Mpox (monkeypox)

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

ACUTE

suspected or confirmed infection: mild or uncomplicated disease

1st line – infection prevention and control

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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 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.[47]

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.[154]

Plus – consider home isolation

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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.[47]

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.[47] 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.[170]

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.[47] NHS England: virtual management of confirmed monkeypox cases Opens in new window

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. 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.[155] NHS England recommends using a risk-stratified clinical approach to aid these decisions.[186] 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.[220]

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.[261] The UKHSA recommends that patients are able to end self-isolation at home once: the patient has been assessed by telephone or video call and has been afebrile for 72 hours and is considered systemically well; 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: 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).[262]

It is important that the patient follows their regional home self-isolation guidelines. For advice, see Patient discussions.

Plus – symptomatic treatment and supportive care

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Treatment recommended for ALL patients in selected patient group

Symptomatic treatment and supportive care are recommended.[47]

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.[221][222] 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.[47][221] 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.[224]

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.[221][225]

Fever: acetaminophen is recommended for the management of fever.[47]

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.[47][221]

Nausea/vomiting: may be treated with antiemetics (e.g., ondansetron, promethazine).[47]

Diarrhea: manage conservatively; antimotility agents are generally not recommended.[47]

Dyspepsia: may be treated with a proton-pump inhibitor (e.g., omeprazole).[47]

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.[47] Wound care is recommended.[228]

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.[47]

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).[47]

Psychosocial support strategies are recommended for the management of sleep issues (e.g., sleep hygiene advice).[47]

Primary options

Fever or mild pain

acetaminophen: children: 10-15 mg/kg orally/intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults: 1000 mg orally/intravenously every 6-8 hours when required, maximum 4000 mg/day

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

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

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

Severe pain

gabapentin: adults: consult specialist for guidance on dose

Pruritus

loratadine: children body weight >30 kg and adults: 10 mg orally once daily

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

Nausea/vomiting

promethazine: adults: 12.5 to 25 mg orally every 4-6 hours when required

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

Plus – monitoring

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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.[47]

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.[47] Follow your local protocols.

suspected or confirmed infection: severe or complicated disease, or at increased risk for severe disease or complications

1st line – infection prevention and control

Back

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 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.[47]

Healthcare workers who are pregnant or severely immunocompromised should not assess or care for patients with suspected or confirmed infection, where possible.[154]

Plus – hospital admission

Back

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.[47] 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. Admit patients 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).[155]

Plus – symptomatic treatment

Back

Treatment recommended for ALL patients in selected patient group

Symptomatic treatment is recommended. Follow your local protocols.[47]

Fever: acetaminophen is recommended for the management of fever.[47]

Nausea/vomiting: may be treated with antiemetics (e.g., ondansetron, promethazine).[47]

Diarrhea: manage conservatively; antimotility agents are generally not recommended.[47]

Dyspepsia: may be treated with a proton-pump inhibitor (e.g., omeprazole).[47]

Primary options

Fever or mild pain

acetaminophen: children: 10-15 mg/kg orally/intravenously every 4-6 hours when required, maximum 60 mg/kg/day; adults: 1000 mg orally/intravenously every 6-8 hours when required, maximum 4000 mg/day

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

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

Severe pain

gabapentin: adults: consult specialist for guidance on dose

Pruritus

loratadine: children body weight >30 kg and adults: 10 mg orally once daily

Nausea/vomiting

promethazine: adults: 12.5 to 25 mg orally every 4-6 hours when required

Dyspepsia

Plus – supportive care

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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.[47]

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).[47]

Provide vitamin A supplementation according to standard recommendations as it aids wound healing and eye health.[47]

For specific information on how to manage complications, see Complications.

Plus – monitoring

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Treatment recommended for ALL patients in selected patient group

Monitor vital signs, neurologic status, volume status, respiratory system, and signs of perfusion.[47]

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.

Consider – antiviral therapy

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Treatment recommended for SOME patients in selected patient group

Consider antiviral therapy in patients with severe disease, those who are at increased 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.[47][116]

Tecovirimat is generally recommended as the first-line treatment if treatment is indicated, including in pregnant or breastfeeding women, children and adolescents, and immunocompromised patients (e.g., advanced or poorly controlled HIV).[24][102][104][116] 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: guidance for tecovirimat use Opens in new window

Other antivirals including brincidofovir and cidofovir may be considered as additive or alternative therapies in: 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; 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. Brincidofovir and cidofovir should not be used simultaneously.[116] 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).[102] 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 breastfeeding women.[104]

Tecovirimat has the potential to cause resistance to poxviruses and caution is required in immunocompromised patients. 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. Two cases of laboratory-confirmed tecovirimat resistance have been reported, but transmission of tecovirimat-resistant virus has not been documented so far.[237] 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).[158]

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.[238]

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.[239] 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.[47] Consult your local public health authority for guidance on the use of antiviral therapy.

Antiviral treatments may interact with HIV antiretroviral therapy and caution is advised in patients on antiretroviral therapy. However, none of the identified drug interactions, so far, should preclude administration of tecovirimat with antiretroviral therapy. Consult your local pharmacist for more information.[24][131]

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

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

The 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.[267] 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

Consider – discontinuation of isolation precautions and discharge

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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.[261] 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.[242]

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.[262]

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.[262]

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.[262]

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Mpox (monkeypox)

Treatment algorithm

suspected or confirmed infection: mild or uncomplicated disease

Primary options

Fever or mild pain

Mild pain

Severe pain

Severe pain

Severe pain

Pruritus

Nausea/vomiting

Nausea/vomiting

Dyspepsia

suspected or confirmed infection: severe or complicated disease, or at increased risk for severe disease or complications

Primary options

Fever or mild pain

Mild pain

Severe pain

Severe pain

Severe pain

Pruritus

Nausea/vomiting

Nausea/vomiting

Dyspepsia

Primary options

Oral dose regimen

Intravenous dose regimen

Secondary options

Tertiary options

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