Herpes simplex testing in neonates in the emergency department

Incidence of Traumatic Lumbar Punctures in Neonates and Infants

OBJECTIVES

 The objective of this study is to examine factors accounting for the incidence of traumatic lumbar puncture (TLP) in infants younger than 1 year old.

STUDY DESIGN

 Retrospective analysis of cerebrospinal fluid (CSF) data from 1,240 neonatal (≤28 days) and 399 infant lumbar puncture (LP) procedures was conducted. Data from two successive LP procedures were obtained from 108 patients. Logistic regression analysis was used to assess factors accounting for the incidence of TLP in the second LP procedure. The following categorical variables were entered into the model: whether the first procedure was traumatic according to criteria of ≥500 and ≥10,000 erythrocytes/µL, whether the LP procedures were performed within a week, and whether the patient was neonatal at the first procedure.

RESULTS

 The incidences of TLP were 42.9% in neonates and 22.5% in infants for the criterion of ≥500 erythrocytes/µL, and 16.6 and 10.3% for the criterion of ≥10,000 erythrocytes/µL. Compared with a nontraumatic first LP procedure, if the first procedure was traumatic according to the criterion of ≥10,000 erythrocytes/µL, the odds ratio (OR) of TLP in the second procedure was 5.86 (p = 0.006). Compared with a longer time, if the successive procedures were performed within a week, the OR of TLP was 9.06 (p < 0.0001) according to the criteria of ≥500 erythrocytes/µL and 3.34 (p = 0.045) according to the criteria of ≥10,000 erythrocytes/µL. If the patient was neonatal at the first procedure, the OR of TLP at the second puncture was 0.32 (p = 0.031) according to the criterion of ≥500 erythrocytes/µL.

CONCLUSION

 The incidence of TLP in neonates is twice as high as that in infants. Successive LP procedures performed within a week and a highly blood-contaminated CSF sample in the first procedure each multiplied the odds of TLP in the second procedure, whereas being a neonate at the time of the first procedure reduced the odds of TLP.

KEY POINTS

· Traumatic LPs increase diagnostic uncertainty.. · Traumatic LPs are twice as common in neonates as in infants.. · Two LPs performed within a week multiplied the odds of traumatic LP.. · Erythrocyte-based criteria for traumatic LP affect the incidence of TLP..

Evaluation for Neonatal HSV in Infants Undergoing Workup for Serious Bacterial Infection: A 5-Year Retrospective Review

OBJECTIVES

To describe the characteristics of infants evaluated for serious bacterial infection, focusing on empirical testing and treatment of herpes simplex virus (HSV) and describe the characteristics of HSV-positive patients.

METHODS

We included infants aged 0 to 60 days undergoing evaluation for serious bacterial infection in the emergency department. This descriptive study was conducted between July 2010 and June 2014 at a tertiary-care children's hospital. Eligible patients were identified on the basis of age at presentation to the hospital and laboratory specimens. Infant characteristics, symptoms on presentation, and laboratory workup were compared between HSV-positive and HSV-negative patients by using the 2-sample t test or the Wilcoxon rank test.

RESULTS

A total of 1633 infants were eligible for inclusion, and 934 (57.2%) were 0 to 28 days of age. HSV was diagnosed in 19 infants, 11 of whom had disseminated disease. Compared with those without HSV, HSV-positive infants were younger, less likely to be febrile and to present with nonspecific symptoms, and more likely to have a mother with HSV symptoms (P < .05). Testing from all recommended locations was only performed in 22% of infants. Infants tested or empirically treated with acyclovir had a longer median length of stay compared with children who were not tested or treated (P < .01).

CONCLUSIONS

The absence of fever should not preclude a workup for HSV in neonates, and when a workup is initiated, emphasis should be placed on obtaining samples from serum, cerebrospinal fluid, and surface specimens. Physicians may benefit from a guideline for evaluation of HSV with specific guidance on high-risk features of presentation and recommended testing.

Diagnosis and Management of Neonatal Herpes Simplex Infection in the Emergency Department

Neonatal herpes simplex virus infection (HSV) is rare in neonates, with an estimated global incidence of 10 per 100,000 live births. Neonatal HSV is challenging to diagnose due to often vague signs and symptoms. Untreated, the mortality of some HSV subtypes exceeds 80%. Overtesting and overtreatment can result in prolonged hospitalizations and expose neonates to medication toxicity. In contrast, prompt evaluation and use of empiric antiviral therapy before the results of definitive testing can improve outcomes for infants with HSV. A wide degree of practice variation exists with respect to testing and treatment for neonatal HSV, and more research is required to safely risk-stratify this population. This review presents the epidemiology, risk factors, presenting features, and emergency department management of neonatal HSV infection.

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

OBJECTIVE

To examine the temporal trends in the incidence and outcomes of neonatal herpes simplex infections (NHSV) in the United States.

STUDY DESIGN

We conducted a retrospective study using the National Inpatient Sample (NIS). Neonates ≤28 days old with ICD-9 codes for NHSV (054.xx) from 2003 to 2014 were included. Trends in the incidence, mortality, length of stay (LOS), and hospital cost were analyzed using Jonckheere-Terpstra test.

RESULTS

NHSV increased from 7.9 to 10 per 100,000 live births from 2003-05 to 2012-14 (P = 0.04). Hospital costs increased from $21,650 to $27,843; P < 0.001). The overall mortality rate and median LOS were 7.9% and 20 days, respectively and there were no significant variations across years during the study period.

CONCLUSIONS

The incidence of NHSV in the United States increased between 2003 and 2014 without a significant change in mortality. NHSV remains a serious health threat and new and effective strategies to prevent NHSV are needed.

Comparison of Herpes Simplex Virus PCR with Culture for Virus Detection in Multisource Surface Swab Specimens from Neonates

The American Academy of Pediatrics currently recommends herpes simplex virus (HSV) culture or PCR for testing of swabs of the conjunctivae, mouth, nasopharynx, and rectum (surface swabs) from neonates. The objectives of this study were to compare the performance and time to results of HSV PCR with those of HSV culture with surface swabs from neonates. Banked multisource surface swab samples that were collected from infants less than or equal to 30 days old from January 2017 to December 2017 and that had previously been cultured for HSV were identified and tested retrospectively by HSV PCR. Surface swab samples from 97 patients were included in the study. Of these 97 patients, 7 (7%) had clinical HSV disease. Of the 7 neonates with HSV disease, 3 (42.9%) had surface swabs positive by culture and 6 (85.7%) had swabs positive by PCR. Limiting the analysis to specimens that were positive only by culture or only by PCR, the specificity for both methods was 100%, but the sensitivity of PCR was 100%, whereas it was 50% for culture. During the study period, 341 HSV cultures and 426 HSV PCRs were performed. The median time from swab collection to reporting of results was 7.6 days (interquartile range [IQR], 7.1 to 7.9 days) for culture and 0.8 days (IQR, 0.6 to 1.0 days) for PCR. HSV PCR of surface swabs from neonates was considerably more rapid and sensitive than HSV culture without yielding false-positive results. Although larger studies are needed to support our findings, strong consideration should be given to utilize PCR instead of culture for the detection of HSV in surface swabs from neonates.

Herpes Simplex Virus Infection in Infants Undergoing Meningitis Evaluation

BACKGROUND

Although neonatal herpes simplex virus (HSV) is a potentially devastating infection requiring prompt evaluation and treatment, large-scale assessments of the frequency in potentially infected infants have not been performed.

METHODS

We performed a retrospective cross-sectional study of infants ≤60 days old who had cerebrospinal fluid culture testing performed in 1 of 23 participating North American emergency departments. HSV infection was defined by a positive HSV polymerase chain reaction or viral culture. The primary outcome was the proportion of encounters in which HSV infection was identified. Secondary outcomes included frequency of central nervous system (CNS) and disseminated HSV, and HSV testing and treatment patterns.

RESULTS

Of 26 533 eligible encounters, 112 infants had HSV identified (0.42%, 95% confidence interval [CI]: 0.35%-0.51%). Of these, 90 (80.4%) occurred in weeks 1 to 4, 10 (8.9%) in weeks 5 to 6, and 12 (10.7%) in weeks 7 to 9. The median age of HSV-infected infants was 14 days (interquartile range: 9-24 days). HSV infection was more common in 0 to 28-day-old infants compared with 29- to 60-day-old infants (odds ratio 3.9; 95% CI: 2.4-6.2). Sixty-eight (0.26%, 95% CI: 0.21%-0.33%) had CNS or disseminated HSV. The proportion of infants tested for HSV (35%; range 14%-72%) and to whom acyclovir was administered (23%; range 4%-53%) varied widely across sites.

CONCLUSIONS

An HSV infection was uncommon in young infants evaluated for CNS infection, particularly in the second month of life. Evidence-based approaches to the evaluation for HSV in young infants are needed.

Clinical Pathway Effectiveness: Febrile Young Infant Clinical Pathway in a Pediatric Emergency Department

OBJECTIVE

Young infants are often treated in emergency departments (EDs) for febrile illnesses. Any delay in care or ineffective management could lead to increased patient morbidity and mortality. A standardized ED clinical pathway may improve care for these patients. The objective of this study is to evaluate the impact of a febrile young infant clinical pathway implemented in a large, urban children's hospital ED on the timeliness and consistency of care.

METHODS

This study used a before-and-after retrospective observational study design comparing 2 separate periods: prepathway from September 2007 through August 2008 and postpathway from September 2009 through August 2010. Subjects were infants aged 56 days or younger presenting with a rectal temperature of 38.0°C or higher. Patients were excluded if they were transferred from another hospital or if they developed a fever after initial presentation.

RESULTS

Five hundred twenty infants were enrolled. The mean time to urine collection and time to the first antibiotic administration were reduced after pathway implementation (23-minute reduction to urine collection vs 36-minute reduction to the first antibiotic administration). There was improvement in the proportion of infants who received the pathway-specific antibiotics based on age (odds ratio, 7.2; 95% confidence interval, 4.4, 11.9) and the proportion of infants who were administered acyclovir based on pathway guidelines (odds ratio, 8.8; 95% confidence interval, 2.9-30.0).

CONCLUSIONS

An ED-based febrile young infant clinical pathway improved the timeliness of initiation of work-up as measured by urine collection and of therapy by an earlier administration of the first antibiotic, as well as decreased variability of care.

Comparative evaluation of the FilmArray meningitis/encephalitis molecular panel in a pediatric population

We compared an FDA cleared molecular meningitis/encephalitis panel to lab developed viral PCRs and bacterial culture. Of the 67 viral PCR or bacterial culture-positive samples, 92.5% were positive for the same target by the panel. Of the 66 negative samples tested, no targets were detected by the panel, for an agreement of 96.2%.