EBM

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EBM

• 2008/06/12
• Present by ???

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• ???
• 34 y/o
• Male
• Chart number 16479778
• ???? 6/2-6/9

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• The patient's son had chicken pox infection in
  recent days.He denied to get chicken pox
  infection before. The fever is up to 38.5c. The
  vesicles over his face was noted. He went to LMD
  and took some medicine but in vein. The fever was
  persistent and the vesicles were noted over
  extremities and abdominal wall. The CxR revealed
  mxed alveolar and interstitial infiltration over
  both lower lung.

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PICO

• P What role does Acyclovir playing in Chickenpox
  infection?
• I Pt Tx by Acyclovir
• C Pt Tx by placebo
• O Chickenpox complications, symptoms, and whole
  course time

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• Acyclovir for treating varicella in otherwise
  healthy children and adolescents (Review)

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Background

• The most common neurological complications are
  cerebellar ataxia and encephalitis.
• Complications of the respiratory system include
  pneumonia and upper respiratory tract infections
  (particularly otitis media)

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• Traditional treatment for chickenpox is
  symptomatic, through the use of lotions to
  relieve itchiness (Brunell 1987) and
  acetaminophen to reduce fever and pain (Avery
  1994).
• Newer treatments include immunoglobulins,
  vaccines, and anti-viral drugs.
• Acyclovir has the potential to shorten the course
  of illness which may result in reduced costs and
  morbidity associated with chickenpox.

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Objectives

• 1) To examine the evidence evaluating the
  efficacy of acyclovir in alleviating symptoms of
  chickenpox and shortening the duration of
  illness.
• 2) To examine complications of chickenpox and
  adverse effects associated with acyclovir as
  reported in the relevant trials.

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Search strategy

• The Cochrane Central Register of Controlled
  Trials (CENTRAL) (The Cochrane Library, Issue 2,
  2005)
• MEDLINE (January 1966 to June 2005
• EMBASE (1988 to June 2005).

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CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW

• Only randomized controlled trials (RCTs)were
  included.
• Evaluated otherwise healthy children zero to 18
  years of age who had chickenpox were included.
• The primary outcome was the amount of time to no
  new lesions
• Other outcomes included the maximum number of
  lesions, time to resolution of fever (37.8C) and
  itching.

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METHODS OF THE REVIEW

• Three studies were included in this analysis
• The mean age of the children in the three trials
  ranged from 5.2 to 14.8 years the minimum age
  was two years and the maximum was 18 years. The
  studies varied in size with 105, 815, and 68
  patients, respectively

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METHODOLOGICAL QUALITY

• The quality scores of included studies, as
  measured by the Jadad scale,were four in one
  trial (Balfour 1990) and three in the remaining
  two trials (Balfour 1992 Dunkle 1991).

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Main results

• Acyclovir was associated with a reduction in the
  number of days with fever (-1.1 days, 95 CI -1.3
  to -0.9) and in reducing the maximum number of
  lesions (-76 lesions, -145 to -8).
• less supportive with respect to the number of
  days to no new lesions and the number of days to
  the relief of itching.
• no clinically important differences between
  acyclovir and placebo with respect to
  complications associated with chickenpox or
  adverse effects associated with the treatment.

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DISCUSSION

• Efficacy of acyclovir (reduction in disease
  severity and a shorter course of disease.)
• Complications and adverse effects
• (no clinically important differences between
  acyclovir and placebo)

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Implications for practice

• that is self-limiting and has few complications
  in otherwise healthy children
• Impractical in obtain a prescription within 24
  hours.
• no formal cost-benefit analysis has been
  conducted.
• acyclovir resistant strain of VZV

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What about of in adult?

• Varicella pneumonia in adults usually leads to
  hospitalization and carries an overall mortality
  of between 10 and 30 percent.
• A double-blind, placebo-controlled trial in 148
  healthy adults. Oral acyclovir (800 mg five times
  daily) or placebo for seven days

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• Early therapy (initiated within 24 hours of rash
  onset) reduced the total time to full crusting of
  lesions from 7.4 days to 5.6 days.
• A 46 percent reduction in the maximum number of
  lesions.
• A shorter duration of fever and lesser severity
  of symptoms

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• Due to the increased risk of complications in
  adults, we recommend the initiation of acyclovir
  in adults with varicella infection, if therapy
  can be initiated within 24 hours of symptom onset