Acyclovir suppression to prevent recurrent genital herpes at delivery

Diagnosis and Management of Genital Herpes: Key Questions and Review of the Evidence for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines

Genital herpes, caused by herpes simplex virus (HSV) type 1 or type 2, is a prevalent sexually transmitted infection (STI). Given that HSV is an incurable infection, there are important concerns about appropriate use of diagnostic tools, management of infection, prevention of transmission to sexual partners, and appropriate counseling. In preparation for updating the Centers for Disease Control and Prevention (CDC) STI treatment guidelines, key questions for management of genital herpes infection were developed with a panel of experts. To answer these questions, a systematic literature review was performed, with tables of evidence including articles that would change guidance assembled. These data were used to inform recommendations in the 2021 CDC STI treatment guidelines.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

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.

[Diagnostic and therapeutic recommendations for sexually transmitted diseases: Genital herpes]

TREATMENT OF THE INITIAL INFECTION OR FIRST CLINICAL EPISODE OF GENITAL HERPES: An initial infection or first clinical episode of genital herpes is treated with oral aciclovir 200mg×5/d for 5 to 10 days depending on clinical status. The recommended dosage for valaciclovir is 1g×2/d and treatment duration is identical to that for aciclovir. TREATMENT OF HERPES RECURRING DURING PREGNANCY: There are no studies of the efficacy of antiviral therapy on the symptoms of genital recurring during pregnancy. However, initial anti-viral treatment using aciclovir or valaciclovir may be given where warranted by symptoms (i.e. duration and severity of symptoms). Valaciclovir may be used instead (equivalent efficacy but better safety data for aciclovir). Valaciclovir may be given at a dosage of 1×500mg b.i.d. p.o. for 5 days. PROPHYLACTIC ANTI-VIRAL TREATMENT DURING PREGNANCY: In female patients presenting an initial infection or infection recurring during pregnancy, although there is no demonstrated benefit for prophylactic treatment in reducing the risk of neonatal herpes, anti-viral prophylaxis is recommended after 36 WA (weeks' amenorrhoea) to limit the need for Caesarean section due to herpetic lesions. The recommended antivirals are aciclovir at a dosage of 400mg t.i.d p.o. or valaciclovir at a dosage of 500mg b.i.d. p.o. until delivery.

[Genital herpes and pregnancy: Epidemiology, clinical manifestations, prevention and screening. Guidelines for clinical practice from the French College of Gynecologists and Obstetrician (CNGOF)]

OBJECTIVES

To analyze the consequences of genital herpes infections in pregnant women.

METHODS

The PubMed database and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.

RESULTS

The symptomatology of herpes genital rash is often atypical (NP2) and not different during pregnancy (Professional consensus). It is most often due to HSV2 (NP2). Seventy percent of pregnant patients have a history of infection with Herpes simplex virus, without reference to genital or labial localization, and this is in most cases type 1 (NP2). The prevalence of clinical herpes lesions at birth in the event of recurrence is about 16% compared with 36% in the case of initial infection (NP4). In HSV+ patients, asymptomatic herpetic excretion is 4 to 10%. The rate of excretion increases in HIV+ patients (20 to 30%) (NP2). The risk of HSV seroconversion during pregnancy is 1 to 5% (NP2), but can reach 20% in case of sero-discordant couple (NP2). Questioning is not always sufficient to determine the history of herpes infection of a patient and her partner (NP2) and the clinical examination is not always reliable (NP2). Herpetic hepatitis and encephalitis are rare and potentially severe (NP4). These diagnoses should be discussed during pregnancy and antiviral therapy should be started as soon as possible (Professional consensus). There is no established link between herpes infection and miscarriages (NP3). There appears to be an association between untreated herpes infection and premature delivery (NP3) but not in the case of treated infections (NP4). Herpetic fetopathies are exceptional (NP4). There is no argument for recommending specific prenatal diagnosis for herpes infection during pregnancy (Professional consensus). Condom use reduces the risk of initial infection in women who are not pregnant (NP3). There is no evidence to justify routine screening during pregnancy (Professional consensus).

CONCLUSION

There is a strong discrepancy between the prevalence of herpetic excretion at the time of delivery and the scarcity of neonatal infections. There is a lack of data on the impact of herpes infections during pregnancy in France. Fetal and maternal consequences are potentially serious but rare.

[Management of pregnant women with recurrent herpes. Guidelines for clinical practice from the French College of Gynecologists, Obstetricians (CNGOF)]

OBJECTIVE

To provide guidelines for the management of woman with genital herpes during pregnancy or labor and with known history of genital herpes.

METHODS

MedLine and Cochrane Library databases search and review of the main foreign guidelines.

RESULTS

Genital herpes ulceration during pregnancy in a woman with history of genital herpes correspond to a recurrence. In this situation, there is no need for virologic confirmation (Grade B). In case of recurrent herpes during pregnancy, antiviral therapy with acyclovir or valacyclovir can be administered but provide low efficiency on duration and severity of symptoms (Grade C). Antiviral treatment proposed is acyclovir (200mg 5 times daily) or valacyclovir (500mg twice daily) for 5 to 10 days (Grade C). Recurrent herpes is associated with a risk of neonatal herpes around 1% (LE3). Antiviral prophylaxis should be offered for women with recurrent genital herpes during pregnancy from 36 weeks of gestation and until delivery (Grade B). There is no evidence of the benefit of prophylaxis in case or recurrence only before the pregnancy. There is no recommendation for systematic prophylaxis for women with history of recurrent genital herpes and no recurrence during the pregnancy. At the onset of labor, virologic testing is indicated only in case of genital ulceration (Professional consensus). In case of recurrent genital herpes at the onset of labor, cesarean delivery will be all the more considered if the membranes are intact and/or in case of prematurity and/or in case of HIV positive woman and vaginal delivery will be all the more considered in case of prolonged rupture of membranes after 37 weeks of gestation in an HIV negative woman (Professional consensus).

CONCLUSION

In case of recurrent genital herpes at the onset of labor and intact membranes, cesarean delivery should be considered. In case of recurrent genital herpes and prolonged rupture of membranes at term, the benefit of cesarean delivery is more questionable and vaginal delivery should be considered.

Invasive Obstetric Procedures and Cesarean Sections in Women With Known Herpes Simplex Virus Status During Pregnancy

Background

Neonatal herpes is a potentially devastating infection that results from acquisition of herpes simplex virus (HSV) type 1 or 2 from the maternal genital tract at the time of vaginal delivery. Current guidelines recommend (1) cesarean delivery if maternal genital HSV lesions are present at the time of labor and (2) antiviral suppressive therapy for women with known genital herpes to decrease HSV shedding from the genital tract at the time of vaginal delivery. However, most neonatal infections occur in infants born to women without a history of genital HSV, making current prevention efforts ineffective for this group. Although routine serologic HSV testing of women during pregnancy could identify women at higher risk of intrapartum viral shedding, it is uncertain how this knowledge might impact intrapartum management, and a potential concern is a higher rate of cesarean sections among women known to be HSV-2 seropositive.

Methods

To assess the effects of prenatal HSV-2 antibody testing, history of genital herpes, and use of suppressive antiviral medication on the intrapartum management of women, we investigated the frequency of invasive obstetric procedures and cesarean deliveries. We conducted a retrospective cohort study of pregnant women delivering at the University of Washington Medical center in Seattle, Washington. We defined the exposure of interest as HSV-2 antibody positivity or known history of genital herpes noted in prenatal records. The primary outcome was intrapartum procedures including fetal scalp electrode, artificial rupture of membranes, intrauterine pressure catheter, or operative vaginal delivery (vacuum or forceps). The secondary outcome was incidence of cesarean birth. Univariate and multivariable logistic regressions were performed.

Results

From a total of 449 women included in the analysis, 97 (21.6%) were HSV-2 seropositive or had a history of genital herpes (HSV-2/GH). Herpes simplex virus-2/GH women not using suppressive antiviral therapy were less likely to undergo intrapartum procedures than women without HSV-2/GH (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.25–0.95; P = .036), but this relationship was attenuated after adjustment for potential confounders (adjusted OR, 0.69; 95% CI, 0.34–1.41; P = .31). There was no difference in intrapartum procedures for women on suppressive therapy versus women without HSV-2/GH (OR, 1.17; 95% CI, 0.66–2.07; P = .60). Similar proportions of cesarean sections were performed within each group of women: 25% without history of HSV-2/GH, 30% on suppressive treatment, and 28.1% without suppressive treatment (global, P = .73).

Conclusions

In this single-site study, provider awareness of genital herpes infection either by HSV serotesting or history was associated with fewer invasive obstetric procedures shown to be associated with neonatal herpes, but it was not associated with an increased rate of cesarean birth.

2017 European guidelines for the management of genital herpes

Genital herpes is one of the commonest sexually transmitted infections worldwide. Using the best available evidence, this guideline recommends strategies for diagnosis, management, and follow-up of the condition as well as for minimising transmission. Early recognition and initiation of therapy is key and may reduce the duration of illness or avoid hospitalisation with complications, including urinary retention, meningism, or severe systemic illness. The guideline covers a range of common clinical scenarios, such as recurrent genital herpes, infection during pregnancy, and co-infection with human immunodeficiency virus.

Sexually transmitted diseases treatment guidelines, 2015

These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.

Herpes simplex virus infection during pregnancy

Genital herpes in pregnancy continues to cause significant maternal morbidity, with an increasing number of infections being due to oral-labial transmission of herpes simplex virus (HSV)-1. Near delivery, primary infections with HSV-1 or HSV-2 carry the highest risk of neonatal herpes infection, which is a rare but potentially devastating disease for otherwise healthy newborns. Prevention efforts have been limited by lack of an effective intervention for preventing primary infections and the unclear role of routine serologic testing.

Clinical practice in prevention of neonatal HSV infection: a survey of obstetrical care providers in Alberta

OBJECTIVE

To identify the current practice patterns of physicians providing prenatal care in Alberta with respect to prevention of neonatal herpes simplex virus (HSV) infection.

METHOD

A 22-item questionnaire was mailed to all obstetricians and family physicians providing obstetrical care in Alberta. The questionnaire included demographic and practice details, and details of management of patients with a history or symptoms of HSV lesions, including practice in prescribing antiviral therapy, recommending elective Caesarean section, and ordering serology. Two reminders were mailed as necessary.

RESULTS

Responses were received from 89 obstetricians (57%) and 94 family physicians (54%). Antiviral therapy was prescribed for the prevention of neonatal HSV infection in the third trimester by 97% of obstetricians versus 84% of family physicians (P = 0.007), with acyclovir being the most commonly prescribed agent. Caesarean section was offered "most of the time" to women with primary HSV infection in the third trimester by 65% of physicians, to women with prodromal symptoms during the intrapartum period by 57% (no significant differences between groups), and to women with HSV lesions by 92% of obstetricians and 82% of family physicians (P = 0.032). Women with a negative HSV history but whose partner had known HSV were offered serological testing "most of the time" by 30% of physicians (no significant difference between groups).

CONCLUSION

Despite the encouraging survey results, obstetrical providers should be encouraged to offer Caesarean section to women with a primary HSV infection in the third trimester and to offer serological testing in discordant couples. These simple strategies can help to prevent neonatal HSV infection and its long-term consequences.

Review of antiviral therapy for herpes labialis, genital herpes and herpes zoster

Acyclovir (Zovirax) was approved for the treatment of herpesvirus infections almost two decades ago. It was the first agent in a novel group of antiviral medications that now include valacyclovir (Valtrex), penciclovir (Denavir and famciclovir (Famvir). These agents have made a dramatic impact on the morbidity associated with herpes simplex virus infections and herpes zoster. Topical and oral antiviral use have shown modest but statistically significant efficacy in treating herpes labialis with most studies demonstrating a significant reduction in episode length and/or healing time. Oral acyclovir, valacyclovir and famciclovir are efficacious and safe for the treatment of the first episode and recurrent genital herpes and are useful as suppressive therapy for individuals with frequent genital herpes recurrences. In addition, high doses of oral acyclovir, valacyclovir and famciclovir have been shown to speed the healing of herpes zoster, and data suggests that these agents also decrease associated acute and chronic pain in people of 50 years of age or older. Further research is required to clarify the safety of these agents in pregnant women with genital herpes, the role of antiviral therapy in decreasing the sexual transmission of genital herpes, and the efficacy and cost-effectiveness of these agents in treating herpes zoster in people below the age of 50 years.

Guidance on management of asymptomatic neonates born to women with active genital herpes lesions

Herpes simplex virus (HSV) infection of the neonate is uncommon, but genital herpes infections in adults are very common. Thus, although treating an infant with neonatal herpes is a relatively rare occurrence, managing infants potentially exposed to HSV at the time of delivery occurs more frequently. The risk of transmitting HSV to an infant during delivery is determined in part by the mother's previous immunity to HSV. Women with primary genital HSV infections who are shedding HSV at delivery are 10 to 30 times more likely to transmit the virus to their newborn infants than are women with recurrent HSV infection who are shedding virus at delivery. With the availability of commercial serological tests that reliably can distinguish type-specific HSV antibodies, it is now possible to determine the type of maternal infection and, thus, further refine management of infants delivered to women who have active genital HSV lesions. The management algorithm presented herein uses both serological and virological studies to determine the risk of HSV transmission to the neonate who is delivered to a mother with active herpetic genital lesions and tailors management accordingly. The algorithm does not address the approach to asymptomatic neonates delivered to women with a history of genital herpes but no active lesions at delivery.

Diagnostics for Herpes Simplex Virus

Herpes simplex virus (HSV) is one of the most common, yet frequently overlooked, sexually transmitted infections. Since the type of HSV infection affects prognosis and subsequent counseling, type-specific testing to distinguish HSV-1 from HSV-2 is recommended. Although PCR has been the diagnostic standard for HSV infections of the central nervous system, until now viral culture has been the test of choice for HSV genital infection. However, HSV PCR, with its consistently and substantially higher rate of HSV detection, will likely replace viral culture as the gold standard for the diagnosis of genital herpes in people with active mucocutaneous lesions, regardless of anatomic location or viral type. Alternatively, type-specific serologic tests based on glycoprotein G should be the test of choice to establish the diagnosis of HSV infection when no active lesion is present. Given the difficulty in making the clinical diagnosis of HSV, the growing worldwide prevalence of genital herpes and the availability of effective antiviral therapy, there is an increased demand for rapid, accurate laboratory diagnosis of patients with HSV.

European guideline for the management of genital herpes, 2010

This is the guideline for genital herpes simplex virus (HSV) management for the IUSTI/WHO Europe, 2010. They describe the epidemiology, diagnosis, clinical features, treatment and prevention of genital HSV infection. They include details on the management of HSV in pregnancy, those who are immunocompromised and the clinical investigation and management of suspected HSV-resistant disease.

Genital herpes

INTRODUCTION

Genital herpes is an infection with herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2), and is among the most common sexually transmitted diseases.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent sexual transmission of herpes simplex virus? What are the effects of interventions to prevent transmission of herpes simplex virus from mother to neonate? What are the effects of antiviral treatment in people with a first episode of genital herpes? What are the effects of interventions to reduce the impact of recurrence? What are the effects of treatments in people with genital herpes and HIV? We searched: Medline, Embase, The Cochrane Library, and other important databases up to January 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 35 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antivirals, caesarean delivery, condoms, oral aciclovir, psychotherapy, recombinant glycoprotein vaccines, serological screening, and counselling.

Herpes simplex virus and human papillomavirus genital infections: new and investigational therapeutic options

Human papillomavirus and Herpes simplex virus are the most common genital viral infections encountered in clinical practice worldwide. We reviewed the literature focusing on new and experimental treatment modalities for both conditions, based on to the evidence-based data available. The modalities evaluated include topical agents such as immune response modifiers (imiquimod, resiquimod, and interferon), antivirals (penciclovir, cidofovir, and foscarnet), sinecatechins, microbiocidals (SPL7013 gel, and PRO 2000 gel), along with experimental (oligodeoxynucleotides), immunoprophylactic, and immunotherapeutic vaccines.

Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics

This report updates and combines into one document earlier versions of guidelines for preventing and treating opportunistic infections (OIs) among HIV-exposed and HIV-infected children, last published in 2002 and 2004, respectively. These guidelines are intended for use by clinicians and other health-care workers providing medical care for HIV-exposed and HIV-infected children in the United States. The guidelines discuss opportunistic pathogens that occur in the United States and one that might be acquired during international travel (i.e., malaria). Topic areas covered for each OI include a brief description of the epidemiology, clinical presentation, and diagnosis of the OI in children; prevention of exposure; prevention of disease by chemoprophylaxis and/or vaccination; discontinuation of primary prophylaxis after immune reconstitution; treatment of disease; monitoring for adverse effects during treatment; management of treatment failure; prevention of disease recurrence; and discontinuation of secondary prophylaxis after immune reconstitution. A separate document about preventing and treating of OIs among HIV-infected adults and postpubertal adolescents (Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents) was prepared by a working group of adult HIV and infectious disease specialists. The guidelines were developed by a panel of specialists in pediatric HIV infection and infectious diseases (the Pediatric Opportunistic Infections Working Group) from the U.S. government and academic institutions. For each OI, a pediatric specialist with content-matter expertise reviewed the literature for new information since the last guidelines were published; they then proposed revised recommendations at a meeting at the National Institutes of Health (NIH) in June 2007. After these presentations and discussions, the guidelines underwent further revision, with review and approval by the Working Group, and final endorsement by NIH, CDC, the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA), the Pediatric Infectious Disease Society (PIDS), and the American Academy of Pediatrics (AAP). The recommendations are rated by a letter that indicates the strength of the recommendation and a Roman numeral that indicates the quality of the evidence supporting the recommendation so readers can ascertain how best to apply the recommendations in their practice environments. An important mode of acquisition of OIs, as well as HIV infection among children, is from their infected mother; HIV-infected women coinfected with opportunistic pathogens might be more likely than women without HIV infection to transmit these infections to their infants. In addition, HIV-infected women or HIV-infected family members coinfected with certain opportunistic pathogens might be more likely to transmit these infections horizontally to their children, resulting in increased likelihood of primary acquisition of such infections in the young child. Therefore, infections with opportunistic pathogens might affect not just HIV-infected infants but also HIV-exposed but uninfected infants who become infected by the pathogen because of transmission from HIV-infected mothers or family members with coinfections. These guidelines for treating OIs in children therefore consider treatment of infections among all children, both HIV-infected and uninfected, born to HIV-infected women. Additionally, HIV infection is increasingly seen among adolescents with perinatal infection now surviving into their teens and among youth with behaviorally acquired HIV infection. Although guidelines for postpubertal adolescents can be found in the adult OI guidelines, drug pharmacokinetics and response to treatment may differ for younger prepubertal or pubertal adolescents. Therefore, these guidelines also apply to treatment of HIV-infected youth who have not yet completed pubertal development. Major changes in the guidelines include 1) greater emphasis on the importance of antiretroviral therapy for preventing and treating OIs, especially those OIs for which no specific therapy exists; 2) information about the diagnosis and management of immune reconstitution inflammatory syndromes; 3) information about managing antiretroviral therapy in children with OIs, including potential drug--drug interactions; 4) new guidance on diagnosing of HIV infection and presumptively excluding HIV infection in infants that affect the need for initiation of prophylaxis to prevent Pneumocystis jirovecii pneumonia (PCP) in neonates; 5) updated immunization recommendations for HIV-exposed and HIV-infected children, including hepatitis A, human papillomavirus, meningococcal, and rotavirus vaccines; 6) addition of sections on aspergillosis; bartonella; human herpes virus-6, -7, and -8; malaria; and progressive multifocal leukodystrophy (PML); and 7) new recommendations on discontinuation of OI prophylaxis after immune reconstitution in children. The report includes six tables pertinent to preventing and treating OIs in children and two figures describing immunization recommendations for children aged 0--6 years and 7--18 years. Because treatment of OIs is an evolving science, and availability of new agents or clinical data on existing agents might change therapeutic options and preferences, these recommendations will be periodically updated and will be available at http://AIDSInfo.nih.gov.

Cyclooxygenase (COX)-inhibiting drug reduces HSV-1 reactivation in the mouse eye model

PURPOSE

To examine the effects of COX inhibitors on suppressing HSV-1 reactivation in a mouse model.

METHODS

BALB/c mice were latently infected with HSV-1 and treated by 0.1% bromfenac Na eye drops, 0.1% pranoprofen eye drops, 0.1 mg oral etodolac 4 times/day, and saline for 4 days. After reactivating the latent HSV-1, we swabbed the mouse ocular surface for the culture of the infectious virus and assessed the viral loads in the eyes and trigeminal ganglia (TGs) using real-time PCR to determine the treatment efficacies.

RESULTS

With stimulated reactivation, 10 of 24 (41.7%), 5 of 10 (50.0%), 17 of 25 (68%), and 16 of 22 eyes (72.7%) showed positive swab results in the bromfenac Na, etodolac, pranoprofen, and saline groups, respectively; and a significant difference was seen only between the bromfenac Na and saline groups (p = 0.033). None of the three drug-treated groups showed any significant difference from the saline group in the viral DNA in the eyes and TGs (p > 0.05).

CONCLUSIONS

Bromfenac Na eye drops can suppress HSV-1 reactivation.

[Update on the treatment of genital herpes]

Genital herpes is a chronic infection characterized by periodic reactivation. It can produce symptomatic disease in the host although asymptomatic viral excretion can also occur. It is currently the main cause of genital ulceration and an important public health problem that has substantial clinical, psychological, and economic repercussions. This review analyzes the currently available therapeutic options and regimens, which are based mainly on systemic use of antiviral agents such as aciclovir, valacyclovir, and famciclovir. In addition, special emphasis is placed on the prevention and management of this infection in specific situations, such as pregnant, pediatric, and immunocompromised patients.

Medications in pregnancy and lactation: Part 2. Drugs with minimal or unknown human teratogenic effect

This is the second of a two-part series on the use of medication during pregnancy and lactation. Pregnancy risk factors together with an increased incidence of chronic diseases and the rise in mean maternal age predict an increase in medication use during gestation. However, as highlighted in the first installment of this series, relatively few medications have specifically been tested for safety and efficacy during pregnancy, and, therefore, responses to those inquiries can be uninformed and inaccurate. Whereas the first installment provided new insight into the nature of medications with known human teratogenic effects, this part concentrates on drugs with minimal or no known human teratogenic effect. It is important that clinicians become familiar with all of the aspects of the drugs they prescribe, in addition to the controversies surrounding them, through consultation with maternal-fetal medicine specialists and through references and Web sites providing up-to-date information in an effort to promote safer prescribing practices.

The impact of cesarean delivery on transmission of infectious agents to the neonate

The rate of cesarean deliveries has increased dramatically over the past decade. Studies to date have highlighted a number of factors on the part of the treating physician and the expectant mother contributing to this increase. Maternal infections are not a major cause of this increase. There are a limited number of infections in a pregnant woman that warrant cesarean delivery to prevent perinatal transmission. This article outlines those infections known to be transmitted perinatally through the infected birth canal and details the current recommendations for cesarean delivery. Pregnant women with active genital herpes lesions or with known herpes simplex virus infection and a prodromal illness consistent with recurrence at the time of presentation in labor should undergo cesarean delivery. Pregnant women who are HIV infected and have detectable viremia (>1000 copies/mL) should be counseled regarding the potential benefits of cesarean delivery as an adjunct to antiretroviral therapy. Hepatitis C virus (HCV) can be transmitted intrapartum, but prevention of HCV transmission by cesarean delivery has not been proved effective and is not generally indicated. A limited number of other infectious agents can be transmitted through the birth canal but do not constitute an indication for cesarean delivery.

Third trimester antiviral prophylaxis for preventing maternal genital herpes simplex virus (HSV) recurrences and neonatal infection

BACKGROUND

Genital herpes simplex virus (HSV) infection is one of the most common viral sexually transmitted infections. The majority of women with genital herpes will have a recurrence during pregnancy. Transmission of the virus from mother to fetus typically occurs by direct contact with virus in the genital tract during birth.

OBJECTIVES

To assess the effectiveness of antenatal antiviral prophylaxis for recurrent genital herpes on neonatal herpes and maternal recurrences at delivery.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 4), MEDLINE (January 1966 to February 2007) and EMBASE (January 1974 to February 2007; handsearched conference proceedings; reviewed bibliographies of all relevant articles for further references; and contacted experts in the field.

SELECTION CRITERIA

Randomized controlled trials which assessed the effectiveness of antivirals compared to placebo or no therapy, on neonatal herpes and maternal disease endpoints among pregnant women with genital herpes.

DATA COLLECTION AND ANALYSIS

Two authors independently applied study selection criteria and extracted data.

MAIN RESULTS

Seven randomized controlled trials (1249 participants) which met our inclusion criteria compared acyclovir to placebo or no treatment (five trials) and valacyclovir to placebo (two trials). The effect of antepartum antiviral prophylaxis on neonatal herpes could not be estimated. There were no cases of symptomatic neonatal herpes in the included studies in either the treatment or placebo groups. Women who received antiviral prophylaxis were significantly less likely to have a recurrence of genital herpes at delivery (relative risk (RR) 0.28, 95% confidence interval (CI) 0.18 to 0.43, I(2 )= 0%). Women who received antiviral prophylaxis were also significantly less likely to have a cesarean delivery for genital herpes (RR 0.30, 95% CI 0.20 to 0.45, I(2) = 27.3%). Women who received antiviral prophylaxis were significantly less likely to have HSV detected at delivery (RR 0.14, 95% CI 0.05 to 0.39, I(2) = 0%).

AUTHORS' CONCLUSIONS

Women with recurrent genital herpes simplex virus should be informed that the risk of neonatal herpes is low. There is insufficient evidence to determine if antiviral prophylaxis reduces the incidence of neonatal herpes. Antenatal antiviral prophylaxis reduces viral shedding and recurrences at delivery and reduces the need for cesarean delivery for genital herpes. Limited information exists regarding the neonatal safety of prophylaxis. The risks, benefits, and alternatives to antenatal prophylaxis should be discussed with women who have a history and prophylaxis initiated for women who desire intervention.

Acquired Nonneoplastic Neonatal and Pediatric Diseases

The lung biopsy is an established procedure to procure a pathologic diagnosis in a child with a suspected pneumonic process of undetermined etiology. Improvements in pediatric anesthesia and surgery have reduced the operative complications to a minimum. A biopsy can usually be taken through a small intercostal incision when localization is not especially important in a patient with diffuse changes (see Chapter 1). The alternative method for tissue sampling is the endoscopic transbronchial biopsy. There is less risk to the patient, but the specimen is smaller and crush artifacts from the instrument are more common.

Genital herpes

INTRODUCTION

Genital herpes is an infection with herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2), and is among the most common sexually transmitted diseases.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to prevent sexual transmission of herpes simplex virus? What are the effects of interventions to prevent transmission of herpes simplex virus from mother to neonate? What are the effects of antiviral treatment in people with a first episode of genital herpes? What are the effects of interventions to reduce the impact of recurrence? What are the effects of treatments in people with genital herpes and HIV? We searched: Medline, Embase, The Cochrane Library and other important databases up to August 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 35 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antivirals, caesarean delivery, condoms, oral acyclovir, psychotherapy, recombinant glycoprotein vaccines, serological screening, and counselling.

Herpes simplex virus infections of the newborn

Herpes simplex virus (HSV) infections are fortunately quite rare in the neonatal population. Nevertheless, due to their life-threatening nature and the tremendous damage that surviving infants can incur, neonatal HSV is actually considered in a differential diagnosis relatively commonly. The availability of safe and effective antiviral therapy for the management of neonatal HSV also can accelerate a clinician's decision to consider HSV as the cause of a neonate's disease presentation, and then to obtain appropriate diagnostic studies and empirically institute antiviral treatment. Decisions on whether to continue antiviral therapy for a full course are predicated on the appropriate interpretation of these diagnostic studies as they subsequently are reported to the treating physician. For HSV-infected neonates, the duration of parenteral acyclovir therapy ranges from 14 to 21 days, depending on the extent of disease. Use of subsequent oral suppressive antiviral therapy is under investigation in randomized controlled trials, and at this time cannot be routinely recommended. This article will summarize the current state of neonatal HSV disease presentation, diagnosis, and management.

Neonatal herpes simplex virus infections in Canada: results of a 3-year national prospective study

OBJECTIVE

The goal was to determine incidence, determinants, and morbidity and mortality rates of neonatal herpes simplex virus infections in Canada.

METHODS

From October 1, 2000, to September 30, 2003, reports of neonatal herpes simplex virus infection were solicited actively from all Canadian pediatricians and pediatric subspecialists on a monthly basis.

RESULTS

Fifty-eight cases of neonatal herpes simplex virus were reported (5.9 cases per 100,000 live births). Cesarean section was performed in 24.6% of cases, 28.1% of patients were born prematurely, 28.6% had birth weights of < 2500 g, and 7.5% had Apgar scores of < 7 at 5 minutes of life. Mothers < 20 years of age and those reporting Aboriginal ethnicity were affected disproportionately; 40% of mothers had no history of genital herpes before delivery, and intrapartum genital lesions were present in only 1 of 58 cases. Of cases with known herpes simplex virus type, 62.5% were herpes simplex virus-1. Localized infections accounted for 59.6% of cases, whereas disseminated disease and central nervous system disease were reported for 17.5% and 22.8%, respectively. Localized infections were more likely to be herpes simplex virus-1 and disseminated and central nervous system infections herpes simplex virus-2. Nine of 58 cases were fatal. All cases with known treatment information (n = 55) were treated with intravenously administered acyclovir.

CONCLUSIONS

This is the first study to examine the national incidence of neonatal herpes simplex virus in Canada. Many women had no genital herpes simplex virus history before delivery, and the majority of cases were herpes simplex virus-1, which has implications for prenatal screening and vaccine/drug development. Follow-up monitoring of case subjects is being performed annually for 3 years, to be completed in October 2006.

Valacyclovir therapy to reduce recurrent genital herpes in pregnant women

OBJECTIVE

The purpose of this study was to estimate the efficacy of valacyclovir suppressive therapy in pregnant women with recurrent genital herpes.

STUDY DESIGN

At 36 weeks' gestation, herpes simplex virus (HSV)-2 seropositive women were randomized to receive oral valacyclovir 500 mg or placebo twice daily until delivery. Genital tract and neonatal specimens were collected weekly for HSV culture and qualitative polymerase chain reaction (PCR) assay to detect viral DNA from the time of randomization to delivery. Both maternal and neonatal toxicity measures were obtained.

RESULTS

The 112 enrolled women (57 valacyclovir, 55 placebo) had similar HSV recurrence risks, including mean number of active HSV recurrences before randomization during the index pregnancy (1.1 +/- 1.9 vs 1.5 +/- 2.1, P = .308) and days between randomization and delivery (20.3 +/- 10.2 vs 22.0 +/- 8.9, P = .344). The number of women with clinical HSV recurrences between the time of randomization and delivery was significantly lower in the valacyclovir versus placebo group (10.5% vs 27.3%; P = .023, RR 0.4, 95% CI 0.2-0.9). Shedding of HSV within 7 days of delivery was similar in the valacyclovir and placebo group (10.4% vs 12.0%, P = .804; RR 0.9, 95% CI 0.3-2.7), as was the number of women with clinical HSV lesions at delivery (5.3% vs 14.6%, P = .121; RR 0.4, 95% CI 0.1-1.3). No neonates had symptomatic congenital HSV infection before discharge or up to 2 weeks' postpartum, and no clinical or laboratory safety concerns were identified.

CONCLUSION

Administration of valacyclovir beginning at 36 weeks' gestation to women with a history of recurrent genital HSV reduced the number of women with subsequent clinical HSV recurrences.

Genital Herpes Complicating Pregnancy

Approximately 22% of pregnant women are infected with herpes simplex virus (HSV)-2, and 2% of women will acquire HSV during pregnancy. Remarkably, up to 90% of these women are undiagnosed because they are asymptomatic or have subtle symptoms attributed to other vulvovaginal disorders. Diagnosis of genital herpes relies on laboratory confirmation with culture or polymerase chain reaction assay of genital lesions and type-specific glycoprotein G-based serologic testing. Neonatal herpes is the most severe complication of genital HSV infection and is caused by contact with infected genital secretions at the time of labor. Maternal acquisition of HSV in the third trimester of pregnancy carries the highest risk of neonatal transmission. Despite advances in the diagnosis and treatment of neonatal herpes, little change in the incidence or serious sequelae from this infection has occurred. As such, prevention of the initial neonatal infection is critically important. Obstetricians are in a unique position to prevent vertical HSV transmission by identifying women with genital lesions at the time of labor for cesarean delivery, prescribing antiviral suppressive therapy as appropriate, and avoiding unnecessary invasive intrapartum procedures in women with genital herpes. Enhanced prevention strategies include identification of women at risk for HSV acquisition during pregnancy by testing women and possibly their partners for HSV antibodies and providing counseling to prevent transmission to women in late pregnancy.

Herpes Simplex Virus Infections in Neonates and Early Childhood

Of the commonly considered congenital infections, those caused by cytomegalovirus (CMV), syphilis, and herpes simplex virus (HSV) are frequently (CMV, HSV) or exclusively (syphilis) acquired sexually by the mother, with subsequent transmission to the developing fetus. Of the other commonly considered congenital infections, including rubella and toxoplasma infections, the mother is exposed to the infectious agent via interpersonal or environmental contacts. Unlike each of these other pathogens, which are transmitted transplacentally to the developing fetus following maternal infection though, HSV usually is transmitted perinatally as the neonate is exposed to the virus during passage through an infected birth canal. This difference in timing of acquisition of infection has had important consequence in the therapeutic advances achieved during the last 30 years in the management of neonatal HSV infections. Because the time period between the acquisition of infection and initiation of effective antiviral therapy is shorter in neonatal herpes than in congenital toxoplasmosis or CMV infections, the outcomes of therapy have the potential to be markedly different. This article will summarize the current state of neonatal HSV disease presentation, diagnosis, and management.

Treatment of sexually transmitted infections in pregnancy

Sexually transmitted infections remain a major public health concern in the United States. An estimated 19 million infections occur each year. The economic burden imposed by sexually transmitted infections is impressive: direct medical costs have been estimated as high as 15.5 billion US dollars annually. Sexually transmitted infections are relatively common during pregnancy, especially in indigent, urban populations. Education, screening, treatment, and prevention are important components of prenatal care for women at increased risk for these infections. Treatment of these sexually transmitted infections is clearly associated with improved pregnancy outcome and reductions in perinatal mortality.

Herpes Simplex Virus Infections of the Newborn

Herpes simplex virus (HSV) infection in newborns is an important cause of death and permanent neurodevelopmental disability among young children. Neonatal HSV infections can be categorized as 1) mucocutaneous (skin-eyes-mouth), 2) disseminated, or 3) encephalitic. In addition, congenital HSV infection, a distinct clinical syndrome, accounts for approximately 5% of HSV infections identified in the neonatal period. Polymerase chain reaction greatly enhances the clinician's ability to diagnosis HSV infections, but as many as 25% of infants with neonatal HSV encephalitis have negative polymerase chain reaction studies of cerebrospinal fluid. Infants with proven or suspected HSV infections should receive acyclovir 60 mg/kg/day divided every 8 hours for 14 days if disease is restricted to the skin, eyes, or mucous membranes and for 21 days if the infant has disseminated infection or encephalitis. The benefit of long-term suppression therapy after completion of the initial treatment regimen has not been established definitively. Despite therapy with acyclovir, the best available anti-HSV drug, a substantial number of HSV-infected infants with disseminated infections or encephalitis die or have long-term neurodevelopmental sequelae.

The cost-effectiveness of routine antenatal screening for maternal herpes simplex virus-1 and -2 antibodies

OBJECTIVE

The purpose of this study was to determine the cost-effectiveness of routine antenatal screening for herpes simplex virus 1 and 2 in women without a known history of genital herpes.

STUDY DESIGN

Decision analysis was used to compare 3 treatment strategies to prevent neonatal herpes infection in women without a known history of genital herpes simplex virus: (1) the current standard of care (no herpes simplex virus screening), (2) antepartum herpes simplex virus-1 and -2 antibody screening of the pregnant woman and her male partner with appropriate counseling, and (3) antepartum herpes simplex virus-1 and -2 antibody screening with appropriate counseling and acyclovir prophylaxis at 36 weeks of gestation in seropositive women.

RESULTS

Our model predicts that using current guidelines, 1 of 5469 women will have a herpes-infected neonate. Strategy 2 and 3 cost $5,812,819 and $4,130,297, respectively, for every significant neurologic sequela or death prevented. The cost-effectiveness of these strategies, expressed as cost per quality life-year gained, was $219,513 and $155,988 respectively. These results were robust in the sensitivity analysis.

CONCLUSION

Routine herpes simplex virus screening in pregnancy is not cost-effective.

Neonatal herpes: What have we learned

Neonatal herpes simplex virus (HSV) infection usually is acquired during the birth process, as the neonate comes in contact with the virus during passage through an infected birth canal. After an incubation period which can last as long as 2 to 4 weeks, neonatal HSV disease then manifests in 1 of 3 ways: (1) disseminated disease, with visceral organ involvement (including infection of the brain in two-thirds to three-quarters of patients); (2) central nervous system disease (with no other visceral organ involvement, but with skin lesions in two-thirds of patients); or (3) disease limited to the skin, eyes, and/or mouth (ie, SEM disease). Diagnostic advances in recent years have focused primarily on applying polymerase chain reaction technology to babies suspected of having neonatal HSV disease. Treatment of neonatal HSV disease with intravenous acyclovir has improved the likelihood of survival substantially, although neurologic morbidity remains a common sequelae, especially among survivors of central nervous system disease. Despite these advances, the duration of time from onset of symptoms and initiation of antiviral therapy has remained unchanged for the past 20 years. The surest way to improve outcomes rapidly at this point is to raise awareness of neonatal HSV disease, resulting in the establishment of earlier diagnoses and more rapid institution of antiviral therapy. In the longer term, development of a bedside nucleic acid detection kit for real-time detection of HSV DNA in the maternal genital tract at the time of delivery could identify which babies are at risk of developing neonatal HSV disease.

Pregnancy outcomes following systemic prenatal acyclovir exposure: Conclusions from the international acyclovir pregnancy registry, 1984-1999

BACKGROUND

Oral acyclovir is commonly used for genital herpes and other herpesvirus infections. Data on potential fetal risk are extremely limited. From 1984 to 1998, the Acyclovir in Pregnancy Registry monitored birth outcomes of women exposed to oral or intravenous acyclovir during pregnancy. This report describes the final results.

METHODS

The registry was publicized to health care providers most likely to diagnose pregnancy; providers called the registry telephone number, then mailed in a brief questionnaire. Pregnancy outcomes were categorized either as outcomes with birth defects or outcomes without birth defects, subcategorized as live births, spontaneous pregnancy losses (including stillbirths), and induced abortions. Birth defects were defined using a modification of the CDC definition for birth defects surveillance systems. Observed rates were compared to the rate (3.2%) of birth defects expected in the general population.

RESULTS

Between June 1, 1984 and June 30, 1998, 1695 pregnancies exposed to oral or IV acyclovir were registered; 461 (27%) were lost to follow-up. A total of 1234 pregnancies in 24 countries were followed, with a total of 1246 outcomes. Among 1246 pregnancy outcomes, 756 involved acyclovir exposure in the first trimester, 197 in the second trimester, and 291 in the third trimester. Among live births with first trimester acyclovir exposure, risk of birth defects was 19 of 596 (3.2%; 95% CI, 2.0-5.0%). No unusual defects or pattern of defects were apparent.

CONCLUSIONS

The observed rates and types of birth defects for pregnancies exposed to acyclovir did not differ significantly from those in the general population. Birth Defects Research (Part A), 2004. Published 2004 Wiley-Liss, Inc.

[Herpes simplex virus infections]

The herpes simplex viruses type 1 and 2 (HSV 1 and 2) as typical members of the larger herpes virus group have the tendency to become latent after an inapparent primary infection. They are transmitted from person to person during episodes of reactivation. HSV 1 and 2 usually cause harmless mucosal infections. Usually HSV are kept in check by the immune system. An impaired immune response leads to HSV infections which can be life-threatening. Genital HSV infections are an important cause of genital ulcerations, and HSV 2 is a predisposing factor for HIV and AIDS. Worldwide the diagnostic possibilities for HSV are often inadequate. Despite the availability of modern chemotherapeutic agents, the treatment of HSV infections is in many cases less than satisfactory. Dermatologists play a major role in the early diagnosis and effective therapy of these infections. In this paper, the latest diagnostic and therapeutic, as well as prophylactic measures and vaccines, are reviewed.

Cost-effectiveness of herpes simplex virus type 2 serologic testing and antiviral therapy in pregnancy

OBJECTIVE

The purpose of this study was to determine whether serologic testing for herpes simplex virus type 2 (HSV-2) in pregnant women and their partners is cost-effective.

STUDY DESIGN

A decision analysis model was developed to investigate the cost-effectiveness of providing type-specific serologic testing at week 15 of pregnancy for all women unaware of their HSV-2 status, and offering antiviral suppressive therapy from week 36 until delivery to all seropositive women. This scenario was compared with current care, in which only a minority of women diagnosed with genital herpes (GH) receives antiviral suppressive therapy (AST). In a third scenario, testing is offered to partners of pregnant women who test seronegative, and antiviral suppressive therapy is offered to the partners who test seropositive.

RESULTS

Compared with current care, offering testing and antiviral suppressive therapy to 100,000 pregnant women resulted in an incremental cost of $3.1 million, 15.7 fewer cases of neonatal herpes, 186 fewer cesarean deliveries, and an incremental cost per quality-adjusted life- year gained (QALY) of $18,680. Offering testing and suppressive therapy to both the pregnant women and their partners resulted in an increased cost of $8.6 million, 16.8 fewer cases of neonatal herpes, 192 fewer cesarean deliveries, and an incremental cost per QALY of $48,946 compared with no testing.

CONCLUSION

Compared with commonly accepted benchmarks for cost-effectiveness (<$50,000/QALY), type-specific HSV-2 serologic testing of pregnant women may be a cost-effective strategy.

Neonatal herpes simplex infection

Tremendous advances have occurred over the past 30 years in the diagnosis and management of neonatal herpes simplex virus (HSV) disease. Mortality in patients with disseminated disease has decreased from 85 to 29%, and that in patients with central nervous system (CNS) disease has decreased from 50 to 4%. Morbidity has been improved more modestly: the proportion of patients with disseminated disease who are developing normally at 1 year has increased from 50 to 83%. While the proportion of patients with neurologic morbidity following CNS disease has remained essentially unchanged over the past three decades, the total number of patients who are developing normally following HSV CNS disease has increased due to the improved survival. Although additional therapeutic advances in the future are possible, more immediate methods for further improvements in outcome for patients with this potentially devastating disease lie in an enhanced awareness of neonatal HSV infection and disease. A thorough understanding of the biology and natural history of HSV in the gravid woman and the neonate provides the basis for such an index of suspicion and is provided in this article.

Antiviral and antiretroviral use in pregnancy

The history of antiviral and antiretroviral therapy is recent compared with many other medical therapies, including traditional antibiotics in pregnancy. There are few long-term data on which to base decisions of management in pregnancy. Accessing up-to-date information is critical to optimizing the safety of care for mothers and their infants. Exposure to medications in pregnancy can be toxic to a fetus in a gestational age-dependent manner. Determination of safe medications for pregnancy must take into consideration the need for certain medications and the possibility of inadvertent exposure in early pregnancy because of unplanned pregnancies. This article reviews the most commonly used antiviral and antiretroviral agents and places emphasis on the issues regarding use in pregnancy.

Treatment of sexually transmitted diseases in women

Guidelines for the treatment of patients with sexually transmitted infection are developed by the Centers for Disease Control and Prevention after consultation with a group of professionals knowledgeable in the field. This article briefly introduces various infections, reviews new diagnostic information, and presents the latest guidelines for therapy. All recommended and alternative regimens are drawn from the most recent treatment guidelines. Although this article focuses primarily on therapy, it also emphasizes the importance of counseling and prevention. Clinicians have the opportunity and obligation to provide education and counseling to patients. Prevention messages should be tailored to the individual patient with consideration given to her specific risk behaviors.