Trends in the incidence, mortality, and cost of neonatal herpes simplex virus hospitalizations in the United States from 2003 to 2014

National Trends in Survival and Short-Term Outcomes of Periviable Births ≤24 Weeks Gestation in the United States, 2009 to 2018

OBJECTIVE

Data from the academic medical centers in the United States showing improvements in survival of periviable infants born at 22 to 24 weeks GA may not be nationally representative since a substantial proportion of preterm infants are cared for in community hospital-based neonatal intensive care units. Our objective was to examine the national trends in survival and other short-term outcomes among preterm infants born at ≤24 weeks gestational age (GA) in the United States from 2009 to 2018.

STUDY DESIGN

This was a retrospective, repeated cross-sectional analysis of the National Inpatient Sample for preterm infants ≤24 weeks GA. The primary outcome was the trends in survival to discharge. Secondary outcomes were the trends in the composite outcome of death or one or more major morbidity (bronchopulmonary dysplasia, necrotizing enterocolitis stage ≥2, periventricular leukomalacia, severe intraventricular hemorrhage, and severe retinopathy of prematurity). The Cochran-Armitage trend test was used for trend analysis. p-Value <0.05 was considered significant.

RESULTS

Among 71,854 infants born at ≤24 weeks GA, 34,251 (47.6%) survived less than 1 day and were excluded. Almost 93% of those who survived <1 day were of ≤23 weeks GA. Among the 37,603 infants included in the study cohort, 48.1% were born at 24 weeks GA. Survival to discharge at GA ≤ 23 weeks increased from 29.6% in 2009 to 41.7% in 2018 (p < 0.001), while survival to discharge at GA 24 weeks increased from 58.3 to 65.9% (p < 0.001). There was a significant decline in the secondary outcomes among all the periviable infants who survived ≥1 day of life.

CONCLUSION

Survival to discharge among preterm infants ≤24 weeks GA significantly increased, while death or major morbidities significantly decreased from 2009 to 2018. The postdischarge survival, health care resource use, and long neurodevelopmental outcomes of these infants need further investigation.

KEY POINTS

· Survival increased significantly in infants ≤24 weeks GA in the United States from 2009 to 2018.. · Death or major morbidity in infants ≤24 weeks GA decreased significantly from 2009 to 2018.. · Death or surgical procedures including tracheostomy, VP shunt placement, and PDA surgical closure in infants <=24 weeks GA decreased significantly from 2009 to 2018..

Herpes Simplex Virus: A Practical Guide to Diagnosis, Management, and Patient Counseling for the Primary Care Clinician

Genital herpes is a chronic, lifelong sexually transmitted viral infection, which can cause recurrent, self-limited genital ulcers. It is caused by herpes simplex virus (HSV) type 1 and type 2 viruses. Genital HSV infection is a very prevalent STI, which causes self-limited, recurrent genital ulcers. Treatment decreases duration of symptoms and signs and can be provided as episodic or suppressive therapy. Genital herpes can have a substantial impact during pregnancy and on sexual health in general. Counseling on natural history, transmission, treatment, and management of sexual partners is an integral part of management of genital herpes.

TORCH Infections

Perinatal and neonatal infections are a significant cause of morbidity and mortality. As such, early recognition and workup when there is clinical concern is essential to supporting affected neonates. This article aims to focus specifically on the effects of toxoplasmosis, rubella, cytomegalovirus, herpes, and other agents (TORCH) infections, discussing epidemiology, diagnostics, and treatment if available. [Pediatr Ann. 2023;52(11):e400-e406.].

Herpes simplex virus infection among neonates suspected of invasive bacterial infection: a population-based cohort study

OBJECTIVE

To estimate the incidence of neonatal herpes simplex virus (HSV) infection and the number of neonates with suspected invasive bacterial infection (IBI) needed to treat (NNT) with acyclovir to ensure prompt treatment of invasive HSV infections.

DESIGN

A nationwide population-based cohort study.

SETTING

All neonatal and paediatric emergency departments in Denmark from 1 January 2010 to 31 December 2019.

PATIENTS

Neonates aged 0-28 days with HSV infection.

MAIN OUTCOME MEASURES

The main outcome measures were incidence and NNT. The NNT was calculated based on neonates with invasive HSV infection whose onset symptoms resembled IBI and the estimated number of Danish neonates who received antibiotics for suspected IBI.

RESULTS

Fifty-four neonates with HSV infection were identified, that is, an incidence of 9 per 100 000 live births. Twenty presented with symptoms resembling IBI, all within the first 14 days of life. Of 18 (78%) neonates, 14 had elevated C reactive protein, 14 of 19 (74%) had elevated alanine aminotransferase and 11 of 17 (65%) had thrombocytopaenia. The estimated NNTs with empiric acyclovir at postnatal ages 0-3, 4-7 and 8-14 days were 1139 (95% CI 523 to 3103), 168 (95% CI 101 to 726) and 117 (95% CI 48 to 198), respectively.

CONCLUSIONS

The incidence of neonatal HSV infection was higher than in previous decades; however, the estimated NNT with empiric acyclovir was high. Therefore, we propose not to treat all neonates suspected of IBI with empiric acyclovir, as current European guidelines suggest. However, HSV should be considered in neonates with signs of infection, especially after the third postnatal day and in neonates with high alanine aminotransferases and thrombocytopaenia.

Clinical Review of Risk of Nephrotoxicity with Acyclovir Use for Treatment of Herpes Simplex Virus Infections in Neonates and Children

OBJECTIVE

This study aims to clarify the risk of nephrotoxicity with intravenous use of acyclovir (ACV) for the treatment of neonates (ages <3 months) and children (ages ≥3 months to <12 years) with herpes simplex virus (HSV) infections and to identify gaps in knowledge that could be further investigated.

METHODS

Multiple databases were searched to identify studies on risk of nephrotoxicity with ACV use for treatment of invasive HSV infections, defined as any neonatal infection or HSV encephalitis (HSE) in children.

RESULTS

There were 5 and 14 studies that evaluated the risk of ACV-associated nephrotoxicity in neonates and children, respectively. The US Food and Drug Administration (FDA) delayed the approval of high (HD; 60 mg/kg/day) ACV in neonates secondary to risk of toxicity. Based on our review, the risk of ACV-associated nephrotoxicity was lower in the neonatal compared with the pediatric population. Acyclovir dose >1500 mg/m2, older age, and concomitant use of nephrotoxic drugs were identified as variables that increased the risk of ACV nephrotoxicity in children. Although the FDA has approved the use of HD ACV for the treatment of HSE in children, the American Academy of Pediatrics recommends a lower dose to minimize the risk of toxicity. The efficacy and safety of high vs lower doses of ACV for the management of HSE in children has yet to be evaluated.

CONCLUSIONS

The risk of ACV-associated nephrotoxicity was lower among neonates compared with older children. Future studies are needed to identify the optimal dosage that minimizes toxicities and maximizes the efficacy of ACV in children with HSE.

Neonatal Herpes Simplex Virus Infection: Epidemiology and Outcomes in the Modern Era

BACKGROUND

Over the past several decades, there have been advances in diagnosis and treatment of neonatal herpes simplex virus (HSV) disease. There has been no recent comprehensive evaluation of the impact of these advances on the management and outcomes for neonates with HSV.

METHODS

Clinical data for initial presentation, treatment, and outcomes were abstracted from medical records of neonates with HSV treated at Seattle Children's Hospital between 1980 and 2016.

RESULTS

One hundred thirty infants with a diagnosis of neonatal HSV were identified. Between 1980 and 2016, high-dose acyclovir treatment for neonatal HSV infection increased from 0% to close to 95%, with subsequent decrease in overall HSV-related mortality from 20.9% to 5.6%. However, even among infants treated with high-dose acyclovir, mortality was 40.9% for infants with disseminated (DIS) disease, and only 55% of infants with central nervous system (CNS) disease were without obvious neurologic abnormalities at 24 months. Over the study period, the time between initial symptoms and diagnosis decreased. Skin recurrences were more common with HSV-2 than HSV-1 (80% vs 55%; P = .02) and in infants with lesions at initial diagnosis (76% vs 47%; P = .02).

CONCLUSION

Changes in the standard of care for management of neonatal HSV disease have led to improvements in timeliness of diagnosis and outcome but mortality in infants with DIS disease and neurologic morbidity in infants with CNS disease remain high. Future research should focus on prevention of perinatal infection and subsequent recurrences.

Gastrostomy Tube Placement and Resource Use in Neonatal Hospitalizations With Down Syndrome

OBJECTIVES

To determine the trends in gastrostomy tube (GT) placement and resource utilization in neonates ≥35 weeks' gestational age with Down syndrome (DS) in the United States from 2006 to 2017.

METHODS

This was a serial cross-sectional analysis of neonatal hospitalizations of ≥35 weeks' gestational age with International Classification of Diseases diagnostic codes for DS within the National Inpatient Sample. International Classification of Diseases procedure codes were used to identify those who had GT. The outcomes of interest were the trends in GT and resource utilization and the predictors of GT placement. Cochran-Armitage and Jonckheere-Terpstra trend tests were used for trend analysis of categorical and continuous variables, respectively. Predictors of GT placement were identified using multivariable logistic regression. P value <.05 was considered significant.

RESULTS

Overall, 1913 out of 51 473 (3.7%) hospitalizations with DS received GT placement. GT placement increased from 1.7% in 2006 to 5.6% in 2017 (P <.001), whereas the prevalence of DS increased from 10.3 to 12.9 per 10 000 live births (P <.001). Median length of stay significantly increased from 35 to 46 days, whereas median hospital costs increased from $74 214 to $111 360. Multiple comorbidities such as prematurity, sepsis, and severe congenital heart disease were associated with increased odds of GT placement.

CONCLUSIONS

There was a significant increase in GT in neonatal hospitalizations with DS, accompanied by a significant increase in resource utilization. Multiple comorbidities were associated with GT placement and the early identification of those who need GT could potentially decrease length of stay and resource use.

Healthcare resource utilisation pattern and costs associated with herpes simplex virus diagnosis and management: a systematic review

OBJECTIVES

Little is known about the economic burden of herpes simplex virus (HSV) across countries. This article aims to summarise existing evidence on estimates of costs and healthcare resource utilisation associated with genital and neonatal HSV infection.

DESIGN

Systematic literature review.

DATA SOURCES

Seven databases were searched from inception to 31 August 2020. A focused search was performed to supplement the results.

ELIGIBILITY CRITERIA

Studies which reported either healthcare resource utilisation or costs associated with HSV-related healthcare, including screening, diagnosis and treatment of genital HSV infection and neonatal herpes prevention and treatment.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed the risk of bias using the Larg and Moss's checklist. All data were summarised narratively.

RESULTS

Out of 11 443 articles, 38 were included. Most studies (35/38, 94.6%) were conducted in high-income countries, primarily the United States, and were more often related to the prevention or management of neonatal herpes (n=21) than HSV genital ulcer disease (n=17). Most analyses were conducted before 2010. There was substantial heterogeneity in the reporting of HSV-related healthcare resource utilisation, with 74%-93% individuals who sought care for HSV, 11.6%-68.4% individuals who received care, while neonates with herpes required a median of 6-34 hospitalisation days. The costs reported were similarly heterogeneous, with wide variation in methodology, assumptions and outcome measures between studies. Cost for screening ranged from US$7-100, treatment ranged from US$0.53-35 for an episodic therapy, US$240-2580 yearly for suppressive therapy, while hospitalisation for neonatal care ranged from US$5321-32 683.

CONCLUSIONS

A paucity of evidence exists on healthcare resource utilisation and costs associated with HSV infection, especially among low-income and middle-income countries. Future research is needed on costs and healthcare utilisation patterns to improve overall understanding of the global economic burden of HSV.

Distinguishing Features Common to Dual Fatal Herpes Simplex Virus Infections That Occur in Both a Pregnant Woman and Her Newborn Infant

Deaths from herpes simplex virus type 1 (HSV-1) and herpes simplex virus type 2 (HSV-2) are rare. A major exception is perinatally acquired HSV-1 or HSV-2 infection where the neonatal death rate is substantial. Fatal HSV infection also occurs occasionally in pregnant women. The goal of this review is to enumerate the reports that describe dual deaths of both a pregnant woman and her newborn from a herpesvirus infection. A total of 15 reports were found in the medical literature, of which five described pregnant women with HSV encephalitis and 10 described women with disseminated HSV infection. When the virus was typed, most cases of dual mother/newborn deaths were caused by HSV-2. Of interest, in two situations caused by HSV-1, the pregnant woman probably acquired her primary HSV-1 infection from one of her children and not by sexual transmission. Complete genomic sequencing was performed on one set of HSV-1 isolates collected from mother (blood) and newborn (blood and skin). The mother's strain and the newborn's skin strain were 98.9% identical. When the newborn's two strains were compared, they were 97.4% identical. Only one mother was tested by the HerpeSelect IgG antibody kit. During the nine days of her undiagnosed disseminated infection preceding her death, her serology was negative. In summary, although dual mother/newborn deaths from HSV infection are rare, they continue to be reported as recently as 2017.

Trends in Acute Myocarditis Related Pediatric Hospitalizations in the United States, 2007-2016

There has been little exploration of acute myocarditis trends in children despite notable advancements in care over the past decade. We explored trends in pediatric hospitalizations for acute myocarditis from 2007 to 2016 in the United States (US). This was a retrospective, serial cross-sectional study of the National Inpatient Sample database from 2007 to 2016, identifying patients ≤18 years hospitalized with acute myocarditis. Patient demographics and incidence trends were examined. Other relevant clinical and resource utilization outcomes were also explored. Out of 60,390,000 weighted pediatric hospitalizations, 6371 were related to myocarditis. The incidence of myocarditis increased from 0.7 to 0.9 per 100,000 children (p <0.0001) over the study period. The mortality decreased from 7.5% to 6.1% (p = 0.02). A significant inflation-adjusted increase by $4,574 in the median hospitalization cost was noted (p = 0.02) while length of stay remained stable (median 6.1 days). Tachyarrhythmias were identified as the most common type of associated arrhythmia. The occurrence of congestive heart failure remained steady at 27%. In conclusion, in-hospital mortality associated with pediatric acute myocarditis has decreased in the United States over years 2007 to 2016 with a concurrent rise in incidence. Despite steady length of stay, hospitalization costs have increased. Future studies investigating long-term outcomes relating to acute myocarditis are warranted.

Sexually Transmitted Infections in Pregnancy: An Update for Primary Care Providers

This article provides an overview of the incidence and prevalence of sexually transmitted infections in pregnant women in the United States. It discusses screening guidelines and best practices related to treatments. Safety, pharmacology, and monitoring of both the woman and her fetus are detailed.

Economic Evaluation: Onsite HSV PCR Capabilities for Pediatric Care

Objective:

Herpes simplex virus (HSV) encephalitis has an overall mortality rate of 11%–29% with treatment. Although rare, HSV encephalitis is frequently tested for and empirically treated, especially in the neonatal population. HSV infection can be diagnosed with polymerase chain reaction (PCR) testing, although this frequently requires sending samples to reference laboratories. The inherent delay in results may lead to prolonging empiric treatment and hospital stay, resulting in increased costs. This study investigates whether onsite HSV PCR testing decreases hospitalization duration, acyclovir treatment duration, and financial cost on an institution.

Project design:

This single-center project utilized the IHI model for improvement to evaluate third-party HSV PCR processing versus an implemented onsite PCR-based meningitis–encephalitis panel for HSV central nervous system evaluation. The primary outcome was hospital cost differential with secondary outcomes, including duration of acyclovir administration and time to result.

Results:

We identified 96 children age 0–18 from 2010 to 2016, 74 patients utilizing offsite third-party testing, and 22 patients utilizing onsite. We observed a per-patient cost savings of $428 ($618.43–$190.43, P = 0.029) upon the implementation of onsite testing. The mean duration of acyclovir therapy decreased from 3.7 to 0.26 days per patient (P < 0.001). Time to result decreased from 4.6 to 0.13 days (P < 0.001).

Conclusions:

Acquisition of real-time local HSV PCR capabilities significantly decreased time to result and empiric medication use while significantly reducing hospital costs in a military treatment facility.

Pyloric Stenosis: National Trends in the Incidence Rate and Resource Use in the United States From 2012 to 2016

OBJECTIVES

Infantile hypertrophic pyloric stenosis (IHPS) is the most common reason for abdominal surgery in infants; however, national-level data on incidence rate and resource use are lacking. We aimed to examine the national trends in hospitalizations for IHPS and resource use in its management in the United States from 2012 to 2016.

METHODS

We performed a retrospective serial cross-sectional study using data from the National Inpatient Sample, the largest health care database in the United States. We included infants aged ≤1 year assigned an International Classification of Diseases, Ninth Revision, or International Classification of Diseases, 10th Revision, code for IHPS who underwent pyloromyotomy or pyloroplasty. We examined the temporal trends in the incidence rate (cases per 1000 live births) according to sex, insurance status, geographic region, and race. We examined resource use using length of stay (LOS) and hospital costs. Linear regression was used for trend analysis.

RESULTS

Between 2012 and 2016, there were 32 450 cases of IHPS and 20 808 149 live births (incidence rate of 1.56 per 1000). Characteristics of the study population were 82.7% male, 53% white, and 63.3% on Medicaid, and a majority were born in large (64%), urban teaching hospitals (90%). The incidence of IHPS varied with race, sex, socioeconomic status, and geographic region. In multivariable regression analysis, the incidence rate of IHPS decreased from 1.76 to 1.57 per 1000 (adjusted odds ratio 0.93; 95% confidence interval 0.92-0.93). The median cost of care was $6078.30, whereas the median LOS was 2 days, and these remained stable during the period.

CONCLUSIONS

The incidence rate of IHPS decreased significantly between 2012 and 2016, whereas LOS and hospital costs remained stable. The reasons for the decline in the IHPS incidence rate may be multifactorial.