in selected patient group
Decisions regarding discontinuation of isolation precautions and discharge should be made in consultation with the local public health authority. In general, precautions should be continued until all lesions have resolved and a fresh layer of skin has formed.[262]Centers for Disease Control and Prevention. Mpox infection prevention and control in healthcare settings. Sep 2024 [internet publication]. https://www.cdc.gov/mpox/hcp/infection-control/healthcare-settings.html 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.[292]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
The UK Health Security Agency recommends that isolation precautions may end when the following criteria are met: the patient is judged to be clinically well enough for safe de-isolation as judged by the clinical team managing the patient; the patient tests negative on polymerase chain reaction for urine, throat swab, and ethylenediamine tetra-acetic acid (EDTA) blood (it is acceptable not to send EDTA blood if no sample was sent previously as the patient was well throughout admission); 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.[315]UK Health Security Agency. De-isolation and discharge of mpox-infected patients. Sep 2024 [internet publication]. https://www.gov.uk/guidance/de-isolation-and-discharge-of-monkeypox-infected-patients-interim-guidance
Patients can be discharged from an isolation facility/ward to another hospital ward, 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.[315]UK Health Security Agency. De-isolation and discharge of mpox-infected patients. Sep 2024 [internet publication]. https://www.gov.uk/guidance/de-isolation-and-discharge-of-monkeypox-infected-patients-interim-guidance
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.[315]UK Health Security Agency. De-isolation and discharge of mpox-infected patients. Sep 2024 [internet publication]. https://www.gov.uk/guidance/de-isolation-and-discharge-of-monkeypox-infected-patients-interim-guidance
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