Neonatal Herpes Simplex Virus Infection Research Articles

Neonatal HSV: Initial Presentation of Disease

Neonatal herpes simplex virus (HSV) infection is a rare (approximately 1500 cases annually) but devastating disease. Identifying infants with possible

Disseminated neonatal Herpes simplex virus infection preceded by four days of prenatal maternal fever

A quick diagnosis for disseminated neonatal Herpes simplex virus (HSV) infection is not easy, potentially affecting morbidity and mortality. We report a case of disseminated HSV occurring at 4 days of life whose mother had fever for 4 days before delivery, a negative history for all sexually transmitted diseases, and a normal genitourinary examination (including visual examination of external genitalia and cervical/vaginal mucosa without colposcopy). A septic work-up done at birth was negative. A second septic work-up at 4 days of age, after clinical deterioration, led to the correct diagnosis and therapy. This case illustrates some of the difficulties in making a rapid diagnosis of neonatal HSV in all cases, especially at this age, and emphasizes the need for inclusion in this differential diagnosis and appropriate presumptive therapy.

Neonatal Herpes Encephalitis: A Rare Cause of Neonatal Refractory Seizures and Challenge for Neonatologist

Neonatal herpes simplex virus (HSV) infections are one of the most severe of all infections acquired during the perinatal period. HSV 2 accounts for majority of the neonatal HSV infections with intrapartum route being the most common pathway for transmission to the newborn. Clinical presentation can vary from skin involvement to disseminated infection, which when present has high mortality and neurological morbidity. Here we report a newborn with refractory seizures, acute infarct on MRI and was diagnosed as a case of HSV encephalitis. Baby was treated with antiviral drug and was discharged successfully and now in follow up.

G300(P) Empirical aciclovir in the management of febrile neonates

Background Neonatal herpes simplex infection can result in serious morbidity and mortality. This study assessed the attitudes of paediatric doctors towards the use of empirical aciclovir in the management of febrile neonates. Methods Invitations to participate in an online survey were sent to paediatric trainees (at senior house officer (SHO) and specialist registrar (SpR) level) and consultants (n = 513) in two medical deaneries in the UK (Wessex and Oxford Deanery) between May and June 2013. Four hypothetical scenarios of a febrile neonate were described to represent disseminated HSV disease (scenario 1), low-risk for HSV (scenario 2), HSV skin, eye and mouth disease (scenario 3) and HSV central nervous system disease (scenario 4). Participants were asked to indicate which antimicrobials they would commence for each scenario. Findings A total of 64 individuals participated (response rate: 12.5%). A substantial proportion of participants indicated they would not commence aciclovir despite the presence of clinical and/or laboratory features suggestive of neonatal HSV infection in scenarios 1(34/63, 54%), 3 (24/57, 42%) and 4 (31/54, 57%). Conversely, a total of 7/60 participants (12%) indicated they would start aciclovir in the scenario with low probability of HSV disease (scenario 2). Throughout, there was a trend for a higher proportion of consultants choosing to commence aciclovir compared with trainees; however, this was not statistically significant. Conclusion The results indicate that there is lack of awareness of key features suggestive of neonatal herpes simplex infection, and highlight the need to integrate guidance on the use of empirical aciclovir in febrile neonates into national guidelines.

Herpes simplex viruses 1 and 2.

1. Daniel Ruderfer, MD* 2. Leonard R. Krilov, MD*,† 1. *Department of Pediatrics, Children’s Medical Center, Winthrop University Hospital, Mineola, NY 2. †Department of Pediatrics, State University of New York at Stony Brook School of Medicine, Stony Brook, NY 1. 1. Gutierrez KM, 2. Arvin AM 1. Feigin RD, 2. Cherry JD, 3. Demmler-Harrison GJ, 4. Kaplan SL Herpes Simplex Viruses 1 and 2. Gutierrez KM, Arvin AM. In: Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL, eds. Feigin and Cherry's Textbook of Pediatric Infectious Diseases. 6th ed. Philadelphia, PA: Saunders Elsevier; 2009:1993–2016 2. 1. Pickering LK, 2. Baker CJ, 3. Kimberlin DW, 4. Long SS Herpes Simplex. American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012:398–408. Herpes images 6, 16, 26, and 45 3. 1. Kimberlin DW, 2. Whitley RJ, 3. Wan W, 4. et al Oral Acyclovir Suppression and Neurodevelopment After Neonatal Herpes. Kimberlin DW, Whitley RJ, Wan W, et al. N Engl J Med. 2011;365:1284–1292 [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] 4. 1. Kimberlin DW, 2. Lin CY, 3. Jacobs RF, 4. et al Natural History of Neonatal Herpes Simplex Virus Infections in the Acyclovir Era. Kimberlin DW, Lin CY, Jacobs RF, et al. Pediatrics. 2001;108:223–229 [OpenUrl][5][Abstract/FREE Full Text][6] 5. 1. Kimberlin DW, 2. Rouse DJ Genital Herpes. Kimberlin DW, Rouse DJ. N Engl J Med. 2004;350:1970–1977 [OpenUrl][7][CrossRef][8][PubMed][9][Web of Science][10] Two ubiquitous members of the 9-member human herpesvirus (HHV) family are herpes simplex virus (HSV) 1 and 2, which belong to the α-herpesvirus subfamily. The common sites of their clinical presentation are the oral and genital mucocutaneous areas, and both viruses can infect nerve cells and remain dormant for the long term in the sensory ganglia. Classic lesions initially appear as fluid-filled vesicles, which later become pustular and ultimately dry out and crust over. However, most infected individuals do not have any clinical manifestation either at the time of initial acquisition or during episodes of reactivation. The host's immune status has a strong influence on disease severity, as does whether infection is primary or recurrent. Recognizing the wide variety of clinical presentations, as well as knowledge of course progression, is invaluable for patient management and family counseling. Both forms of HSV can infect either oral or genital mucocutaneous sites, with HSV-1 predominately infecting oral sites and HSV-2 mainly infecting genital sites. Even in persons initially infected at both oral and genital sites with HSV-1 or HSV-2, HSV-1 is more likely to recur at oral sites, and HSV-2 reactivates more frequently in the genital areas. HSV infection can become invasive, causing severe disease, but this is uncommon and may represent a state of immunodeficiency. Polymerase chain reaction (PCR) is considerably more sensitive than is culture of vesicular fluid for detection of HSV on mucosal surfaces. The sensitivity of viral culture decreases as lesions heal. For patients who have no active lesions but a history of genital ulcers, diagnosis … [1]: {openurl}?query=rft.jtitle%253DNew%2BEngland%2BJournal%2Bof%2BMedicine%26rft.stitle%253DNEJM%26rft.issn%253D0028-4793%26rft.aulast%253DKimberlin%26rft.auinit1%253DD.%2BW.%26rft.volume%253D365%26rft.issue%253D14%26rft.spage%253D1284%26rft.epage%253D1292%26rft.atitle%253DOral%2Bacyclovir%2Bsuppression%2Band%2Bneurodevelopment%2Bafter%2Bneonatal%2Bherpes.%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJMoa1003509%26rft_id%253Dinfo%253Apmid%252F21991950%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1056/NEJMoa1003509&link_type=DOI [3]: /lookup/external-ref?access_num=21991950&link_type=MED&atom=%2Fpedsinreview%2F36%2F2%2F86.atom [4]: /lookup/external-ref?access_num=000295578700006&link_type=ISI [5]: {openurl}?query=rft.jtitle%253DPediatrics%26rft.stitle%253DPediatrics%26rft.issn%253D0031-4005%26rft.aulast%253DKimberlin%26rft.auinit1%253DD.%2BW.%26rft.volume%253D108%26rft.issue%253D2%26rft.spage%253D223%26rft.epage%253D229%26rft.atitle%253DNatural%2BHistory%2Bof%2BNeonatal%2BHerpes%2BSimplex%2BVirus%2BInfections%2Bin%2Bthe%2BAcyclovir%2BEra%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.108.2.223%26rft_id%253Dinfo%253Apmid%252F11483781%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [6]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=108/2/223&atom=%2Fpedsinreview%2F36%2F2%2F86.atom [7]: {openurl}?query=rft.jtitle%253DNew%2BEngland%2BJournal%2Bof%2BMedicine%26rft.stitle%253DNEJM%26rft.issn%253D0028-4793%26rft.aulast%253DKimberlin%26rft.auinit1%253DD.%2BW.%26rft.volume%253D350%26rft.issue%253D19%26rft.spage%253D1970%26rft.epage%253D1977%26rft.atitle%253DGenital%2BHerpes%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJMcp023065%26rft_id%253Dinfo%253Apmid%252F15128897%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [8]: /lookup/external-ref?access_num=10.1056/NEJMcp023065&link_type=DOI [9]: /lookup/external-ref?access_num=15128897&link_type=MED&atom=%2Fpedsinreview%2F36%2F2%2F86.atom [10]: /lookup/external-ref?access_num=000221218800009&link_type=ISI

Electroencephalography as an Adjunct in the Diagnosis of HSV Encephalitis in Preterm Twins.

Neonatal herpes simplex virus (HSV) infections are rare, with an estimated 1500 cases diagnosed annually in the United States.1 Intrapartum exposure to HSV in vaginal secretions leads to 85% of neonatal HSV infections, while intrauterine and postpartum infection accounts for 5% and 10% of infections, respectively.2 Irrespective of the route of exposure, neonatal HSV infection can cause devastating disease if not recognized and treated early.3 Primary maternal HSV infections carry a considerably higher risk of vertical transmission compared with reactivated latent infection or asymptomatic viral shedding because of the higher titer of virus found in the maternal genital track and the lack of transplacental transfer of protective IgG to the fetus.2 Other important risk factors for transmission include prolonged rupture of membranes, which increases the likelihood of ascending infection, and the use of intrapartum fetal scalp monitoring.2 Neonatal disease is classified as cutaneous/mucosal, central nervous system (CNS; with an encephalitic presentation), or disseminated disease involving multiple organs with or without CNS involvement.3 CNS and disseminated disease have the highest risk of morbidity and mortality, and favorable clinical outcomes are more likely if intravenous acyclovir is started promptly.2,3 However, treatment is frequently delayed because the presenting symptoms of neonatal HSV infection are often nonspecific. Despite decades of research there has not been a significant shortening of the time to institution of therapy.3 Because of the potentially devastating consequences of neonatal HSV infection, many researchers have evaluated screening of pregnant women for HSV infection and third trimester prophylaxis of HSV-positive women. Unfortunately, serological screening of pregnant women is of little use in preventing neonatal HSV infection because seropositivity does not predict the presence of infectious virus in the genital secretions of pregnant women at the time of parturition.4 Likewise, antenatal surveillance cultures to detect HSV in maternal genital secretions had poor correlation with the presence of infectious virus at the time of delivery.5 Third trimester prophylaxis has been demonstrated to reduce the incidence of genital lesions in pregnant women at delivery, the detection of HSV in genital secretions, and the rate of Caesarean delivery; however, the evidence is insufficient to support a recommendation for prophylaxis of pregnant women.6 It should be kept in mind as well that Caesarean delivery does not eliminate the risk of neonatal HSV infection, and in the setting of premature or prolonged rupture of membranes may provide little benefit.7 Because of the diagnostic uncertainty and the lack of effective preventive measures, some researchers support the use of acyclovir along with empiric broad-spectrum antibiotics for infants undergoing a rule out sepsis workup, though to date no standard of care has been defined.1 The cases described here illustrate the diagnostic uncertainty posed by neonatal HSV encephalitis. We propose an evidence-based application of routine electroencephalography (EEG) to aid in the workup of equivocal cases.

Hospitalization Cost per Case of Neonatal Herpes Simplex Virus Infection From Claims Data

The purpose of this study was to estimate the average excess inpatient cost of neonatal herpes simplex virus (NHSV) infection from 2005 to 2009 insurance claims data. The estimated adjusted average excess inpatient cost for neonate admissions with HSV diagnosis and >7 days of hospitalization was $40,044 [95% confidence interval (CI), $33,529-$47,775]. When disaggregated by the days of admission, cost estimates were: 8-13 days, $23,918 [CI, $19,490-$29,282]; 14-21 days, $44,358 [CI, $34,654-$56,673]; >21 days, $68,916 [CI, $49,905-$94,967]). Although these estimates are not representative of the entire US, they can inform future economic evaluation studies on NHSV interventions.

Population-based surveillance of neonatal herpes simplex virus infection in Australia, 1997-2011.

Neonatal herpes simplex virus (HSV) infection is uncommon, but mortality after disseminated disease and morbidity after encephalitis are high. For the last decade, increased dose and duration of acyclovir has been advised to prevent disease progression and recurrence. We sought to determine prospectively the epidemiologic, clinical, and secular trends of this condition in Australia. This was prospective national active surveillance for neonatal HSV disease through the Australian Paediatric Surveillance Unit from 1997 to 2011. Case notification triggered a questionnaire requesting de-identified data from the pediatric clinician. We identified 131 confirmed cases of neonatal HSV disease in 15 years from 261 notifications (95% response). The reported incidence (3.27 cases per 100 000 live births overall; 95% confidence interval [CI], 2.73-3.86) was stable. Overall mortality was 18.8% (95% CI, 12.1-25.5); the mortality rate was significantly lower in the latter part of the study period, 2005-2011, compared with 1997-2004 (P = .04). There were significantly more young mothers (<20 years of age) compared with Australian birth record data (18.5% vs 4.8%; P < .001). HSV-1 infection was more common than HSV-2 (62.7% vs 37.3%; P < .001), and the rate of HSV-1 infections increased significantly over the surveillance period (P < .05). From 2002, most infants received high-dose acyclovir. The time from symptom onset to initiation of therapy in survivors did not change over time. Mortality from neonatal HSV infection has fallen but remains high. HSV-1 is the major serotype causing neonatal disease in Australia. Young mothers represent an important target group for prevention.

Clinical and Laboratory Characteristics of Disseminated Herpes Simplex Virus Infection in Neonates

Disseminated herpes simplex virus (HSV) infection is the most fulminant type of neonatal HSV infection and has the highest mortality. Early diagnosis and treatment are essential for patient survival. We describe the clinical presentation, laboratory characteristics, and outcomes of neonates with disseminated HSV infection at our institution. A retrospective review of electronic medical records from 2006 to 2013 was performed. Only neonates with disseminated HSV infection, confirmed by using polymerase chain reaction or viral culture results, were included. Twenty-two cases were identified; the age range was 1 to 14 days. The majority of patients did not have a maternal history of HSV or a history of maternal fever at delivery. Eleven of the patients were delivered by cesarean delivery, and 3 of these patients did not have prolonged rupture of membranes. Neonatal fever, the most common historical characteristic, was present in only one-half of the patients. Pneumonia and respiratory distress were present in one-half of the patients. Serum aspartate aminotransferase and alanine aminotransferase levels were elevated in most, but not all, patients. The blood HSV polymerase chain reaction was positive in all patients tested. Of the 22 study patients, 16 survived and 6 died. The majority of the patients who died had respiratory disease and a delay in the initiation of acyclovir therapy. Disseminated HSV infection in neonates can be challenging to diagnose and is associated with high mortality. Clinicians must strongly consider this diagnosis, test the blood for HSV polymerase chain reaction, and initiate early treatment in the appropriate clinical scenarios.

Possible Neonatal Herpes Simplex Virus (HSV) Acquired Postpartum from Maternal Oral HSV Reactivation after Neuraxial Morphine.

In this report, we describe a case of a neonatal oral herpes simplex virus (HSV) infection possibly acquired from a mother who had oral HSV reactivation in association with neuraxial morphine. Neuraxial morphine is commonly administered for postpartum analgesia after cesarean delivery. While there is evidence that neuraxial morphine increases the risks of oral HSV reactivation in parturients, there has been no report of neonatal HSV infection directly acquired from a mother who had HSV recurrence from neuraxial morphine.

Prevention and management of neonatal herpes simplex virus infections.

Human herpes simplex virus (HSV) infection in neonates can result in devastating outcomes, including mortality and significant morbidity. All infants are potentially at risk for neonatal HSV infection. This position statement reviews epidemiology, transmission and risk factors, with a focus on intrapartum infection. It considers diagnosis and prognosis according to infection category, along with testing modalities and limitations. Recommendations for managing newborns known to have been exposed intrapartum to HSV are based on expert opinion because a randomized trial to compare management options is not feasible. Guidance is provided for the empirical management of infants with suspected clinical sepsis, including those who do not respond to antibacterial therapy. The present statement replaces a 2006 position statement by the Canadian Paediatric Society.

Herpes Simplex Virus Infection in Neonates and Young Infants with Sepsis

Background:Neonatal herpes infection is the most serious complication of Herpes Simplex Virus (HSV) infection during pregnancy and perinatal period. Few studies have reported neonatal HSV infection in developing countries.Objectives:The aim of this study was to detect the HSV infection among neonates and infants with sepsis.Materials and Methods:In a cross sectional study all infants aged less than 3 months, admitted to neonatal intensive care unit and pediatric emergency ward of Ghaem Hospital (a university hospital with 900 beds) in Mashhad (Northeast of Iran) with clinical diagnosis of sepsis and at least one inclusion criteria during one year from November 2009 to October 2010, were enrolled in the study. Polymerase chain reaction (PCR) was done on clinical samples obtained from patients.Results:Among 150 neonates and infants younger than 3 months old with sepsis, the PCR results for detecting the HSV DNA, were positive in 6 samples of 5 patients (3.3 %). None of the mothers had symptomatic HSV infection during delivery. The mean age of the patients was 18 days. Two of them died due to shock and disseminated intravascular coagulation (DIC).Conclusions:In neonates and infants with primary diagnosis of sepsis, HSV infection should be considered especially if the clinical condition does not improve after 48 hours of antibiotic therapy, and sepsis still exists with elevated liver enzymes.

Disseminated neonatal herpes simplex virus infection presenting with pneumonia and progressive respiratory failure

Disseminated neonatal herpes simplex virus (HSV) infection represents the most severe form of neonatal herpes, and is associated with high morbidity and mortality. Early recognition of disseminated HSV disease in the neonate can be difficult, since the clinical presentation often mimics bacterial sepsis with absence of cutaneous vesicles. We describe a 5-day-old male infant with disseminated HSV-2 disease, who initially presented with pneumonia and progressive respiratory failure requiring extracorporeal membrane oxygenation. Laboratory data were significant for leukopenia, thrombocytopenia and disseminated intravascular coagulation. Chest radiograph showed diffuse pulmonary infiltrates. Tracheal aspirate cultures grew HSV-2. The patient was treated with a 3 weeks course of intravenous acyclovir. The key feature in this case is to recognize that HSV can present in neonates with rapidly progressive pneumonitis and sepsis syndrome.

Neonatal Herpes with Classical Skin, Mucous and Eye Involvement: A Case Report

Neonatal herpes simplex virus infection (HSV) is a vertically transmitted infection, transferred to baby from mother during or before delivery and also through infected secretions after birth. Incidence varies all over the world varying from 1: 3200 births to 1: 60000 births. Untreated infections are often life threatening. It should be considered as a differential diagnosis in a febrile infant less than 1 month old with risk factors. Definitive culture or polymerase chain reactions are used for the diagnosis. Treatment consists of anti-viral therapy with acyclovir. Early diagnosis and prompt treatment will alleviate the related morbidity and mortality. Here we report a case of neonatal herpes simplex virus infection diagnosed early and treated effectively with acyclovir.

Neonatal Meningoencephalitis caused by Herpes Simplex Virus Type 2

Despite its rare occurrence, early diagnosis and appropriate treatment for neonatal herpes simplex virus infection aremandatory due to its high morbidity and mortality. In Korea, there has been no epidemiologic data on neonatal herpessimplex virus infection, and even case reports are rare. We observ...

Neonatal herpes in Serbia: Is it a problem or not?

With 20-80% mortality, neonatal infection caused by herpes simplex virus (HSV) or neonatal herpes is among the most severe of all perinatal infections. The majority of neonatal HSV infections are acquired during delivery, although in utero and postnatal infections do occur. Primary maternal infection is associated with a high rate of transmission (~50%), compared to &lt;3% in infants of women with reactivated disease. Other factors that influence transmission include HSV type, premature delivery, etc. Clinical manifestations have been classified into three forms: skin-eye-mouth disease, CNS and disseminated disease. The diagnosis of neonatal HSV infection includes the detection of HSV DNA by PCR in samples from neonate and mother. The incidence of neonatal herpes differs widely between different countries. In Serbia, the data about neonatal herpes incidence are scarce. The results of our pilot study showed that the minimal estimation of the national incidence of neonatal herpes is 7.5 per 100 000. Therefore, the set up and implementation of a national neonatal herpes surveillance system might provide valuable information for the accurate assessment of disease burden and development of an effective prevention strategy in Serbia.

TLR3 impairment in human newborns

Newborns are highly susceptible to viral infections. We hypothesized that this susceptibility could be due to a dysregulated expression of innate virus-sensing receptors, i.e., TLR3, TLR7, TLR8, and TLR9 and the cytosolic receptors retinoic acid-inducible gene I, melanoma differentiation-associated protein 5, protein kinase R, and IFN-γ-inducible protein 16. Cord blood mononuclear cells (CBMCs) expressed mRNA for all these receptors except for TLR3. In peripheral blood mononuclear cells (PBMCs), TLR3 mRNA was preferentially expressed in cytotoxic cells, particularly CD56(dim) NK cells. Cord NK cells in contrast showed low TLR3 mRNA expression and lacked TLR3 protein expression. Cord NK cells did not produce IFN-γ in response to polyinosinic-polycytidylic acid [poly(I:C)], whereas strong IFN-γ production was observed in poly(I:C)-stimulated adult NK cells. Cord NK cells had poor cytotoxic function that was only marginally enhanced by exposure to the TLR3 ligand poly(I:C). Opposite to NK cells from adults, their cytotoxicity was not improved by herpes simplex virus (HSV) exposure and they were unable to kill HSV-infected cells. There were no differences in the TLR3 mRNA levels among men, women, and pregnant women, implying that TLR3 is not under sex hormone control. However, decidual NK cells expressed low levels of TLR3 mRNA, which was attributed to their CD56(bright) phenotype. Our data show that cord blood NK cells have deficient TLR3 expression associated with an inability to respond to poly(I:C) and HSV activation and to kill HSV-infected cells. This might explain why newborns are particularly sensitive to neonatal HSV infections.

P27 Therapeutic drug monitoring and viral load monitoring in a case of disseminated neonatal herpes simplex virus infection

P27 Therapeutic drug monitoring and viral load monitoring in a case of disseminated neonatal herpes simplex virus infection

Neonatal Herpes Simplex Virus Infection

Herpes simplex virus (HSV) infection can cause significant morbidity and mortality in neonates (age less than 29 days) and occurs in 0.2% to 0.5% of neonates undergoing evaluation for serious bacterial illness in the emergency department. This article reviews the clinical features, diagnosis, and recommended treatment of neonatal HSV. The 3 clinical classifications of neonatal HSV infection are described and include: disseminated, central nervous system, and skin, eye, or mouth diseases. A comprehensive medical evaluation is described for the neonate with suspected HSV, including tests to identify the virus and to classify neonates accurately, because treatment and prognosis differ between disease classifications. Also presented are current recommendations for treatment of acute illness with parenteral acyclovir, as well as long-term oral acyclovir after acute illness. Current evidence and expert opinions are presented regarding the initiation of empiric HSV treatment for neonates undergoing serious bacterial illness evaluation.

Current Practice Patterns Regarding Diagnostic Investigations and Empiric Use of Acyclovir by Canadian Pediatric Emergency Physicians in Febrile Neonates

The aim of this study was to assess current attitudes and approaches to the febrile neonate in terms of diagnostic investigations and empiric treatment of suspected herpes simplex virus (HSV) infection. Between March 2010 and November 2010, a survey describing a hypothetical case of a febrile neonate presenting to the ED without clear signs of an HSV infection was sent to tertiary care pediatric emergency physicians across Canada. Participants were asked multiple choice and open-ended questions to obtain information about their choice of investigations, empiric treatment, and impression of the likelihood of HSV in the case. Survey data were analyzed using univariate statistics. Blood culture (98.6%), complete blood count (99.3%), lumbar puncture (81.2%), and nasopharyngeal swabs for respiratory viruses (61.6%) were most commonly performed by the 139 respondents, whereas 33% reported they would send cerebrospinal fluid for HSV polymerase chain reaction. Most (76%) would administer empiric antibiotics, whereas 5.8% included acyclovir to their treatment regimen. Greater than 50% included positive maternal history as an important factor in determining a febrile neonate's risk of HSV infection. Thirty-four percent reported that the wellness of the child, the presence of skin changes (37%), and the presence of any worrisome neurologic sign or symptom (37%) would influence their decision for investigations and empiric administration of acyclovir. Canadian pediatric emergency physicians are aware of risk factors for neonatal HSV infection and tailor their history and diagnostic investigations toward the diagnosis of HSV infection, but very few empirically administer acyclovir. Examination of future Canadian HSV guidelines for this patient population is warranted.