Diagnostic and therapeutic management for suspected neonatal herpes simplex virus infection

Inconsistent Management of Neonatal Herpes Simplex Virus Infections

OBJECTIVES

The incidence of neonatal herpes simplex virus (nHSV) infections is monitored periodically in the Netherlands, yet management and outcome is unknown. Comprehensive national guidelines are lacking. We aim to describe management and outcome in the last decade to explore current diagnostic and therapeutic challenges. We aim to identify possible variability in management of patients with a suspected nHSV infection.

METHODS

We conducted a retrospective case series of management and outcome of nHSV infections at 2 tertiary care center locations in the Netherlands.

RESULTS

An nHSV infection was diagnosed in 1% (12 of 1348) of patients in whom polymerase chain reaction for HSV was performed. Of the patients with nHSV infection, 3 of 12 died, and 4 of 9 (44%) survivors suffered neurologic sequelae. Neurologic symptoms at presentation were seen in only 2 of 8 patients with nHSV encephalitis. A cerebral spinal fluid analysis was performed in 3 of 6 patients presenting with skin lesions. Only 3 of 6 patients with neurologic symptoms received suppressive therapy. nHSV infection was diagnosed in 8 of 189 (4%) patients who were empirically treated.

CONCLUSIONS

Management of nHSV infection, particularly when presented with skin lesions, is inconsistent. Many infants without a HSV infection are exposed to antiviral medication. There is substantial interhospital variation in diagnostic and therapeutic management of a suspected infection. Comprehensive guidelines need to be developed to standardize management of suspected nHSV infection.

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

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 χ² 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 = .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.

Diagnosis of congenital/perinatal infections by neonatologists: a national survey

OBJECTIVE

To describe the clinical approach used by neonatologists for diagnosis of congenital/perinatal infections (CPI); no such data currently exist.

STUDY DESIGN

A national survey regarding the diagnosis of toxoplasma, syphilis, rubella, cytomegalovirus, and herpes simplex virus (HSV) infection in neonates.

RESULT

We received 553 (11%) responses. Central nervous system calcification or hydrocephalus was the commonest trigger to pursue a CPI diagnosis (98%); maternal history was the least frequent (67%). Four hundred twenty-two (76%) used general screening such as "TORCH titer screen" (57%) or total IgG or IgM (39%). Further evaluation targeted known clinical sequelae; but cerebrospinal fluid testing was used in only 65% of those suspected of having HSV or syphilis. Fifty-six percent chose a treponemal instead of a non-treponemal test for syphilis. Multivariable analyses did not identify factors associated with the clinical diagnostic approach.

CONCLUSION

We observed clinically important deviations from CPI diagnostic test recommendations in a national cohort of neonatologists.

Seasonal influence on TORCH infection and analysis of multi-positive samples with indirect immunofluorescence assay

Background

TORCH including the pathogens of Toxoplasma gondii (TOX), rubella virus (RV), cytomegalovirus (CMV), and herpes simplex virus (HSV) causes intrauterine infections and poses a worldwide threat to women especially in pregnancy. In this study, we described the seasonal difference in TORCH infection and analyzed the anti‐TORCH IgM multipositive serum samples by the indirect immunofluorescence assays (IFA).

Methods

To observe the seasonal influence of the anti‐TORCH IgG and IgM antibodies, a retrospective study was conducted with 10 669 women (20–40 y old) before pregnancy from August 2016 to July 2017. Totally 199 ELISA anti‐TORCH IgM multipositive serum samples were further tested by IFAs for false‐positive analysis.

Results

The prevalence of positive HSV1‐IgM, RV‐IgM, HSV2‐IgM, CMV‐IgM, and TOX‐IgM in the present population was 6.30%, 2.55%, 1.94%, 1.24%, and 0.67%, respectively. Additionally, the prevalence of positive RV‐IgM, CMV‐IgM, and HSV1‐IgM was statistically different among four seasons, with the highest positive rates of RV‐IgM (4.12%) in autumn, CMV‐IgM (1.75%) in summer, and HSV1‐IgM (7.53%) in winter. The confirmatory IFAs showed that the positive rates of RUV‐IgM, CMV‐IgM, and HSV2‐IgM were significantly different from those in ELISA screening experiments. Interestingly, only 32.7% (65/199) of the TORCH IgM multipositive results were consistent with those by the IFA, indicating that cross‐reaction caused false positives were common in ELISA IgM antibody screening.

Conclusion

The TORCH infection displayed different prevalence among four seasons in our 12‐month retrospective study. The IgM multipositives by ELISA screening may need further confirmation analysis due to its relatively high cross‐reaction rate.

Neonatal Herpes Simplex Viral Infections and Acyclovir: An Update

Neonatal herpes simplex virus (HSV) infections have high morbidity and mortality rates. Optimization of treatment and prevention strategies are imperative to improve the care and outcomes of neonates infected with HSV. Management of HSV includes reducing neonatal transmission, treating acute infections, and limiting adverse neurodevelopmental outcomes and future cutaneous outbreaks after acute infections. Transmission risk may be affected by route of delivery and maternal suppressive therapy. Neonatal HSV infections are divided into 3 categories: localized skin, eyes, or mouth; localized central nervous system; or disseminated infections. Parenteral acyclovir, the pharmacologic agent of choice, is used when treating each type of infection. However, dosage strategies and durations of therapy may vary based on disease state severity, presentation, and patient characteristics. Oral acyclovir may be used as suppressive therapy after acute treatment completion in specific neonatal populations, reducing long-term adverse neurodevelopmental outcomes and future skin eruptions. The mortality rate remains high even with treatment.

Management of herpesvirus infections

Management of human herpesviruses remains a considerable clinical challenge, in part due to their ability to cause both lytic and latent disease. Infection with the Herpesviridae results in lifelong infection, which can reactivate at any time. Control of herpesviruses is by the innate and adaptive immune systems. Herpesviruses must evade the host innate immune system to establish infection. Once infected, the adaptive immune response, primarily CD8(+) T-cells, is crucial in establishing and maintaining latency. Latent herpesviruses are characterised by the presence of viral DNA in infected cells and limited or no viral replication. These characteristics provide a challenge to clinicians and those developing antiviral agents. The scope of this review is two-fold. First, to provide an overview of all antivirals used against herpesviruses, including their mechanism of action, pharmacokinetics, side effects, resistance and clinical uses. And second, to address the management of each of the eight herpesviruses both in the immunocompetent and immunocompromised host, providing evidence for clinical management and therapeutic options, which is important to the clinician engaged in the management of these infections.

How to use... neonatal TORCH testing

Toxoplasma gondii, rubella, cytomegalovirus and herpes simplex virus have in common that they can cause congenital (TORCH) infection, leading to fetal and neonatal morbidity and mortality. During the last decades, TORCH screening, which is generally considered to be single serum testing, has been increasingly used inappropriately and questions have been raised concerning the indications and cost-effectiveness of TORCH testing. The problems of TORCH screening lie in requesting the screening for the wrong indications, wrong interpretation of the single serum results and in case there is a good indication for diagnosis of congenital infection, sending in the wrong materials. This review provides an overview of the pathogenesis, epidemiology and clinical consequences of congenital TORCH infections and discusses the indications for, and interpretation of, TORCH screens.

Mucosal herpes immunity and immunopathology to ocular and genital herpes simplex virus infections

Herpes simplex viruses type 1 and type 2 (HSV-1 and HSV-2) are amongst the most common human infectious viral pathogens capable of causing serious clinical diseases at every stage of life, from fatal disseminated disease in newborns to cold sores genital ulcerations and blinding eye disease. Primary mucocutaneous infection with HSV-1 & HSV-2 is followed by a lifelong viral latency in the sensory ganglia. In the majority of cases, herpes infections are clinically asymptomatic. However, in symptomatic individuals, the latent HSV can spontaneously and frequently reactivate, reinfecting the muco-cutaneous surfaces and causing painful recurrent diseases. The innate and adaptive mucosal immunities to herpes infections and disease remain to be fully characterized. The understanding of innate and adaptive immune mechanisms operating at muco-cutaneous surfaces is fundamental to the design of next-generation herpes vaccines. In this paper, the phenotypic and functional properties of innate and adaptive mucosal immune cells, their role in antiherpes immunity, and immunopathology are reviewed. The progress and limitations in developing a safe and efficient mucosal herpes vaccine are discussed.

Value of herpes simplex virus type-specific serology: a case report

Genital herpes, usually caused by herpes simplex virus type 2 (HSV-2), is one of the most common sexually transmitted diseases in humans. By contrast, intrauterine HSV-2 infections have been described rarely in the literature. Our report describes a case of neonate who was delivered after 30+2 gestational weeks by cesarean section. He presented with a respiratory distress syndrome resulting in broncho-pulmonary dysplasia. At the age of 6 weeks, a chorioretinal scar was detected. During the 4th month of age, the infant developed recurrent HSV-2 infection with nasal lesions. The retrospective type-specific serologic diagnosis revealed previous HSV-2 infection of the mother resulting in prenatal HSV-2 infection of the infant. In conclusion, intrauterine HSV-2 infections may be underrepresented since they may not be associated with severe congenital malformations and the diagnosis requires the use of HSV type-specific serologic methods not widely applied in microbiological laboratories.

Empiric acyclovir for neonatal herpes simplex virus infection

BACKGROUND

Because neonatal herpes simplex virus (NHSV) infection is difficult to diagnose, there has been a move towards using more empiric acyclovir (ACV).

OBJECTIVE

The purpose of this study was to review the use of ACV to optimize future management of NHSV.

METHODS

Charts were reviewed for infants started on intravenous ACV up to day 43 of life--January 2001 through February 2007--at five hospitals in Edmonton and Calgary.

RESULTS

ACV was started for possible (N = 115) or proven (N = 3) herpes simplex virus (HSV) infection. Six of the infants with possible HSV infection later had proven HSV infection. Seizures (34%), hemodynamic instability (29%) and skin lesions (24%) were the most common indications for ACV. Among the 118 infants, 106 (90%) had cerebrospinal fluid obtained and 82 (69%) had at least one surface swab for HSV but 4 (3%) had no specimens submitted for HSV detection. ACV was continued for 3.9 ± 3.5 days in the infants with no proven HSV disease. Possible nephrotoxicity from ACV was recorded in 3 of these 109 infants and in none of the infants with proven HSV disease.

CONCLUSIONS

Clinicians in Alberta primarily consider the diagnosis of NHSV infection when confronted with a neonate with seizures, hemodynamic instability or suspicious skin lesions, but need to consider the diagnosis more often if all cases are to be treated at first presentation. They often perform incomplete investigations to rule out NHSV infection. Adverse events from ACV appear to be uncommon when the drug is used for suspected NHSV disease.