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Module 17310 lessonsRxPrep 2023 Chapter 23, reconciled with CDC genital herpes, genital ulcer, pregnancy, neonatal, and current valacyclovir labeling

Genital Herpes

Connect HSV latency and anatomic testing to first episodes, recurrences, suppression, CNS disease, resistance, pregnancy, neonatal care, and humane transmission counseling.

01

Explain HSV entry, sensory ganglion latency, reactivation, and asymptomatic shedding.

02

Choose lesion NAAT, culture, and type specific serology for the correct diagnostic question.

03

Treat every first clinical episode with an evidence based systemic antiviral regimen.

04

Build an advance start plan for recurrent episodic therapy.

05

Individualize daily suppression by recurrence burden, transmission goals, and preference.

06

Recognize disseminated, meningeal, and encephalitic disease that requires IV acyclovir.

07

Detect antiviral toxicity and manage suspected acyclovir resistance.

08

Protect pregnancy and choose delivery management from acquisition timing, lesions, and prodrome.

09

Recognize and treat neonatal skin, eye, mouth, CNS, and disseminated HSV.

10

Counsel about type, disclosure, safer sex, pregnancy, and stigma without moral judgment.

173.01

Lesson

Follow HSV From Mucosa to Latency and Back

HSV replicates at mucocutaneous surfaces, enters sensory nerves, and persists in ganglia. Antivirals suppress active replication but do not remove latent virus.

What to learn
  • Mucosal entry
  • Sensory ganglion
  • Reactivation
  • Asymptomatic shedding
  • Type specific course
Clinical pathwayMap the viral cycle
01SurfaceDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02Sensory nerveSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03GanglionDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04ReactivationSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Trace the infection cycle

Active replication at an epithelial surface produces vesicles, erosions, or ulcers. Virus then travels along sensory neurons and establishes lifelong latency.

Separate infection from visible disease

Reactivation can produce a classic recurrence, an unrecognized mild episode, or asymptomatic shedding. Transmission therefore can occur when no lesion is visible.

Use type to predict natural history

Genital HSV-2 has more frequent recurrence and shedding. Genital HSV-1 recurrence and shedding decline more rapidly, especially during the first year.

Define what antivirals can do

Acyclovir, valacyclovir, and famciclovir inhibit active viral replication. They shorten illness and reduce recurrence or shedding, but they do not eradicate latency.

Quick check

0 of 1 answered
01Which statement best explains transmission between recognized outbreaks?
Answer every question to submit.
173.02

Lesson

Match the Test to the Clinical Question

A fresh lesion offers the most direct diagnostic opportunity. Type specific lesion NAAT is preferred, while culture and serology answer narrower questions.

What to learn
  • Lesion NAAT
  • Viral culture
  • HSV type
  • Serology
  • Ulcer differential
Clinical pathwayChoose the diagnostic path
01LesionDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02NAAT and typeSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03ContextDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04ConfirmSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Prefer lesion NAAT

Swab a vesicle or ulcer base for HSV NAAT or PCR and request HSV-1 and HSV-2 differentiation. Molecular testing is more sensitive than culture.

Know when culture matters

Culture sensitivity declines as lesions heal, but culture can provide an isolate for phenotypic susceptibility when treatment failure suggests resistance.

Use serology selectively

Type specific glycoprotein G serology can help when lesions are absent, symptoms are atypical with negative direct testing, or a partner has genital herpes.

Protect against false certainty

Low positive HSV-2 serology may require confirmation with another method. HSV IgM is not useful. Evaluate syphilis and other causes when a genital ulcer is present.

Quick check

0 of 1 answered
01What is the preferred test for a new genital vesicle?
Answer every question to submit.
173.03

Lesson

Treat Every First Clinical Episode

A first episode can become prolonged or severe even when the initial examination looks limited. Systemic therapy is indicated for every first clinical episode.

What to learn
  • Seven to ten days
  • Acyclovir
  • Valacyclovir
  • Famciclovir
  • Healing based extension
Clinical pathwayControl the first episode
01RecognizeDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02TreatSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03ProtectDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04ReassessSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Choose a complete oral regimen

Use acyclovir 400 mg orally three times daily, valacyclovir 1 g orally twice daily, or famciclovir 250 mg orally three times daily for 7 to 10 days.

Build administration safety

Review kidney function, hydration, swallowing, adherence, interactions, pregnancy, and access. Valacyclovir offers lower pill burden through improved oral bioavailability.

Extend for incomplete healing

If lesions remain unhealed after 10 days, reassess adherence, diagnosis, immune status, complications, and resistance, then extend treatment when clinically appropriate.

Reject topical monotherapy

Topical antiviral treatment provides minimal clinical benefit for genital herpes and is discouraged. Use systemic therapy according to severity.

Quick check

0 of 1 answered
01What is appropriate for a mild first clinical episode?
Answer every question to submit.
173.04

Lesson

Put Recurrent Treatment in the Patient's Hands

Episodic therapy has the greatest benefit when it begins during prodrome or within one day of lesion onset. Advance access is therefore part of the regimen.

What to learn
  • Prodrome
  • Advance supply
  • Short course
  • Renal dosing
  • Self start plan
Clinical pathwayWin the early treatment window
01ProdromeDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02Self startSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03CompleteDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04ReviewSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Start at the biologic window

Teach the patient's prodrome and first lesion pattern. Waiting for a clinic visit can miss the period when suppression shortens the episode most effectively.

Use a valacyclovir regimen

Options for recurrent HSV-2 include valacyclovir 500 mg orally twice daily for 3 days or 1 g orally daily for 5 days.

Use an acyclovir or famciclovir regimen

Acyclovir options include 800 mg twice daily for 5 days or 800 mg three times daily for 2 days. Famciclovir has validated one, two, and five day regimens.

Do not mix indications

First episode, recurrent episode, suppression, zoster, and CNS disease use different doses and durations. Confirm indication and renal function before selecting a schedule.

Quick check

0 of 1 answered
01When should recurrent episodic therapy begin?
Answer every question to submit.
173.05

Lesson

Use Suppression as a Shared Clinical Decision

Daily therapy can reduce frequent recurrences by about 70 to 80 percent, improve quality of life, and reduce but not eliminate HSV-2 transmission.

What to learn
  • Recurrence burden
  • Quality of life
  • Daily valacyclovir
  • Residual transmission
  • Annual review
Clinical pathwayBalance benefit and residual risk
01BurdenDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02PreferenceSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03SuppressDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04Layer preventionSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Offer all standard options

Suppressive regimens include acyclovir 400 mg twice daily, valacyclovir 500 mg or 1 g daily, and famciclovir 250 mg twice daily.

Recognize the lower dose boundary

Valacyclovir 500 mg daily may be less effective in patients with at least 10 episodes per year. Breakthrough frequency should prompt adherence, dose, diagnosis, and resistance review.

Reduce transmission without promising zero risk

Valacyclovir 500 mg daily reduces transmission in discordant heterosexual couples with symptomatic HSV-2. Condoms and avoiding sex during prodrome or lesions remain necessary.

Revisit, do not force interruption

Discuss ongoing value each year because recurrence often declines. Routine drug holidays and routine laboratory monitoring are not required for most otherwise healthy patients.

Quick check

0 of 1 answered
01Which statement about daily suppression is accurate?
Answer every question to submit.
173.06

Lesson

Escalate Invasive and Neurologic HSV Immediately

Disseminated disease, hepatitis, pneumonitis, meningitis, and encephalitis require IV therapy, organ assessment, and renal safety rather than an outpatient recurrence regimen.

What to learn
  • IV acyclovir
  • Meningitis
  • Encephalitis
  • Renal safety
  • Neurologic urgency
Clinical pathwayEscalate invasive disease
01SyndromeDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02IV exposureSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03Organ supportDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04MonitorSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Treat severe systemic disease

Use acyclovir 5 to 10 mg/kg IV every 8 hours for severe, disseminated, pneumonitis, hepatitis, or hospitalized HSV, with renal adjustment and supportive care.

Treat HSV-2 meningitis

Use acyclovir 5 to 10 mg/kg IV every 8 hours until clinical improvement, then valacyclovir 1 g orally three times daily to complete 10 to 14 days.

Treat encephalitis without delay

Use acyclovir 10 mg/kg IV every 8 hours for 14 to 21 days. Begin empirically when the syndrome is suspected while obtaining CSF PCR and neuroimaging.

Prevent acyclovir injury

Adjust for kidney function, infuse appropriately, maintain hydration, and follow creatinine, urine output, nephrotoxins, confusion, tremor, and other neurotoxicity findings.

Quick check

0 of 1 answered
01What is the correct response to suspected HSV encephalitis?
Answer every question to submit.
173.07

Lesson

Separate Delayed Healing From Antiviral Resistance

Immunocompromise can make lesions severe, atypical, and prolonged. Progression during correctly dosed adherent therapy requires a structured resistance evaluation.

What to learn
  • HIV
  • Adherence audit
  • Phenotypic testing
  • Cross resistance
  • Foscarnet
Clinical pathwayInvestigate persistent lesions
01VerifyDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02CultureSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03ConsultDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04RescueSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Adapt care in HIV

First episode therapy is similar, but healing can require longer treatment. Suppressive and episodic regimens can use higher frequency schedules from HIV guidance.

Investigate persistent lesions

Review dose, renal adjustment, adherence, absorption, immune status, and alternate ulcer causes. Obtain viral culture for phenotypic sensitivity when resistance is suspected.

Understand cross resistance

Acyclovir resistance usually confers resistance to valacyclovir and often famciclovir because the drugs depend on related viral activation and targets.

Use foscarnet with intensive monitoring

IV foscarnet is preferred for acyclovir-resistant genital herpes. Monitor kidney function, calcium, magnesium, potassium, phosphate, seizures, infusion toxicity, and genital ulceration.

Quick check

0 of 1 answered
01What is preferred for proven acyclovir-resistant genital herpes?
Answer every question to submit.
173.08

Lesson

Protect the Newborn Before Labor Begins

Neonatal risk depends strongly on acquisition timing and maternal immunity. Near delivery acquisition has much greater transmission risk than established recurrent infection.

What to learn
  • Acquisition timing
  • Thirty-six weeks
  • Prodrome
  • Lesion examination
  • Delivery route
Clinical pathwayProtect the delivery pathway
01TimingDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02SuppressSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03ExamineDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04DeliverSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Stratify by acquisition timing

Transmission risk is about 30 to 50 percent when genital herpes is acquired near delivery and below 1 percent with recurrent disease or first half acquisition.

Use late pregnancy suppression

For recurrent genital herpes, begin acyclovir 400 mg orally three times daily or valacyclovir 500 mg orally twice daily at 36 weeks.

Examine at labor

Ask about burning, pain, or other prodrome and examine for genital lesions. Vaginal delivery is appropriate when neither lesions nor prodrome is present.

Use cesarean delivery for active risk

Cesarean delivery reduces neonatal exposure when lesions or prodrome are present at labor. Suppression reduces recurrence at term but does not guarantee vaginal delivery.

Quick check

0 of 1 answered
01A laboring patient has recurrent genital lesions. What reduces neonatal exposure?
Answer every question to submit.
173.09

Lesson

Recognize Neonatal HSV Before Vesicles Appear

Neonatal HSV can present as skin, eye, and mouth disease, CNS disease, or disseminated infection. Absence of skin lesions does not make invasive disease safe to exclude.

What to learn
  • Exposure
  • Surface testing
  • CSF PCR
  • Fourteen days
  • Twenty-one days
Clinical pathwayFind the neonatal compartment
01ExposureDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02EvaluateSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03TreatDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04Prove clearanceSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Evaluate the exposed newborn

Maternal lesions or near term acquisition should trigger pediatric infectious disease involvement. Testing can include mucosal PCR or cultures, blood PCR, CSF studies, liver tests, and eye examination.

Treat limited disease systemically

Skin, eye, and mouth disease receives acyclovir 20 mg/kg IV every 8 hours for 14 days after CNS and disseminated disease are excluded.

Treat CNS or disseminated disease longer

Use acyclovir 20 mg/kg IV every 8 hours for 21 days, with kidney function, blood counts, neurologic status, liver, lung, and coagulation monitoring.

Prove CNS viral clearance

Repeat CSF HSV PCR near the end of CNS therapy. Continue IV treatment and retest when PCR remains positive rather than stopping automatically.

Quick check

0 of 1 answered
01How long is neonatal CNS HSV treated with IV acyclovir?
Answer every question to submit.
173.10

Lesson

Make Counseling Clinically Precise and Human

Accurate counseling reduces transmission, improves treatment choices, and counters the stigma that can cause more harm than the physical recurrence.

What to learn
  • Disclosure
  • Asymptomatic shedding
  • Condoms
  • Pregnancy planning
  • Psychosocial care
Clinical pathwayBuild an honest prevention plan
01ExplainDefine the biology

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

02DiscloseSelect the evidence

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

03Reduce riskDeliver the intervention

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

04SupportSecure the next decision

Connect viral biology, anatomic risk, antiviral exposure, follow-up, and prevention.

Explain what a diagnosis means

HSV is common and lifelong. A result usually cannot establish exactly when transmission occurred, and it is not evidence of recent infidelity or personal failure.

Build a layered prevention plan

Avoid sexual contact during prodrome or lesions, use condoms consistently, disclose to partners, and consider suppression. Each layer reduces risk, but none eliminates it.

Connect reproductive planning

Patients who are pregnant or planning pregnancy should inform obstetric clinicians and partners. Prevention of near delivery acquisition deserves special attention.

Treat distress as part of care

Assess anxiety, depression, coercion, partner safety, and misinformation. Offer reliable resources and revisit episodic versus suppressive therapy through shared decision-making.

Quick check

0 of 1 answered
01Which counseling statement is accurate?
Answer every question to submit.

Module test

Check the connections.

Each attempt draws 10 questions from the complete 130 question bank.

130 questions in this module bank10 questions per attempt

Each attempt draws a fresh set and rearranges the answer choices.

References

Current clinical foundation.

Lecture material was synthesized with the following contemporary guidance. Verify local policy and current guidance before applying clinical information.

  1. CDC Genital Herpes
  2. CDC Genital Ulcer Disease
  3. CDC Herpes During Pregnancy
  4. FDA Valtrex Prescribing Information
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