Clinical And Laboratory Characteristics Of Central Nervous System Herpes Simplex Virus Infection In Neonates And Young Infants

We conducted a retrospective review of electronic medical records of all cases of bacterial meningitis in neonates and young infants at our institution from 2004 to 2014. Fifty-six cases were identified. The most common causative organism was group B streptococcus, followed by Escherichia coli and then Listeria monocytogenes. Forty-four of the 56 patients in the study had abnormalities of the blood white blood cell (WBC) count. The most common WBC count abnormalities were leukopenia and elevation of the immature to total (I:T) neutrophil ratio. Six patients in the case series lacked cerebrospinal fluid (CSF) pleocytosis. Overall, just 3 of the 56 patients had normal WBC count with differential, CSF WBC count, and urinalysis. Only 1 of the 56 patients was well appearing with all normal lab studies. Our study indicates that bacterial meningitis may occur without CSF pleocytosis but very infrequently occurs with all normal lab studies and well appearance.

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“…Our experience of 26 cases of HSV meningitis in neonates and young infants, over a slightly shorter time period, has been published. 8 …”

Section: Discussionmentioning

confidence: 99%

Etiology and Laboratory Abnormalities in Bacterial Meningitis in Neonates and Young Infants

Kotzbauer

Travers

Shapiro

et al. 2017

Clinics and Practice

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“…20 Another retrospective study of 26 infants with CNS HSV disease found that seizures occurred in 54% of patients; in 35%, the seizures were present at presentation. 21 A clinical trial that enrolled 186 infants with neonatal HSV disease found that seizures were present in 57% of infants with CNS disease and in 22% of infants with disseminated disease; overall 27% of infants had seizures at presentation. 22 This suggests that a significant proportion of seizures are likely due to HSV disease and not necessarily due to acyclovir exposure.…”

Section: Discussionmentioning

confidence: 99%

Safety of High-dose Acyclovir in Infants With Suspected and Confirmed Neonatal Herpes Simplex Virus Infections

Ericson

Gostelow

Autmizguine

et al. 2017

Pediatric Infectious Disease Journal

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Background Acyclovir is used to treat herpes simplex virus (HSV) disease in infants. Treatment with high dose acyclovir, 60 mg/kg/day, is recommended; however, the safety of this dosage has not been assessed in the past 15 years, and this dosage is not currently approved for infants by the US Food and Drug Administration. Methods We included infants with neonatal HSV disease treated with ≥14 days of intravenous acyclovir starting in the first 120 days of life admitted to 1 of 42 neonatal intensive care units managed by the Pediatrix Medical Group from 2002–2012. We determined the frequency and proportion of infants with clinical and laboratory adverse events (AEs) as well as the number and proportion of infant days with laboratory AEs occurring during acyclovir exposure. Results We identified 89 infants during the study period with 1658 days of acyclovir exposure. Almost all received high-dose acyclovir therapy (79/89, 89%). The most common clinical AEs were hypotension and seizure, both occurring in 9% of infants. Thrombocytopenia was the most common laboratory AE occurring in 25% of infants and on 9% of infant-days. Elevated creatinine occurred in 2% of infants and 0.2% of infant-days and no infants developed renal failure requiring dialysis. Overall, 45% of infants had ≥1 AE. Conclusions In this cohort of infants treated during the high-dose acyclovir era, AEs were common, but usually not severe. Many of the AEs reported in this cohort may be related to the underlying infection rather than due to acyclovir exposure.

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“…In non-highrisk infants ,22 days old, our approach recommends a CSF PCR without other testing or empirical acyclovir because of case series of infants with early isolated CNS disease who present with nonspecific symptoms and normal CSF indices. 25,27 For this population, there was lower adherence compared with older non-high-risk infants, with some receiving acyclovir and some not undergoing CSF testing. This incomplete adherence may represent ongoing provider concern about testing without empirically treating despite efforts to educate providers about the potential for isolated CNS disease with normal CSF cell counts and the opportunity for rapid local PCR testing to prevent significant delays in acyclovir administration, noting that before our guideline, many of these infants would have received no evaluation for HSV.…”

Section: Figurementioning

confidence: 97%

“…[18][19][20][21][22][23][24][25][26][27][28] Researchers do report that infants with isolated central nervous system (CNS) disease can rarely present with nonspecific symptoms and without CSF pleocytosis. [25][26][27] Considering the test characteristics of the HSV CSF PCR, [28][29][30] we felt that non-high-risk infants within the age range when perinatally acquired HSV most commonly presents (,22 days) 24-26, 31,32 could be screened for CNS disease with HSV CSF PCR only. Although infants can present .21 days of age, they do so with such insufficient frequency that we felt the risks of false-positive testing outweighed the benefit of a broad screening approach in this subset of older infants.…”

Section: Settingmentioning

confidence: 99%

Using Quality Improvement to Implement a Standardized Approach to Neonatal Herpes Simplex Virus

et al. 2019

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OBJECTIVES: Neonatal herpes simplex virus (HSV) infections are associated with high mortality and long-term morbidity. However, incidence is low and acyclovir, the treatment of choice, carries risk of toxicity. We aimed to increase the percentage of patients 0 to 60 days of age who are tested and treated for HSV in accordance with local guideline recommendations from 40% to 80%.METHODS: This quality improvement project took place at 1 freestanding children's hospital. Multiple plan-do-study-act cycles were focused on interventions aimed at key drivers including provider buy-in, guideline availability, and accurate identification of high-risk patients. A run chart was used to track the effect of interventions on the percentage managed per guideline recommendations over time by using established rules for determining special cause. Pre-and postimplementation acyclovir use was compared by using a x 2 test. In HSV-positive cases, delayed acyclovir initiation, defined as .1 day from presentation, was tracked as a balancing measure. RESULTS:The median percentage of patients managed according to guideline recommendations increased from 40% to 80% within 8 months. Acyclovir use decreased from 26% to 7.9% (P , .001) in non-high-risk patients but did not change significantly in high-risk patients (73%-83%; P 5 .15). There were no cases of delayed acyclovir initiation in HSV-positive cases.CONCLUSIONS: Point-of-care availability of an evidence-based guideline and interventions targeted at provider engagement improved adherence to a new guideline for neonatal HSV management and decreased acyclovir use in non-high-risk infants. Further study is necessary to confirm the safety of these recommendations in other settings.

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Clinical And Laboratory Characteristics Of Central Nervous System Herpes Simplex Virus Infection In Neonates And Young Infants

Cited by 10 publications

References 10 publications

Etiology and Laboratory Abnormalities in Bacterial Meningitis in Neonates and Young Infants

Etiology and Laboratory Abnormalities in Bacterial Meningitis in Neonates and Young Infants

Safety of High-dose Acyclovir in Infants With Suspected and Confirmed Neonatal Herpes Simplex Virus Infections

Using Quality Improvement to Implement a Standardized Approach to Neonatal Herpes Simplex Virus

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