Treatment Options
Most patients with mpox have mild, self-limited disease, which can be managed with supportive care alone r18
Consider systemic antiviral treatment for the following patients after consultation with state health authorities or CDC through the Emergency Operations Center (telephone, 1-770-488-7100): r18
- Patients with severe disease or severe disease-related complications (eg, hemorrhagic disease, confluent lesions, sepsis, encephalitis, ocular disease, bronchopneumonia, or other conditions requiring hospitalization)
- Patients at high risk of severe disease, such as those with significant immunocompromise or conditions affecting skin integrity, children, or pregnant or breastfeeding adults
- Patients with infection involving high-risk anatomical areas (eg, eyes, mouth, genitals, anus) with potential for serious adverse outcomes
High clinical suspicion is sufficient for consideration of treatment initiation r29
Currently there are no treatments approved specifically for mpox virus infection, but several antiviral agents originally developed for treatment of smallpox and other viral infections may be considered; they may be obtained from the Strategic National Stockpile upon request from state health authorities after consultation with CDC. Efficacy data for these agents are lacking, owing to infeasibility of human smallpox experimentation r18
- Tecovirimat r19r61
- Approved for treatment of human smallpox disease in adults and children weighing at least 3 kg
- Demonstrated efficacy against a diverse range of orthopoxviruses per in vitro and in vivo animal studies; efficacy data for treating mpox in humans is being collected r62
- Antiviral agent of choice for treatment of mpox virus infections in people; other agents can be considered as alternative or additive therapy in special circumstances such as disease progression on tecovirimat, concern for tecovirimat resistance, and tecovirimat resistance or intolerance r18
- Patients eligible for treatment with tecovirimat should be informed of and consider voluntary enrollment in the STOMP trial (Study of Tecovirimat for Human Monkeypox Virus) being conducted by the National Institute of Allergy and Infectious Diseases to evaluate tecovirimat efficacy; all high-risk patients will be enrolled in an open-label arm and receive tecovirimat, while other adult participants will be randomized to tecovirimat or placebo r18r63
- If participation in the STOMP trial is declined or otherwise infeasible, tecovirimat can also be accessed via the CDC's EA-IND protocol (expanded access–investigational new drug), allowing tecovirimat use in treatment of mpox during an outbreak r64
- Instructions on obtaining and using tecovirimat (via the STOMP trial or the CDC's EA-IND protocol), as well as required forms, are available at the CDC website r19r63
- Tecovirimat is available through the Strategic National Stockpile upon request from state and territorial health departments; certain states and territories have pre-positioned supplies to facilitate faster access
- CDC has streamlined the process for health care professionals to provide tecovirimat treatment for patients with mpox under its EA-IND protocol r63
- Treatment can begin upon receipt of the medication, after informed consent is obtained
- Required forms under the EA-IND can be returned to CDC after treatment begins
- "Patient's Guide to Mpox Treatment with Tecovirimat (TPOXX)" is also available at the CDC website r65
- Available in capsule and injection form
- Injection is generally contraindicated in severe renal impairment; exceptions may be considered if enteral administration is not anticipated to be dependable or feasible, based on individual patient risk-benefit assessment by the treating clinician that determines IV tecovirimat clinically necessary in consultation with CDC r64
- A recent report on clinical use of tecovirimat for treatment of mpox infection under the CDC EA-IND protocol found that among 549 treated patients, 99.8% were prescribed oral tecovirimat, 93.1% were not hospitalized, and very few adverse events were reported overall r66
- Cidofovir r67
- Originally approved for treatment of cytomegalovirus in patients with AIDS; has been used for other viral infections
- Demonstrated efficacy against a diverse range of orthopoxviruses per in vitro and in vivo animal studies; efficacy data for treating mpox in humans is unavailable
- CDC has an EA-IND protocol that allows use in treatment of mpox in an outbreak
- IV infusion; must be administered with probenecid
- Brincidofovir is a prodrug of cidofovir; brincidofovir and cidofovir should not be administered concurrently
- BLACK BOX WARNINGS for renal impairment and neutropenia
- Contraindicated in patients with severe renal impairment, those receiving potentially nephrotoxic agents, and those with hypersensitivity to cidofovir or severe hypersensitivity to probenecid or other sulfa-containing medications
- VIGIV (vaccinia immune globulin intravenous) r68
- Approved for treatment of complications due to vaccinia vaccination
- Efficacy data for treating mpox in humans is unavailable
- CDC has an EA-IND protocol that allows use in treatment of mpox in an outbreak
- Can be considered for prophylactic use after mpox exposure if smallpox or mpox vaccination is contraindicated
- For IV use only
- BLACK BOX WARNING for interactions with glucose monitoring systems
- Measure blood glucose level with a glucose-specific method during VIGIV therapy; VIGIV contains maltose and may falsely elevate glucose readings with some types of glucose monitoring systems
- Contraindicated in patients with history of anaphylaxis or other severe reaction to IV immune globulin, and in IgA-deficient patients with anti-IgA antibodies and history of IgA hypersensitivity
- Brincidofovir r69
- Approved for treatment of human smallpox disease in adults and children, including neonates
- Demonstrated efficacy against a diverse range of orthopoxviruses per in vitro and in vivo animal studies; efficacy data for treating mpox in humans is unavailable
- Available from Strategic National Stockpile upon receipt of an FDA-authorized single-patient emergency use IND
- Available in tablet and oral suspension form
- Brincidofovir is a prodrug of cidofovir and may have an improved safety profile; brincidofovir and cidofovir should not be administered concurrently
- BLACK BOX WARNING for increased mortality risk when used for prolonged durations
- No contraindications noted in prescribing information
- Trifluridine r70
- Approved for treatment of primary keratoconjunctivitis and recurrent epithelial keratitis due to herpes simplex virus, types 1 and 2
- Has demonstrated in vitro activity against orthopoxviruses; has been the preferred treatment for ocular vaccinia infection resulting as complication of smallpox vaccination with ACAM2000 vaccine r32
- May be considered for use in patients with ocular mpox involvement; prophylactic use can be considered for patients with eye-adjacent lesions r71
- For topical ophthalmic use only
- Contraindicated in patients who develop hypersensitivity reactions or chemical intolerance to trifluridine
Other management considerations should be individualized depending on specific mpox disease manifestations or disease-related complications, and may include the following: r72r73
- Fever
- Antipyretic medications and external cooling measures
- Pain r72
- Topical steroids, topical anesthetic agents, OTC analgesics (eg, acetaminophen, NSAIDs), and prescription analgesics (eg, gabapentin, opioids)
- Inflammation/lymphadenopathy
- Antiinflammatory and analgesic medications
- Pruritus/itching
- Oral antihistamines; topical agents such as calamine lotion, petroleum jelly, or colloidal oatmeal
- Oropharyngeal lesions
- Mucosal care, saltwater rinses, oral antiseptic mouthwash, local anesthetic agents, prescription analgesic mouthwash
- Rectal lesions
- Stool softeners, warm sitz baths, general pain control measures
- Genital lesions
- General pain control measures, topical steroids for localized swelling
- Vomiting/diarrhea
- Oral or IV hydration and antiemetic/antidiarrheal medications
- Respiratory tract
- Suctioning, incentive spirometry, chest physiotherapy, bronchodilators, antibiotics for secondary respiratory infections, nebulizer treatments, bronchoscopy, noninvasive ventilation, intubation/ventilation
- Sepsis
- Antibiotics, IV fluids, vasopressors, supplemental oxygen
- Skin compromise
- Cleaning, moist dressings, topical antibiotics, surgical debridement, skin grafts
- Secondary skin infection
- Antibiotics, incision and drainage, advanced wound management
Additional guidance has been developed for the following specific clinical manifestations of mpox:
- Ocular involvement r71r74r75r76
- Ocular involvement is an uncommon but potentially serious manifestation of mpox infection
- Though high rates (up to 27% prevalence) of ocular involvement have been reported with endemic mpox disease, less than 1% of 2022-2023 outbreak–related cases have had eye involvement r77
- Ocular disease may result in a range of ocular complications, including corneal scarring and loss of vision; bacterial superinfection may also result in severe adverse outcomes
- Ophthalmologic consultation should be obtained urgently if ocular mpox involvement is suspected, and a comprehensive ophthalmic examination should be performed, with appropriate isolation protocols and personal protective equipment in place
- Systemic antiviral therapy should be considered for patients severe mpox disease or severe disease-related complications, which include eye involvement
- Though efficacy data is lacking, tecovirimat is frequently given for systemic therapy; VIGIV may also be considered after consultation with CDC
- Topical antiviral therapy with trifluridine may be considered in consultation with an ophthalmologist; prophylactic treatment with topical trifluridine can also be considered for patients with eye-adjacent lesions
- Topical lubricants and antibiotics can be considered to prevent bacterial superinfection; topical steroids may exacerbate corneal damage and should be avoided
- Hand hygiene and avoidance of eye rubbing should be discussed with patients who have mpox, to minimize risk of eye involvement
- Skin lesions
- General measures r78
- Wash skin with mild soap and water
- Adhere to recommended isolation and infection control measures
- Antimicrobial agents are required only if concern for bacterial infection exists
- Silicone-based gels or sheeting may be used after lesions have healed, if there are scarring concerns
- Sun protection should be emphasized during and after lesion resolution to minimize pigmentation and scarring issues
- Lesions and scabs should not be scratched or unroofed
- Baths, sitz baths, and warm or cool compresses may help to sooth irritated skin
- Severe lesions r79
- Wounds should be cleansed with mild soap and water
- Antimicrobial soaks as part of wound cleaning may help remove biofilms and colonizing organisms
- Topical plain white petrolatum and occlusive nonstick dressings should be used to promote healing
- Protective coatings such as white petrolatum, zinc oxide paste, or silicone film should be used to protect large or highly exudative wounds
- Adult incontinence pads may help with management of perianal discharge or exudate
- Routine use of topical antimicrobial agents is not indicated and may be harmful
- Specialist consultation should be sought for severe wounds with significant involvement of high-risk anatomical sites, such as the eyelids, perioral area, ears, genitals, and perianal region
- Significant pitting or scarring may occur as lesions heal
- There should be low threshold to test for and treat potential coinfections
Drug therapy
- There are no treatments approved specifically for mpox; dosing recommendations are based on approved uses in smallpox or other viral infections
- Antivirals
- Tecovirimat r19r61
- Oral
- Administer within 30 minutes after a full meal containing moderate or high fat (approximately 600 calories and 25 grams of fat), or after a feeding for nursing or bottle-fed infants or children r63
- Capsules may be opened and mixed with water or food for those who cannot swallow capsules, especially infants and children r63
- Tecovirimat Oral capsule; Neonates weighing less than 3 kg: 33.3 mg PO every 12 hours. Standard duration is 14 days, but may be longer or shorter.
- Tecovirimat Oral capsule; Neonates weighing 3 to 5 kg: 50 mg PO every 12 hours. Standard duration is 14 days, but may be longer or shorter.
- Tecovirimat Oral capsule; Infants weighing less than 3 kg: 33.3 mg PO every 12 hours. Standard duration is 14 days, but may be longer or shorter.
- Tecovirimat Oral capsule; Infants and Children weighing 3 to 5 kg: 50 mg PO every 12 hours. Standard duration is 14 days, but may be longer or shorter.
- Tecovirimat Oral capsule; Infants and Children weighing 6 to 12 kg: 100 mg PO every 12 hours. Standard duration is 14 days, but may be longer or shorter.
- Tecovirimat Oral capsule; Children weighing 13 to 24 kg: 200 mg PO every 12 hours. Standard duration is 14 days, but may be longer or shorter.
- Tecovirimat Oral capsule; Children and Adolescents weighing 25 to 39 kg: 400 mg PO every 12 hours. Standard duration is 14 days, but may be longer or shorter.
- Tecovirimat Oral capsule; Children and Adolescents weighing 40 to 119 kg: 600 mg PO every 12 hours. Standard duration is 14 days, but may be longer or shorter. With the CDC or a mpox treatment expert, consider early use of combination therapy (i.e., tecovirimat plus VIGIV, brincidofovir, or cidofovir) in people with HIV and severe disease.
- Tecovirimat Oral capsule; Adolescents weighing 120 kg or more: 600 mg PO every 8 hours. Standard duration is 14 days, but may be longer or shorter. With the CDC or a mpox treatment expert, consider early use of combination therapy (i.e., tecovirimat plus VIGIV, brincidofovir, or cidofovir) in people with HIV and severe disease.
- Tecovirimat Oral capsule; Adults weighing 40 to 119 kg: 600 mg PO every 12 hours. Standard duration is 14 days, but may be longer or shorter. With the CDC or a mpox treatment expert, consider early use of combination therapy (i.e., tecovirimat plus VIGIV, brincidofovir, or cidofovir) in people with HIV and severe disease.
- Tecovirimat Oral capsule; Adults weighing 120 kg or more: 600 mg PO every 8 hours. Standard duration is 14 days, but may be longer or shorter. With the CDC or a mpox treatment expert, consider early use of combination therapy (i.e., tecovirimat plus VIGIV, brincidofovir, or cidofovir) in people with HIV and severe disease.
- Intravenous
- Transition patients to oral therapy to complete the treatment course as soon as oral therapy is tolerated; the duration of IV tecovirimat is 14 days if the patient's condition necessitates IV administration r63
- Tecovirimat Solution for injection; Neonates weighing less than 6 kg: 6 mg/kg/dose IV every 12 hours for 14 days.
- Tecovirimat Solution for injection; Infants and Children weighing less than 12 kg: 6 mg/kg/dose IV every 12 hours for 14 days.
- Tecovirimat Solution for injection; Children and Adolescents weighing 13 to 34 kg: 6 mg/kg/dose IV every 12 hours for 14 days.
- Tecovirimat Solution for injection; Children and Adolescents weighing 35 to 119 kg: 200 mg IV every 12 hours for 14 days. With the CDC or a mpox treatment expert, consider early use of combination therapy (i.e., tecovirimat plus VIGIV, brincidofovir, or cidofovir) in people with HIV and severe disease.
- Tecovirimat Solution for injection; Adolescents weighing 120 kg or more: 300 mg IV every 12 hours for 14 days. With the CDC or a mpox treatment expert, consider early use of combination therapy (i.e., tecovirimat plus VIGIV, brincidofovir, or cidofovir) in people with HIV and severe disease.
- Tecovirimat Solution for injection; Adults weighing 35 to 119 kg: 200 mg IV every 12 hours for 14 days. With the CDC or a mpox treatment expert, consider early use of combination therapy (i.e., tecovirimat plus VIGIV, brincidofovir, or cidofovir) in people with HIV and severe disease.
- Tecovirimat Solution for injection; Adults weighing 120 kg or more: 300 mg IV every 12 hours 14 days. With the CDC or a mpox treatment expert, consider early use of combination therapy (i.e., tecovirimat plus VIGIV, brincidofovir, or cidofovir) in people with HIV and severe disease.
- Cidofovir r80
- Administer oral probenecid with each cidofovir dose to minimize nephrotoxicity potential
- Cidofovir Solution for injection; Adults: 5 mg/kg/dose IV once weekly for 2 weeks, then 5 mg/kg/dose IV every 2 weeks. For people with HIV and severe disease, guidelines recommend considering 5 mg/kg/dose IV once weekly for 2 doses as an adjunct to tecovirimat.
- Brincidofovir r81
- Administer on an empty stomach
- Brincidofovir Oral suspension; Neonates: 6 mg/kg/dose PO once weekly for 2 doses (on days 1 and 8).
- Brincidofovir Oral suspension; Infants and Children weighing less than 10 kg: 6 mg/kg/dose PO once weekly for 2 doses (on days 1 and 8).
- Brincidofovir Oral suspension; Children and Adolescents weighing 10 to 47 kg: 4 mg/kg/dose PO once weekly for 2 doses (on days 1 and 8).
- Brincidofovir Oral suspension; Children and Adolescents weighing 48 kg or more: 200 mg PO once weekly for 2 doses (on days 1 and 8).
- Brincidofovir Oral suspension; Adults weighing less than 48 kg: 4 mg/kg/dose PO once weekly for 2 doses (on days 1 and 8).
- Brincidofovir Oral tablet; Adults weighing 48 kg or more: 200 mg PO once weekly for 2 doses (on days 1 and 8). For people with HIV and severe disease, guidelines recommend considering brincidofovir as an adjunct to tecovirimat.
- Trifluridine
- Trifluridine Ophthalmic drops, solution; Children and Adolescents: 1 drop in the affected eye(s) every 2 hours (Max: 9 drops/day) until reepithelialization, then 1 drop in the affected eye(s) every 4 hours (Min: 5 drops/day) for 7 days. Continue treatment until all periocular lesions have healed. Max duration: 21 days.
- Trifluridine Ophthalmic drops, solution; Adults: 1 drop in the affected eye(s) every 2 hours (Max: 9 drops/day) until reepithelialization, then 1 drop in the affected eye(s) every 4 hours (Min: 5 drops/day) for 7 days. Continue treatment until all periocular lesions have healed. Max duration: 21 days.
- Probenecid r80
- Administer oral probenecid with each cidofovir dose to minimize nephrotoxicity potential
- Probenecid Oral tablet; Adults: 2 g PO given 3 hours prior to each cidofovir infusion, followed by 1 g PO at 2 and 8 hours following completion of the infusion.
- Vaccinia immune globulin r82
- Human Vaccinia Virus Immune Globulin Solution for injection; Neonates: 6,000 units/kg/dose IV as soon as symptoms appear; may consider a higher initial dose of 9,000 units/kg/dose IV for severe disease. Higher doses (e.g., 9,000 units/kg/dose, 24,000 units/kg/dose) may be considered if there is no response to the initial dose. Repeat dosing may be considered depending on the severity of symptoms and response to treatment. Base dose on actual body weight.
- Human Vaccinia Virus Immune Globulin Solution for injection; Infants, Children, and Adolescents: 6,000 units/kg/dose IV as soon as symptoms appear; may consider a higher initial dose of 9,000 units/kg/dose IV for severe disease. Higher doses (e.g., 9,000 units/kg/dose, 24,000 units/kg/dose) may be considered if there is no response to the initial dose. Repeat dosing may be considered depending on the severity of symptoms and response to treatment. Base dose on actual body weight.
- Human Vaccinia Virus Immune Globulin Solution for injection; Adults: 6,000 units/kg/dose IV as soon as symptoms appear; may consider a higher initial dose of 9,000 units/kg/dose IV for severe disease. Higher doses (e.g., 9,000 units/kg/dose, 24,000 units/kg/dose) may be considered if there is no response to the initial dose. Repeat dosing may be considered depending on the severity of symptoms and response to treatment. Base dose on actual body weight. For people with HIV and severe disease, guidelines recommend considering 6,000 to 9,000 Units/kg IV as an adjunct to tecovirimat.
- Vaccines
Comorbidities
- HIV r51r83r84
- Patients with advanced or uncontrolled HIV are at higher risk of severe or complicated mpox infection and prolonged mpox symptoms; effective antiretroviral therapy appears to attenuate risk r85
- In a recent report describing 57 adults hospitalized with severe manifestations of mpox for which CDC provided clinical consultation, 82% had HIV infection and 72% had known CD4 count less than 50 cells/mm³ r86
- Signs and symptoms of mpox are generally similar in patients with and without HIV; significant immunocompromise such as in advanced or uncontrolled HIV may predispose to disseminated or atypical rash (ie, genital lesions or confluent rash)
- Antiretroviral therapy and prophylaxis for opportunistic infections should be continued in all patients with HIV who develop mpox
- Mpox vaccination, antiviral treatments, and close monitoring are priorities for this population and should account for viral suppression and CD4 count in weighing risk of severe outcomes from mpox
- Assessment for drug interactions between available antiviral treatments for mpox and antiretroviral therapy for HIV is advised
- Tecovirimat should especially be considered for patients with mpox who have advanced or uncontrolled HIV disease, owing to risk of severe mpox disease; treatment should be initiated as early as possible in these patients
- Other antiviral therapies (ie, cidofovir, brincidofovir, VIGIV) can be considered in severe cases with disease progression or lack of improvement despite tecovirimat
- Vaccination with Jynneos vaccine is considered safe in patients with HIV; ACAM2000 vaccine should not be used in this population, regardless of immune status, owing to risk of progressive vaccinia and other severe adverse effects
- Other immunocompromise r51
- Significant immunocompromise is considered to include the following:
- Moderate or severe primary immunodeficiency
- Active treatment for a solid tumor or hematologic malignancy
- Transplant-associated immunosuppression
- Active treatment with high-dose corticosteroids, alkylating agents, antimetabolites, other transplant-related immunosuppressive drugs, severely immunosuppressive chemotherapy agents, tumor necrosis factor blockers, or other immunosuppressive or immunomodulatory agents
- History of CAR T-cell therapy (using chimeric antigen receptors) or hematopoietic cell transplant
- Patients with significant immunocompromise are at increased risk of severe mpox
- Significant immunocompromise may predispose to disseminated or atypical mpox lesions
- Assessment for drug interactions between available antiviral treatments for mpox and immunosuppressive therapies is advised
- Tecovirimat is the antiviral therapy of choice in patients with mpox who have significant immunocompromise
- Other antiviral therapies can be considered based on individual clinical circumstances
- Vaccination with Jynneos vaccine is considered safe in patients who are immunocompromised, including those with primary immunodeficiency or from immunosuppressive therapies; ACAM2000 vaccine should not be used, due to risk of progressive vaccinia and other severe adverse effects
Special populations
- Pregnant or breastfeeding patients r44r87
- Very limited data exist regarding mpox in pregnancy; it is unclear whether pregnancy increases risk of infection or more severe outcomes, although pregnant and breastfeeding patients are still considered a priority group for antiviral treatment
- Adverse pregnancy outcomes, including vertical transmission and fetal loss, have been reported in patients with mpox infection during pregnancy r43
- Signs and symptoms of mpox are similar in pregnant and nonpregnant patients
- If antiviral treatment is deemed to be indicated, after consultation with CDC, then tecovirimat should be first line therapy for patients who are pregnant, recently pregnant, or breastfeeding
- In animal studies, tecovirimat did not demonstrate any specific fetal effects, whereas cidofovir and brincidofovir showed evidence of teratogenicity
- There is no human data on tecovirimat in breastfeeding; it is unknown whether levels of tecovirimat expressed in breastmilk are sufficient for treatment of a breastfeeding child with mpox
- Jynneos vaccine data in humans are insufficient to assess vaccine-associated risks in pregnancy and breastfeeding, but Jynneos vaccination can be considered in patients who are otherwise eligible; ACAM2000 vaccine is contraindicated in pregnancy and breastfeeding, owing to risk of vaccinia virus infection and other severe adverse effects
- Patients in isolation for mpox should not breastfeed and should not have direct skin to skin contact with infants until criteria for discontinuation of isolation for mpox have been met
- Children and adolescents r42r88
- Reported pediatric cases in the current outbreak have been infrequent and generally mild; current evidence suggests that cases in children are generally not more severe than those in adults
- Household exposures are the main route of transmission for children; male to male sexual contact is the predominant route for adolescents, as for adults
- Adolescents present similarly to adults, but rash distribution differs in younger children; in a recent report on pediatric patients with mpox in the United States, rash distribution in children was mainly on the trunk and face, and no children younger than 12 years had anogenital lesions r88
- Diagnostic testing recommendations are similar for children and adults
- Management considerations are similar for children and adults
- Antiviral treatment should be considered for children and adolescents with: r42
- Severe disease or severe disease-related complications (eg, hemorrhagic disease, confluent lesions, sepsis, encephalitis, ocular disease, bronchopneumonia, or other conditions requiring hospitalization)
- Severe immunocompromise or conditions affecting skin integrity
- Infection involving high-risk anatomical areas (eg, eyes, face, genitals, anus) with potential for serious adverse outcomes
- Age younger than 1 year
- Tecovirimat is first line antiviral treatment for children and adolescents; other treatments, including cidofovir, brincidofovir, and VIGIV, can be considered, but they should be used with caution (owing to potential toxicity) r42
- No vaccines are currently licensed specifically for mpox prevention in children or adolescents; Jynneos vaccine can be offered for pediatric cases under an FDA emergency use authorization, after consultation with jurisdictional health authorities and CDC r42r89
- No significant adverse events have been reported to date in infants and children who have received Jynneos vaccine
- Pediatric data are lacking for ACAM2000 vaccine; many serious adverse effects, including progressive vaccinia and encephalitis, were reported in young children when the vaccine precursor to ACAM2000, which also contained replication-competent vaccinia virus, was used for smallpox prevention up through the early 1970s
- VIGIV and tecovirimat can also be considered for use as mpox postexposure prophylaxis through EA-IND authorization if vaccines are otherwise contraindicated; effectiveness of these medications as postexposure prophylaxis is unknown r42