Maternal antiviral therapy for genital herpes does not prevent neonatal infection

Abstract

Pinninti et al evaluated 8 neonates from 4 states who developed herpes simplex virus (HSV) infection, even though their mothers received antiviral therapy to suppress genital herpes. A wide-spread practice among obstetricians, acyclovir suppressive therapy effectively reduces the number of clinical outbreaks during pregnancy, which reduces concern, as well as the number of cesarean deliveries performed among treated women.The risk of neonatal herpes in untreated women who have a recurrence of genital herpes and deliver vaginally is known to be low (ie, <5%). Although a case series certainly cannot determine incidence of an event, these reported cases are remarkable because they occurred in neonates who would be at low risk even if mothers were untreated. They document transmission during subclinical maternal HSV shedding despite suppressive therapy. Those of us who care for children taking acyclovir suppressive therapy (eg, following treatment of neonatal HSV or because of recurrent facial HSV) have the anecdotal experience that within just a few days of missed doses there frequently is immediate “escape” of HSV and a clinical recurrence—as if only the virus lytic phase was temporally and temporarily prevented by continuous acyclovir. The number of hours from the last maternal dose of an oral acyclovir product to delivery was not known precisely in this case series. It would seem prudent that women taking suppressive therapy should continue to take appropriate doses through labor until delivery, and that pediatricians should consider HSV infection among diagnostic possibilities in ill neonates, regardless of history of maternal suppressive therapy. A further sobering finding in this series was that one infant had acyclovir-resistant HSV documented during the course of infection.Article page 134▶ Pinninti et al evaluated 8 neonates from 4 states who developed herpes simplex virus (HSV) infection, even though their mothers received antiviral therapy to suppress genital herpes. A wide-spread practice among obstetricians, acyclovir suppressive therapy effectively reduces the number of clinical outbreaks during pregnancy, which reduces concern, as well as the number of cesarean deliveries performed among treated women. The risk of neonatal herpes in untreated women who have a recurrence of genital herpes and deliver vaginally is known to be low (ie, <5%). Although a case series certainly cannot determine incidence of an event, these reported cases are remarkable because they occurred in neonates who would be at low risk even if mothers were untreated. They document transmission during subclinical maternal HSV shedding despite suppressive therapy. Those of us who care for children taking acyclovir suppressive therapy (eg, following treatment of neonatal HSV or because of recurrent facial HSV) have the anecdotal experience that within just a few days of missed doses there frequently is immediate “escape” of HSV and a clinical recurrence—as if only the virus lytic phase was temporally and temporarily prevented by continuous acyclovir. The number of hours from the last maternal dose of an oral acyclovir product to delivery was not known precisely in this case series. It would seem prudent that women taking suppressive therapy should continue to take appropriate doses through labor until delivery, and that pediatricians should consider HSV infection among diagnostic possibilities in ill neonates, regardless of history of maternal suppressive therapy. A further sobering finding in this series was that one infant had acyclovir-resistant HSV documented during the course of infection. Article page 134▶