How is acyclovir-resistant herpes simplex virus (HSV) infection treated?

Updated: Mar 17, 2020
  • Author: Sean P McGregor, DO, PharmD; Chief Editor: William D James, MD  more...
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Acyclovir resistance is not common but does occur at higher rates in immunocompromised patients. [58] Acyclovir resistance can be attributed to thymidine kinase mutations and confers cross-resistance among the antiviral nucleoside analogs (acyclovir, valacyclovir, famciclovir, and penciclovir). [58] Agents that inhibit HSV-DNA polymerase (foscarnet and cidofovir) can be used in cases in which acyclovir resistance is suspected. Acyclovir resistance should be suspected in cases with persistent lesions or recurrences in patients on treatment. [48] Treatment with either intravenous foscarnet or cidofovir is effective for such cases. Additionally, a compounded topical preparation of cidofovir 1% gel applied once daily for 5 days may be a useful adjunctive or alternative treatment. [48, 59, 60] Resiquimod is an agonist of Toll-like receptors 7 and - that has been studied in patients with recurrent genital herpes. Topical resiquimod 0.01% gel applied twice weekly for 3 weeks increased the number of days to healing by 6-8 days and was associated significantly more erythema and erosions in comparison with vehicle. [61]

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