Mpox — Treatment and Management — Clinical Pathway: Emergency Department, Outpatient Specialty Care and Primary Care

Mpox (Monkeypox) Clinical Pathway — Emergency Department, Outpatient Specialty Care and Primary Care

Treatment and Management

Supportive care is the mainstay of treatment for mpox.

Symptomatic Management

Skin Lesions
  • Keep clean and dry when not showering or bathing to prevent bacterial superinfection.
  • Do not touch or pick scabs, high risk for autoinoculation and superinfection (as well as scarring). Keep lesions covered to reduce transmission risk.
  • Always wash hands with soap and hot water after touching any lesion.
  • Pruritus managed with oral antihistamines and inert, anti-irritant topical agents such as calamine lotion or petroleum jelly.
  • After scab falls off, can apply Aquaphor® ointment to help prevent scarring.
Pain Control
  • Mild-Moderate
    • Analgesics
      • Acetaminophen
      • NSAIDs
    • Topical lidocaine 4% cream applied to lesions up to 3-4 times daily to intact skin
  • Severe
    • If severe pain not controlled by topical agents and over the counter analgesics, may need ER or inpatient for pain management and assessment for superinfection
  • Consider
    • Gabapentin (5 mg/kg/dose (Max 300 mg) TID)
    • Opioid, tramadol with consent
Gastrointestinal
  • Managed with appropriate hydration and electrolyte replacement
  • Antiemetics as needed
  • Anti-motility agents not generally recommended given the potential for ileus
Oral Lesions
  • Magic mouthwash
    • 5-15 mL swished in the mouth and spit out every 3-8 hours
    • Maximum 8 doses in a 24-hour period
    • Use cotton-tipped applicator
    • If patient is unable to swish and spit
  • Oral antiseptics to keep lesions clean
    • Chlorhexidine mouthwash
  • Topical benzocaine/lidocaine gels for temporary relief, especially to facilitate eating and drinking, but limit to recommended doses
Superinfection
  • If progressive worsening of lesions with pus, spreading erythema, or swelling, consider super infection with S. aureus or Streptococcal species. Most may be managed with mupirocin. Larger or multiple lesions may require systemic antibiotics. For oral and IV antibiotic recommendations, refer to the Cellulitis/Abscess Clinical Pathway.
  • For suspected superinfections that do not respond to these or are severe enough to warrant admission, please consult Infectious Diseases.
Prodromal Symptom Management
  • Analgesics
    • Acetaminophen
    • NSAIDs
  • Hydration
Anorectal Pain/Proctitis
  • Sitz baths
    • Soak perianal region in salt or Epsom salt and lukewarm water then pat dry or air dry
  • Stool softeners
  • NSAIDs/Acetaminophen
  • Topical lidocaine
    • Allow patients to self-administer
    • Can also consider topical nifedipine or diltiazem (needs compounding pharmacy)
Genital/Urethral Pain
  • For patients ≥ 12 years of age
    • Phenazopyridine 200 mg TID to provide symptomatic relief of urinary burning, itching, frequency and urgency; caution if used for > 2 days
  • Topical lidocaine
    • Allow patients to self-administer
  • If pain is severe, consider urinary catheterization

Antivirals

There are 3 potential antivirals with data from in-vitro or animal studies against orthopox virus. Cidofovir and brincidofovir are limited by significant toxicities and lack of availability respectfully and will not be discussed further. Tecovirimat (TPOXX®) is discussed below.

Tecovirimat (TPOXX)

General

  • Unknown efficacy in humans, but has demonstrated clinical efficacy in non-human primates infected with orthopox
  • Clinical data in humans for orthopox is very limited and evolving
  • Safety data is limited to adults
  • It is currently available from the CDC under a non-research expanded access investigational new drug (EA-IND) protocol

Consultation with Infectious Diseases is recommended for patients with orthopox for whom Tecovirimat treatment is being considered. IV form will be administered at Main Hospital (Philadelphia Campus) or KOPH hospital and ID should be consulted when considering tecovirimat administration.

CDC: Guidance for Tecovirimat Use Under Expanded Access Investigational New Drug Protocol during 2022 U.S. Mpox Cases  

Tecovirimat (TPOXX) — Treatment in People Infected with Mpox Virus

  • With Severe Disease
    • Hemorrhagic disease, confluent lesions, sepsis, encephalitis, or other conditions requiring hospitalization
  • Tecovirimat Should be Considered for Use in People Who Have the Following Clinical Manifestations
    • Severe disease — consider severe disease when a patient has conditions such as hemorrhagic disease; large number of lesions such that they are confluent; sepsis; encephalitis; ocular or periorbital infections; or other conditions requiring hospitalization
    • Involvement of anatomic areas which might result in serious sequelae that include scarring or strictures — these include lesions directly involving the pharynx causing dysphagia, inability to control secretions, or need for parenteral feeding; penile foreskin, vulva, vagina, urethra, or rectum with the potential for causing strictures or requiring catheterization; anal lesions interfering with bowel movements (for example, severe pain); and severe infections (including secondary bacterial skin infections), especially those that require surgical intervention such as debridement
  • Tecovirimat Should Also be Considered for Use in People Who are at High Risk for
    Severe Disease
    • People currently experiencing severe immunocompromise due to conditions such as advanced or poorly controlled human immunodeficiency virus (HIV), leukemia, lymphoma, generalized malignancy, solid organ transplantation, therapy with alkylating agents, antimetabolites, radiation, tumor necrosis factor inhibitors, or high-dose corticosteroids, being a recipient of a hematopoietic stem cell transplant < 24 months post-transplant or ≥ 24 months but with graft-versus-host disease or disease relapse, or having autoimmune disease with immunodeficiency as a clinical component1
    • Pediatric populations, particularly patients younger than 1 year of age2
    • Pregnant or breastfeeding people3
    • People with a condition affecting skin integrity — conditions such as atopic dermatitis, eczema, burns, impetigo, varicella zoster virus infection, herpes simplex virus infection, severe acne, severe diaper dermatitis with extensive areas of denuded skin, psoriasis, or Darier disease (keratosis follicularis)

Admission Considerations

  • All CHOP ER referrals for suspected or confirmed mpox cases should be called to 215-590-2160 and clinician should state nature of exposure or date of positive test
  • Negative pressure room
  • Expanded Precautions
  • ED referral considerations

 

References

  1. Clinical Course and Outcome of Human Monkeypox in Nigeria  
  2. Epidemiologic and Clinical Features of Children and Adolescents Aged < 18 Years with Monkeypox  
  3. Maternal and Fetal Outcomes Among Pregnant Women With Human Monkeypox Infection in the Democratic Republic of Congo