Challenges in the care of young infants with suspected neonatal herpes simplex virus.

Abstract

As pediatric hospitalists, we often care for neonates and young infants <2 months of age that are admitted to the hospital because of concern for serious infection. Although there are certain clinical signs and symptoms that raise our concern for neonatal herpes simplex virus (HSV; eg, seizures, vesicular rash, critical illness), there is considerable variability in the management of this population when these provocative symptoms are absent. Should we test for HSV in all well-appearing newborns with fever? Or should there be an age cutoff below which all newborns are tested? If we perform testing, should we always start acyclovir? Should we obtain viral studies of mucosal surfaces routinely or only when we have a high level of suspicion? What role should HSV PCR from suspected HSV lesions of the skin, eye or mouth play, as opposed to viral culture? Under what circumstances is it safe to discontinue acyclovir after the CSF HSV PCR is negative? Neonatal HSV is rare, with only ∼1500 cases in the United States each year,1 yet the consequences of delayed treatment are significant.2 There is little controversy concerning the initiation of HSV testing for infants with clinical signs and symptoms suggestive of HSV. Empiric treatment with high-dose intravenous acyclovir is also not controversial because high-dose acyclovir has been the standard treatment for more than a decade and has a low side-effect profile relative to the risk of untreated HSV infection.3,4 However, for infants without clinical signs of HSV, the decision to include empiric testing and treatment is less clear. Although a maternal history of fever and primary HSV infection are associated with neonatal HSV,5 the absence of maternal history of known HSV is not helpful in predicting which infants should be evaluated for HSV infection.6 Given that many …