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Chen N, Kilpatrick R, VerHage EJ, Smith PB, Bukhari A, Hornik CD, Tolia VN, Benjamin DK, Greenberg RG. Epidemiology and treatment of herpes simplex virus in the neonatal intensive care unit. J Perinatol 2024:10.1038/s41372-024-02150-8. [PMID: 39394454 DOI: 10.1038/s41372-024-02150-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2024] [Revised: 10/02/2024] [Accepted: 10/07/2024] [Indexed: 10/13/2024]
Abstract
OBJECTIVE Describe the epidemiology and clinical characteristics of infants in the neonatal intensive care unit (NICU) with acyclovir exposure and herpes simplex virus (HSV) infection. STUDY DESIGN Our primary analysis was to evaluate the prevalence of HSV infection among infants in the NICU who received acyclovir. We compared characteristics of infants with and without HSV and used multivariable regression analyses to assess associations between infection and clinical outcomes. RESULT Of 1,057,061 infants, 17,910 (2%) received acyclovir. Of those who received acyclovir, 1090 (5%) had HSV. Infection was associated with lower gestational age and lower birth weight. Multivariable models demonstrated that infected infants had higher mortality, greater postmenstrual age at discharge, and longer length of stay. CONCLUSION Infants in the NICU who received acyclovir and have HSV are more likely to be born at lower gestational age, have lower birth weight, and have higher morbidities and mortality.
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Affiliation(s)
- Nellie Chen
- Duke University School of Medicine, Durham, NC, USA
| | - Ryan Kilpatrick
- Division of Newborn Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Erik J VerHage
- Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Areej Bukhari
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Department of Pediatrics (Infectious Diseases), Atrium Health Levine Children's Hospital and Wake Forest University School of Medicine, Charlotte, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Veeral N Tolia
- Pediatrix Center for Research, Quality, Education and Safety, Sunrise, FL, USA
| | - Daniel K Benjamin
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
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2
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Dantuluri KL, Ahmed A. Universal versus targeted treatment of neonatal herpes simplex virus among neonates presenting for sepsis evaluations. Curr Opin Infect Dis 2024; 37:413-418. [PMID: 39079178 DOI: 10.1097/qco.0000000000001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
PURPOSE OF REVIEW The American Academy of Pediatrics recently published guidance for the evaluation and management of febrile infants. However, guidance on testing and empiric treatment for neonatal herpes simplex virus (HSV) remains less standardized and subject to clinical practice variation. RECENT FINDINGS Recent reports reveal that high numbers of infants presenting for sepsis evaluations need to be treated empirically with acyclovir to capture one case of neonatal HSV. Clinical and laboratory risk factors for neonatal HSV identified in the literature can be used for a targeted approach to testing and treating infants for HSV to optimize resource utilization. SUMMARY The literature supports a targeted approach to evaluation and empiric acyclovir treatment for neonatal HSV, but additional studies are needed to validate this approach given the rarity of disease.
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Affiliation(s)
- Keerti L Dantuluri
- Division of Infectious Diseases, Department of Pediatrics, Levine Children's Hospital at Atrium Health and Wake Forest University School of Medicine, Charlotte, North Carolina, USA
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Graf RJ, Viviana Hoyos García I, Dendi A, White NO, Pifer T, Harris R, Salamon D, Mejias A, Sánchez PJ. Mucosal Site Detection of Herpes Simplex Virus in Neonates. J Pediatr 2024; 275:114212. [PMID: 39059717 DOI: 10.1016/j.jpeds.2024.114212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 06/03/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024]
Abstract
From 2001 to 2023, 17 (14%) of 120 neonates with confirmed herpes simplex virus infection tested positive for herpes simplex virus by polymerase chain reaction (PCR) from only mucosal sites without a clinical mucosal lesion. Whether mucosal PCR positivity reflects early infection that may lead to recognizable disease, transient colonization, or a false-positive PCR result remains a clinical conundrum and warrants further study.
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Affiliation(s)
- Rachel J Graf
- The Ohio State University College of Medicine, Columbus, OH; Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Ohio Perinatal Research Network, Columbus, OH
| | - Ingrith Viviana Hoyos García
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Ohio Perinatal Research Network, Columbus, OH; Department of Pediatrics, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | - Alvaro Dendi
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Ohio Perinatal Research Network, Columbus, OH; Department of Neonatology, Centro Hospitalario Pereira Rossell, Universidad de la República, Montevideo, Uruguay
| | | | - Traci Pifer
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Ohio Perinatal Research Network, Columbus, OH; Division of Pediatric Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Rachelle Harris
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Ohio Perinatal Research Network, Columbus, OH
| | - Douglas Salamon
- Department of Laboratory Medicine, Microbiology Laboratory, Nationwide Children's Hospital, Columbus, OH
| | - Asuncion Mejias
- Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, TN
| | - Pablo J Sánchez
- The Ohio State University College of Medicine, Columbus, OH; Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Abigail Wexner Research Institute at Nationwide Children's Hospital, Center for Perinatal Research, Ohio Perinatal Research Network, Columbus, OH; Division of Pediatric Infectious Diseases, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH.
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4
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Foote HP, Thomassy H, Baquero L, Cayli M, Jacobs E, Paladugu A, Roy A, Heyward E, Clark RH, Hornik CP, Benjamin DK, Benjamin DK, Greenberg RG. Acyclovir Dosing Practices Across a Multicenter Cohort of Neonatal Intensive Care Units. Pediatr Infect Dis J 2024:00006454-990000000-00925. [PMID: 38920385 DOI: 10.1097/inf.0000000000004459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
BACKGROUND Acyclovir is the first-line therapy for neonatal herpes simplex virus infections. Therapy can mitigate morbidity and mortality but carries a risk for toxicity. We aimed to compare acyclovir dosing in neonatal intensive care units to published recommendations based on population pharmacokinetic (PopPK) analysis. METHODS We performed a multicenter cohort study of infants in neonatal intensive care units managed by the Pediatrix Medical Group from 1997 to 2020. We included all infants who received acyclovir with complete dosing information. Our primary outcome was the proportion of courses with dosing within 80%-120% of the PopPK recommended daily dose and at the recommended dosing frequency. We compared dosing before and after the publication of the 2014 PopPK recommendations using linear probability modeling. RESULTS We identified 6862 infants with complete dosing information across 308 centers. Dosing met PopPK recommendations for 41% of treatment courses for infants <30 weeks postmenstrual age (PMA), 71% for infants 30 to <36 weeks PMA and <1% for infants ≥ 36 weeks PMA. Comparison of dosing from 1997 to 2013 with that from 2015 to 2020 showed a significant increase in dosing meeting PopPK recommendations for infants <30 weeks PMA (P = 0.008) and infants 30 to <36 weeks PMA (P = 0.02) but not infants ≥ 36 weeks PMA (P = 0.29). No significant increase in dosing meeting PopPK recommendations was seen for any PMA group when comparison was limited to more recent years (2008-2013 vs. 2015-2020). CONCLUSIONS Dosing meeting PopPK recommendations increased over time for some PMA groups, but dosing different than PopPK recommendations remains common. More research is needed to clarify optimal dosing strategies in these infants.
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Affiliation(s)
- Henry P Foote
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Haley Thomassy
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Leonardo Baquero
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Mina Cayli
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Elijah Jacobs
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Anish Paladugu
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Anisha Roy
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- High School or College Student Affiliated With the Duke Clinical Research Institute's R25 Summer Training in Academic Research Program
| | - Elizabeth Heyward
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | - Christoph P Hornik
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - Daniel K Benjamin
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Rachel G Greenberg
- From the Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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5
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Dungu KHS, Lund S, Malchau Carlsen EL, Hartling UB, Matthesen AT, Franck KT, Thomsen MK, Justesen US, Nielsen HL, Nielsen ACY, Henriksen TB, Nygaard U. Herpes simplex virus infection among neonates suspected of invasive bacterial infection: a population-based cohort study. Arch Dis Child Fetal Neonatal Ed 2023; 108:655-660. [PMID: 37225392 DOI: 10.1136/archdischild-2023-325583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/16/2023] [Indexed: 05/26/2023]
Abstract
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.
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Affiliation(s)
- Kia Hee Schultz Dungu
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Stine Lund
- Department of Neonatology, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Ulla Birgitte Hartling
- Department of Paediatrics and Adolescent Medicine, Odense University Hospital, Odense, Denmark
| | - Astrid Thaarup Matthesen
- Department of Paediatrics and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Kristina Træholt Franck
- Department of Virus and Microbiological Special Diagnostics, Statens Serum Institut, Copenhagen, Denmark
| | | | - Ulrik Stenz Justesen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Hans Linde Nielsen
- Department of Clinical Microbiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Tine Brink Henriksen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ulrikka Nygaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
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Shahoud F, Rathore MH, Shah CC, Alissa R. The Many Faces of Neurological Neonatal Herpes Simplex Virus Infection. Cureus 2023; 15:e41580. [PMID: 37559852 PMCID: PMC10406570 DOI: 10.7759/cureus.41580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/11/2023] Open
Abstract
This case series explores the various manifestations of central nervous system (CNS) involvement in neonatal herpes simplex virus (HSV) infection and highlights the challenges involved in their diagnosis and treatment. Neonatal HSV infection is a rare but serious condition that can have significant neurological consequences. The article presents three cases of neonatal HSV infection, all involving the CNS, each characterized by distinct clinical features and outcomes. Case 1 describes a three-week-old male with severe HSV meningoencephalitis resulting in poor response to treatment and death. Cases 2 and 3 describe younger neonates who presented early in the disease course with disseminated infection and skin, eye, and mouth (SEM) lesions. Although both patients had CNS involvement, their outcomes were remarkably favorable. The wide range of clinical presentations of CNS manifestations in neonatal HSV infection, ranging from nonspecific to evident neurological symptoms, underscores the need for a high index of suspicion and comprehensive evaluation to ensure early diagnosis and appropriate treatment. However, it also notes that even with timely treatment, some cases may still have a poor prognosis.
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Affiliation(s)
- Fadi Shahoud
- Pediatrics/Infectious Diseases, University of Florida College of Medicine, Jacksonville, USA
| | - Mobeen H Rathore
- Pediatrics/Infectious Diseases, University of Florida College of Medicine, Jacksonville, USA
| | - Chetan C Shah
- Pediatric Radiology, Nemours Children's Health System, Jacksonville, USA
| | - Rana Alissa
- Pediatrics, University of Florida College of Medicine, Jacksonville, USA
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7
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Backes IM, Byrd BK, Slein MD, Patel CD, Taylor SA, Garland CR, MacDonald SW, Balazs AB, Davis SC, Ackerman ME, Leib DA. Maternally transferred mAbs protect neonatal mice from HSV-induced mortality and morbidity. J Exp Med 2022; 219:e20220110. [PMID: 36156707 PMCID: PMC9516843 DOI: 10.1084/jem.20220110] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/29/2022] [Accepted: 09/01/2022] [Indexed: 01/11/2023] Open
Abstract
Neonatal herpes simplex virus (nHSV) infections often result in significant mortality and neurological morbidity despite antiviral drug therapy. Maternally transferred herpes simplex virus (HSV)-specific antibodies reduce the risk of clinically overt nHSV, but this observation has not been translationally applied. Using a neonatal mouse model, we tested the hypothesis that passive transfer of HSV-specific human mAbs can prevent mortality and morbidity associated with nHSV. The mAbs were expressed in vivo via vectored immunoprophylaxis or recombinantly. Through these maternally derived routes or through direct administration to pups, diverse mAbs to HSV glycoprotein D protected against neonatal HSV-1 and HSV-2 infection. Using in vivo bioluminescent imaging, both pre- and post-exposure mAb treatment significantly reduced viral load in mouse pups. Together these studies support the notion that HSV-specific mAb-based therapies could prevent or improve HSV infection outcomes in neonates.
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Affiliation(s)
- Iara M. Backes
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Thayer School of Engineering, Dartmouth College, Hanover, NH
| | - Brook K. Byrd
- Thayer School of Engineering, Dartmouth College, Hanover, NH
| | - Matthew D. Slein
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Thayer School of Engineering, Dartmouth College, Hanover, NH
| | - Chaya D. Patel
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Sean A. Taylor
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Callaghan R. Garland
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | | | - Scott C. Davis
- Thayer School of Engineering, Dartmouth College, Hanover, NH
| | - Margaret E. Ackerman
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH
- Thayer School of Engineering, Dartmouth College, Hanover, NH
| | - David A. Leib
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH
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8
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DesPain AW, Pearman R, Hamdy RF, Campos J, Badolato GM, Breslin K. Impact of CSF Meningitis and Encephalitis Panel on Resource Use for Febrile Well-Appearing Infants. Hosp Pediatr 2022; 12:1002-1012. [PMID: 36200374 DOI: 10.1542/hpeds.2021-006433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To determine whether the BioFire FilmArray Meningitis/Encephalitis (ME) panel is associated with decreased resource use for febrile infants. The ME panel has a rapid turnaround time (1-2 hours) and may shorten length of stay (LOS) and antimicrobial use for febrile well-appearing infants. METHODS Retrospective cohort study of febrile well-appearing infants ≤60 days with cerebrospinal fluid culture sent in the emergency department from July 2017 to April 2019. We examined the frequency of ME panel use and its relationship with hospital LOS and initiation and duration of antibiotics and acyclovir. We used nonparametric tests to compare median durations. RESULTS The ME panel was performed for 85 (36%) of 237 infants. There was no difference in median hospital LOS for infants with versus without ME panel testing (42 hours, interquartile range [IQR] 36-52 vs 40 hours, IQR: 35-47, P = .09). More than 97% of infants with and without ME panel testing were initiated on antibiotics. Patients with ME panel were more likely to receive acyclovir (33% vs 18%; odds ratio: 2.2, 95%: confidence interval 1.2-4.0). There was no difference in median acyclovir duration with or without ME panel testing (1 hour, IQR: 1-7 vs 4.2 hours, IQR: 1-21, P = .10). When adjusting for potential covariates, these findings persisted. CONCLUSIONS ME panel use was not associated with differences in hospital LOS, antibiotic initiation, or acyclovir duration in febrile well-appearing infants. ME panel testing was associated with acyclovir initiation.
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Affiliation(s)
- Angelica W DesPain
- Division of Emergency Medicine, The Children's Hospital of San Antonio, San Antonio, Texas
| | | | - Rana F Hamdy
- Division of Infectious Diseases
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC
| | - Joseph Campos
- Division of Laboratory Medicine, Children's National Hospital, Washington, DC
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9
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O'Bryant SC, Cruz AT, Fielder EK. Post-Circumcision Hemorrhage From Disseminated Herpes Simplex Virus-2. Clin Pediatr (Phila) 2022; 61:679-683. [PMID: 35686359 DOI: 10.1177/00099228221101730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shelease C O'Bryant
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | - Andrea T Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA.,Section of Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
| | - Elaine K Fielder
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
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10
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Backes IM, Leib DA, Ackerman ME. Monoclonal antibody therapy of herpes simplex virus: An opportunity to decrease congenital and perinatal infections. Front Immunol 2022; 13:959603. [PMID: 36016956 PMCID: PMC9398215 DOI: 10.3389/fimmu.2022.959603] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/20/2022] [Indexed: 11/25/2022] Open
Abstract
The fetal/neonatal period represents both a unique window of opportunity for interventions as well as vulnerability to a number of viral infections. While Herpesviruses such as herpes simplex virus (HSV) are highly prevalent and typically of little consequence among healthy adults, they are among the most consequential infections of early life. Despite treatment with antiviral drugs, neonatal HSV (nHSV) infections can still result in significant mortality and lifelong neurological morbidity. Fortunately, newborns in our pathogen-rich world inherit some of the protection provided by the maternal immune system in the form of transferred antibodies. Maternal seropositivity, resulting in placental transfer of antibodies capable of neutralizing virus and eliciting the diverse effector functions of the innate immune system are associated with dramatically decreased risk of nHSV. Given this clear epidemiological evidence of reduced risk of infection and its sequelae, we present what is known about the ability of monoclonal antibody therapies to treat or prevent HSV infection and explore how effective antibody-based interventions in conjunction with antiviral therapy might reduce early life mortality and long-term morbidity.
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Affiliation(s)
- Iara M Backes
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
- Thayer School of Engineering, Dartmouth College, Hanover, NH, United States
| | - David A Leib
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
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11
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Ericson JE, Benjamin DK, Boakye-Agyeman F, Cotten CM, Adler-Shohet F, Laughon M, Poindexter B, Harper B, Payne EH, Kaneshige K, Smith PB, Smith PB. Exposure-safety relationship for acyclovir in the treatment of neonatal herpes simplex virus disease. Early Hum Dev 2022; 170:105616. [PMID: 35763957 PMCID: PMC9645023 DOI: 10.1016/j.earlhumdev.2022.105616] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 06/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neonatal herpes simplex virus (HSV) disease has been treated with high-dose (20 mg/kg/dose) acyclovir since 1991. AIMS Determine the safety of acyclovir in infants with neonatal HSV treated with high-dose acyclovir; examine the association between acyclovir dose and exposure with adverse events (AEs). STUDY DESIGN We obtained demographic information and acyclovir dosing via medical records. Acyclovir exposure was calculated using an established pharmacokinetic model. SUBJECTS Infants <120 days of age with neonatal HSV discharged from four academic children's hospitals. OUTCOME MEASURES We identified clinical and laboratory adverse events (AEs). RESULTS AND CONCLUSIONS We identified 49 infants with neonatal HSV treated with acyclovir; 42 infants had complete 21-day dosing information. Median mean daily dose was 59 mg/kg/day. Clinical AEs were common among all gestational and postnatal age groups. Rash was the most common clinical AE (37 %). Mild laboratory AEs occurred in 2-37 % of infants. The median maximum doses (mg/kg/day) were higher among infants with hypokalemia, elevated blood urea nitrogen, and thrombocytosis. For all other laboratory AEs, the median maximum doses for infants without events were higher or equal to the median maximum dose of infants with the AE. The odds of experiencing any clinical or laboratory AE did not differ by predicted acyclovir exposure for either area under the curve (AUC) or maximum concentration (Cmax) (odds ratio [OR] = 1.00 [0.98, 1.03] and OR = 1.01 [0.93, 1.12], respectively). Although AEs were common with high-dose acyclovir exposure, severe AEs were rare. Acyclovir exposure was not associated with AEs.
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Affiliation(s)
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC,Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Felix Boakye-Agyeman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - C. Michael Cotten
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC,Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | - Matthew Laughon
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Barrie Harper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - P. Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States of America.
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12
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Kidszun A, Bruns A, Schreiner D, Tippmann S, Winter J, Pokora RM, Urschitz MS, Mildenberger E. Characteristics of neonatal herpes simplex virus infections in Germany: results of a 2-year prospective nationwide surveillance study. Arch Dis Child Fetal Neonatal Ed 2022; 107:188-192. [PMID: 34257101 PMCID: PMC8867279 DOI: 10.1136/archdischild-2021-321940] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/25/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess incidence and burden of neonatal herpes simplex virus (HSV) infections and to explore possible transmission routes. METHODS A 2-year prospective nationwide surveillance study performed in 2017 and 2018. All German paediatric departments (n=464 in 2017, n=441 in 2018) were contacted on a monthly basis to report potential cases of neonatal HSV infections. Infants with a postnatal age of ≤60 days and a positive HSV PCR or HSV culture from skin, mucous membrane, vesicles or conjunctival smear, blood or cerebrospinal fluid were included in the study. RESULTS 37 cases were analysed. 29 patients who exhibited no or only mild clinical symptoms were discharged home without organ damage or neurological abnormalities. Four patients showed significant neurological impairment, one patient required liver transplantation and two patients died during in-patient treatment. The 2-year incidence of neonatal HSV infections was 2.35 per 100 000 live births (95% CI 1.69 to 3.02) and disease-specific mortality was 0.13 per 100 000 live births (95% CI 0.04 to 0.21). Data on possible transmission routes were available in 23 cases. In 20 cases, an orofacial HSV infection was present in one or more family members. An active maternal genital HSV infection was reported in 3 cases. CONCLUSION Neonatal HSV infections are rare in Germany. Most infants have a benign clinical course, but some infants are severely affected. Postnatal HSV exposure may account for a considerable number of neonatal HSV infections.
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Affiliation(s)
- André Kidszun
- Division of Neonatology, Department of Paediatrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
- Division of Neonatology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Bruns
- Division of Neonatology, Department of Paediatrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Daniel Schreiner
- Division of Neonatology, Department of Paediatrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Susanne Tippmann
- Division of Neonatology, Department of Paediatrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Julia Winter
- Division of Neonatology, Department of Paediatrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Roman M Pokora
- Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Michael S Urschitz
- Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Department of Paediatrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Rheinland-Pfalz, Germany
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13
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Treasure JD, Shah SS, Hall M, Mahant S, Berry JG, Kimberlin DW, Schondelmeyer AC. Variation in Diagnostic Testing and Empiric Acyclovir Use for HSV Infection in Febrile Infants. Hosp Pediatr 2021; 11:922-930. [PMID: 34400513 DOI: 10.1542/hpeds.2020-003129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Clinicians evaluating for herpes simplex virus (HSV) in febrile infants must balance detection with overtesting, and there is no universally accepted approach to risk stratification. We aimed to describe variation in diagnostic evaluation and empirical acyclovir treatment of infants aged 0 to 60 days presenting with fever and determine the association between testing and length of stay (LOS). METHODS In this retrospective 44-hospital observational study, we used the Pediatric Health Information System database to identify infants aged ≤60 days evaluated for fever in emergency departments from January 2016 through December 2017. We described hospital-level variation in laboratory testing, including HSV, imaging and other diagnostic evaluations, acyclovir use, and LOS. We assessed the relationship between HSV testing and LOS using generalized linear mixed effects models adjusted for age and illness severity. RESULTS In 24 535 encounters for fever, the median HSV testing frequency across hospitals was 35.6% (interquartile range [IQR]: 28.5%-53.5%) for infants aged 0 to 21 days and 12% (IQR: 8.6%-15.7%) for infants aged 22 to 60 days. Among HSV-tested patients, median acyclovir use across hospitals was 79.2% (IQR: 68.1%-89.7%) for those aged 0 to 21 days and 63.6% (IQR: 44.1%-73%) for those aged 22 to 60 days. The prevalence of additional testing varied substantially by hospital and age group. Risk-adjusted LOS for HSV-tested infants was significantly longer than risk-adjusted LOS for those not tested (2.6 vs 1.9 days, P < .001). CONCLUSIONS Substantial variation exists in diagnostic evaluation and acyclovir use, and infants who received HSV testing had a longer LOS than infants who did not. This variability supports the need for further studies to help clinicians better risk-stratify febrile infants and to guide HSV testing and treatment decisions.
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Affiliation(s)
| | - Samir S Shah
- Divisions of Hospital Medicine and
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Sanjay Mahant
- Division of Pediatric Medicine, Department of Pediatrics, Institute of Health Policy, Evaluation and Management, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Jay G Berry
- Division of General Pediatrics, Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts
| | - David W Kimberlin
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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14
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Cruz AT, Nigrovic LE, Xie J, Mahajan P, Thomson JE, Okada PJ, Uspal NG, Mistry RD, Garro A, Schnadower D, Kulik DM, Curtis SJ, Miller AS, Fleming AH, Lyons TW, Balamuth F, Arms JL, Louie J, Aronson PL, Thompson AD, Ishimine PT, Schmidt SM, Pruitt CM, Shah SS, Grether-Jones KL, Bradin SA, Freedman SB. Predictors of Invasive Herpes Simplex Virus Infection in Young Infants. Pediatrics 2021; 148:peds.2021-050052. [PMID: 34446535 DOI: 10.1542/peds.2021-050052] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To identify independent predictors of and derive a risk score for invasive herpes simplex virus (HSV) infection. METHODS In this 23-center nested case-control study, we matched 149 infants with HSV to 1340 controls; all were ≤60 days old and had cerebrospinal fluid obtained within 24 hours of presentation or had HSV detected. The primary and secondary outcomes were invasive (disseminated or central nervous system) or any HSV infection, respectively. RESULTS Of all infants included, 90 (60.4%) had invasive and 59 (39.6%) had skin, eyes, and mouth disease. Predictors independently associated with invasive HSV included younger age (adjusted odds ratio [aOR]: 9.1 [95% confidence interval (CI): 3.4-24.5] <14 and 6.4 [95% CI: 2.3 to 17.8] 14-28 days, respectively, compared with >28 days), prematurity (aOR: 2.3, 95% CI: 1.1 to 5.1), seizure at home (aOR: 6.1, 95% CI: 2.3 to 16.4), ill appearance (aOR: 4.2, 95% CI: 2.0 to 8.4), abnormal triage temperature (aOR: 2.9, 95% CI: 1.6 to 5.3), vesicular rash (aOR: 54.8, (95% CI: 16.6 to 180.9), thrombocytopenia (aOR: 4.4, 95% CI: 1.6 to 12.4), and cerebrospinal fluid pleocytosis (aOR: 3.5, 95% CI: 1.2 to 10.0). These variables were transformed to derive the HSV risk score (point range 0-17). Infants with invasive HSV had a higher median score (6, interquartile range: 4-8) than those without invasive HSV (3, interquartile range: 1.5-4), with an area under the curve for invasive HSV disease of 0.85 (95% CI: 0.80-0.91). When using a cut-point of ≥3, the HSV risk score had a sensitivity of 95.6% (95% CI: 84.9% to 99.5%), specificity of 40.1% (95% CI: 36.8% to 43.6%), and positive likelihood ratio 1.60 (95% CI: 1.5 to 1.7) and negative likelihood ratio 0.11 (95% CI: 0.03 to 0.43). CONCLUSIONS A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.
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Affiliation(s)
| | - Lise E Nigrovic
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jianling Xie
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute
| | - Prashant Mahajan
- School of Medicine, Wayne State University, Detroit, Michigan.,Medical School, University of Michigan, Ann Arbor, Michigan
| | - Joanna E Thomson
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Pamela J Okada
- Southwestern Medical Center, University of Texas, Dallas, Texas
| | - Neil G Uspal
- School of Medicine, University of Washington, Seattle, Washington
| | - Rakesh D Mistry
- School of Medicine, University of Colorado, Aurora, Colorado
| | - Aris Garro
- Alpert Medical School of Brown University, Providence, Rhode Island
| | - David Schnadower
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,School of Medicine, Washington University, St Louis, Missouri
| | - Dina M Kulik
- University of Toronto and the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sarah J Curtis
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Aaron S Miller
- School of Medicine, St Louis University, St Louis, Missouri
| | | | - Todd W Lyons
- Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Fran Balamuth
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph L Arms
- Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Jeffrey Louie
- Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Paul L Aronson
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Amy D Thompson
- Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Paul T Ishimine
- School of Medicine, University of California-San Diego, San Diego, California
| | - Suzanne M Schmidt
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christopher M Pruitt
- School of Medicine, University of Alabama-Birmingham, Birmingham, Alabama.,Medical University of South Carolina, South Carolina, Charleston, South Carolina
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and the Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Stephen B Freedman
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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15
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Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada TA, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda H, Abe T, Andoh K, Iida Y, Ishihara T, Ide K, Ito K, Ito Y, Inata Y, Utsunomiya A, Unoki T, Endo K, Ouchi A, Ozaki M, Ono S, Katsura M, Kawaguchi A, Kawamura Y, Kudo D, Kubo K, Kurahashi K, Sakuramoto H, Shimoyama A, Suzuki T, Sekine S, Sekino M, Takahashi N, Takahashi S, Takahashi H, Tagami T, Tajima G, Tatsumi H, Tani M, Tsuchiya A, Tsutsumi Y, Naito T, Nagae M, Nagasawa I, Nakamura K, Nishimura T, Nunomiya S, Norisue Y, Hashimoto S, Hasegawa D, Hatakeyama J, Hara N, Higashibeppu N, Furushima N, Furusono H, Matsuishi Y, Matsuyama T, Minematsu Y, Miyashita R, Miyatake Y, Moriyasu M, Yamada T, Yamada H, Yamamoto R, Yoshida T, Yoshida Y, Yoshimura J, Yotsumoto R, Yonekura H, Wada T, Watanabe E, Aoki M, Asai H, Abe T, Igarashi Y, Iguchi N, Ishikawa M, Ishimaru G, Isokawa S, Itakura R, Imahase H, Imura H, Irinoda T, Uehara K, Ushio N, Umegaki T, Egawa Y, Enomoto Y, Ota K, Ohchi Y, Ohno T, Ohbe H, Oka K, Okada N, Okada Y, Okano H, Okamoto J, Okuda H, Ogura T, Onodera Y, Oyama Y, Kainuma M, Kako E, Kashiura M, Kato H, Kanaya A, Kaneko T, Kanehata K, Kano KI, Kawano H, Kikutani K, Kikuchi H, Kido T, Kimura S, Koami H, Kobashi D, Saiki I, Sakai M, Sakamoto A, Sato T, Shiga Y, Shimoto M, Shimoyama S, Shoko T, Sugawara Y, Sugita A, Suzuki S, Suzuki Y, Suhara T, Sonota K, Takauji S, Takashima K, Takahashi S, Takahashi Y, Takeshita J, Tanaka Y, Tampo A, Tsunoyama T, Tetsuhara K, Tokunaga K, Tomioka Y, Tomita K, Tominaga N, Toyosaki M, Toyoda Y, Naito H, Nagata I, Nagato T, Nakamura Y, Nakamori Y, Nahara I, Naraba H, Narita C, Nishioka N, Nishimura T, Nishiyama K, Nomura T, Haga T, Hagiwara Y, Hashimoto K, Hatachi T, Hamasaki T, Hayashi T, Hayashi M, Hayamizu A, Haraguchi G, Hirano Y, Fujii R, Fujita M, Fujimura N, Funakoshi H, Horiguchi M, Maki J, Masunaga N, Matsumura Y, Mayumi T, Minami K, Miyazaki Y, Miyamoto K, Murata T, Yanai M, Yano T, Yamada K, Yamada N, Yamamoto T, Yoshihiro S, Tanaka H, Nishida O. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020). J Intensive Care 2021; 9:53. [PMID: 34433491 PMCID: PMC8384927 DOI: 10.1186/s40560-021-00555-7] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 02/08/2023] Open
Abstract
The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
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Affiliation(s)
- Moritoki Egi
- Department of Surgery Related, Division of Anesthesiology, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-2, Chuo-ku, Kobe, Hyogo, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Medical School, Yamadaoka 2-15, Suita, Osaka, Japan.
| | - Tomoaki Yatabe
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kazuaki Atagi
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Joji Kotani
- Department of Surgery Related, Division of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takumi Taniguchi
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Ryosuke Tsuruta
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Hospital, Yamagata, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Naoto Hosokawa
- Department of Infectious Diseases, Kameda Medical Center, Kamogawa, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College, Osaka, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Mai Inada
- Member of Japanese Association for Acute Medicine, Tokyo, Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yusuke Kawai
- Department of Nursing, Fujita Health University Hospital, Toyoake, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Support and Practice, Hiroshima University Hospital, Hiroshima, Japan
| | - Chikashi Takeda
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Tokorozawa, Japan
| | | | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine/Infectious Disease, Hitachi General Hospital, Hitachi, Japan
| | - Kei Hayashida
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tomoya Hirose
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Shinya Miura
- The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - Kohkichi Andoh
- Division of Anesthesiology, Division of Intensive Care, Division of Emergency and Critical Care, Sendai City Hospital, Sendai, Japan
| | - Yuki Iida
- Department of Physical Therapy, School of Health Sciences, Toyohashi Sozo University, Toyohashi, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kenta Ito
- Department of General Pediatrics, Aichi Children's Health and Medical Center, Obu, Japan
| | - Yusuke Ito
- Department of Infectious Disease, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yu Inata
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Akemi Utsunomiya
- Human Health Science, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Unoki
- Department of Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Akira Ouchi
- College of Nursing, Ibaraki Christian University, Hitachi, Japan
| | - Masayuki Ozaki
- Department of Emergency and Critical Care Medicine, Komaki City Hospital, Komaki, Japan
| | - Satoshi Ono
- Gastroenterological Center, Shinkuki General Hospital, Kuki, Japan
| | | | | | - Yusuke Kawamura
- Department of Rehabilitation, Showa General Hospital, Tokyo, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenji Kubo
- Department of Emergency Medicine and Department of Infectious Diseases, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Kiyoyasu Kurahashi
- Department of Anesthesiology and Intensive Care Medicine, International University of Health and Welfare School of Medicine, Narita, Japan
| | | | - Akira Shimoyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Takeshi Suzuki
- Department of Anesthesiology, Tokai University School of Medicine, Isehara, Japan
| | - Shusuke Sekine
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Motohiro Sekino
- Division of Intensive Care, Nagasaki University Hospital, Nagasaki, Japan
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sei Takahashi
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Hiroshi Takahashi
- Department of Cardiology, Steel Memorial Muroran Hospital, Muroran, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
| | - Goro Tajima
- Nagasaki University Hospital Acute and Critical Care Center, Nagasaki, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masanori Tani
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Yusuke Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Takaki Naito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaharu Nagae
- Department of Intensive Care Medicine, Kobe University Hospital, Kobe, Japan
| | | | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shin Nunomiya
- Department of Anesthesiology and Intensive Care Medicine, Division of Intensive Care, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Naoki Hara
- Department of Pharmacy, Yokohama Rosai Hospital, Yokohama, Japan
| | - Naoki Higashibeppu
- Department of Anesthesiology and Nutrition Support Team, Kobe City Medical Center General Hospital, Kobe City Hospital Organization, Kobe, Japan
| | - Nana Furushima
- Department of Anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Hirotaka Furusono
- Department of Rehabilitation, University of Tsukuba Hospital/Exult Co., Ltd., Tsukuba, Japan
| | - Yujiro Matsuishi
- Doctoral program in Clinical Sciences. Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Minematsu
- Department of Clinical Engineering, Osaka University Hospital, Suita, Japan
| | - Ryoichi Miyashita
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuji Miyatake
- Department of Clinical Engineering, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Megumi Moriyasu
- Division of Respiratory Care and Rapid Response System, Intensive Care Center, Kitasato University Hospital, Sagamihara, Japan
| | - Toru Yamada
- Department of Nursing, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroyuki Yamada
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuhei Yoshida
- Nursing Department, Osaka General Medical Center, Osaka, Japan
| | - Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | | | - Hiroshi Yonekura
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Eizo Watanabe
- Department of Emergency and Critical Care Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hideki Asai
- Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Japan
| | - Takakuni Abe
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Yutaka Igarashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Masami Ishikawa
- Department of Anesthesiology, Emergency and Critical Care Medicine, Kure Kyosai Hospital, Kure, Japan
| | - Go Ishimaru
- Department of General Internal Medicine, Soka Municipal Hospital, Soka, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Ryuta Itakura
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hisashi Imahase
- Department of Biomedical Ethics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruki Imura
- Department of Infectious Diseases, Rakuwakai Otowa Hospital, Kyoto, Japan
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan
| | | | - Kenji Uehara
- Department of Anesthesiology, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Noritaka Ushio
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Takeshi Umegaki
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Yuko Egawa
- Advanced Emergency and Critical Care Center, Saitama Red Cross Hospital, Saitama, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshifumi Ohchi
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Takanori Ohno
- Department of Emergency and Critical Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | | | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yohei Okada
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiromu Okano
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo, Japan
| | - Jun Okamoto
- Department of ER, Hashimoto Municipal Hospital, Hashimoto, Japan
| | - Hiroshi Okuda
- Department of Community Medical Supports, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Takayuki Ogura
- Tochigi prefectural Emergency and Critical Care Center, Imperial Gift Foundation Saiseikai, Utsunomiya Hospital, Utsunomiya, Japan
| | - Yu Onodera
- Department of Anesthesiology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yuhta Oyama
- Department of Internal Medicine, Dialysis Center, Kichijoji Asahi Hospital, Tokyo, Japan
| | - Motoshi Kainuma
- Anesthesiology, Emergency Medicine, and Intensive Care Division, Inazawa Municipal Hospital, Inazawa, Japan
| | - Eisuke Kako
- Department of Anesthesiology and Intensive Care Medicine, Nagoya-City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hiromi Kato
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiro Kanaya
- Department of Anesthesiology, Sendai Medical Center, Sendai, Japan
| | - Tadashi Kaneko
- Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Keita Kanehata
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroyuki Kawano
- Department of Gastroenterological Surgery, Onga Hospital, Fukuoka, Japan
| | - Kazuya Kikutani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hitoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takahiro Kido
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan
| | - Sho Kimura
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroyuki Koami
- Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, USA
| | - Daisuke Kobashi
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Iwao Saiki
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Masahito Sakai
- Department of General Medicine Shintakeo Hospital, Takeo, Japan
| | - Ayaka Sakamoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Tetsuya Sato
- Tohoku University Hospital Emergency Center, Sendai, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Center for Advanced Joint Function and Reconstructive Spine Surgery, Graduate school of Medicine, Chiba University, Chiba, Japan
| | - Manabu Shimoto
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinya Shimoyama
- Department of Pediatric Cardiology and Intensive Care, Gunma Children's Medical Center, Shibukawa, Japan
| | - Tomohisa Shoko
- Department of Emergency and Critical Care Medicine, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Yoh Sugawara
- Department of Anesthesiology, Yokohama City University, Yokohama, Japan
| | - Atsunori Sugita
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Intensive Care, Okayama University Hospital, Okayama, Japan
| | - Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiro Suhara
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Kenji Sonota
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kohei Takashima
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Sho Takahashi
- Department of Cardiology, Fukuyama City Hospital, Fukuyama, Japan
| | - Yoko Takahashi
- Department of General Internal Medicine, Koga General Hospital, Koga, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Yuuki Tanaka
- Fukuoka Prefectural Psychiatric Center, Dazaifu Hospital, Dazaifu, Japan
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Taichiro Tsunoyama
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kenichi Tetsuhara
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Kentaro Tokunaga
- Department of Intensive Care Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Yoshihiro Tomioka
- Department of Anesthesiology and Intensive Care Unit, Todachuo General Hospital, Toda, Japan
| | - Kentaro Tomita
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Mitsunobu Toyosaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yukitoshi Toyoda
- Department of Emergency and Critical Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Nagata
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Tadashi Nagato
- Department of Respiratory Medicine, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Yoshimi Nakamura
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yuki Nakamori
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Isao Nahara
- Department of Anesthesiology and Critical Care Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Chihiro Narita
- Department of Emergency Medicine and Intensive Care Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoya Nishimura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Kei Nishiyama
- Division of Emergency and Critical Care Medicine Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Tomohisa Nomura
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Taiki Haga
- Department of Pediatric Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Hagiwara
- Department of Emergency and Critical Care Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Katsuhiko Hashimoto
- Research Associate of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Toshiaki Hamasaki
- Department of Emergency Medicine, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Takuya Hayashi
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Minoru Hayashi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Atsuki Hayamizu
- Department of Emergency Medicine, Saitama Saiseikai Kurihashi Hospital, Kuki, Japan
| | - Go Haraguchi
- Division of Intensive Care Unit, Sakakibara Heart Institute, Tokyo, Japan
| | - Yohei Hirano
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Ryo Fujii
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Center, Imperial Foundation Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Motoki Fujita
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Masahito Horiguchi
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Jun Maki
- Department of Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Naohisa Masunaga
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Center, Chiba, Japan
| | - Takuya Mayumi
- Department of Internal Medicine, Kanazawa Municipal Hospital, Kanazawa, Japan
| | - Keisuke Minami
- Ishikawa Prefectual Central Hospital Emergency and Critical Care Center, Kanazawa, Japan
| | - Yuya Miyazaki
- Department of Emergency and General Internal Medicine, Saiseikai Kawaguchi General Hospital, Kawaguchi, Japan
| | - Kazuyuki Miyamoto
- Department of Emergency and Disaster Medicine, Showa University, Tokyo, Japan
| | - Teppei Murata
- Department of Cardiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Machi Yanai
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takao Yano
- Department of Critical Care and Emergency Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Naoki Yamada
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan
| | - Tomonori Yamamoto
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shodai Yoshihiro
- Pharmaceutical Department, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
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16
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Fernandes N, Sthapit B, Mhanna M, Abughali N. Evaluation of suspected neonatal herpes simplex virus infection in preterm versus term newborns in the neonatal intensive care unit. J Neonatal Perinatal Med 2021; 13:387-394. [PMID: 32083595 DOI: 10.3233/npm-190334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND While national guidelines are available for the evaluation and management of term infants at risk for herpes simplex virus (HSV) infection, such guidelines are lacking for preterm infants. We sought to determine the risk factors and clinical characteristics of preterm vs. term infants who were evaluated and treated empirically for HSV infection in the neonatal intensive care unit (NICU). METHODS In a retrospective cohort study, medical records of all infants who were admitted to our NICU (2009-2016) and who were evaluated and empirically treated for HSV were reviewed for mothers' and infants' demographics, clinical characteristics, and laboratory findings. RESULTS During the study period 4.2% (103/2,471) of all preterm infants, and 6.0% (112/1,865) of all term infants were evaluated and treated empirically for neonatal HSV. Among all infants who were evaluated and treated for HSV, 5.5% (12/215) had neonatal HSV disease, of whom 83.3% (10/12) were preterm infants. In comparison to term, preterm infants were more likely to be evaluated and treated, if they had a maternal history of HSV [OR 2.51 (95% CI: 1.41-4.48)], prolonged rupture of membranes [2.64 (1.221-5.73)], leukopenia [3.65 (1.94-6.87)] and thrombocytopenia [2.25 (0.85-5.89)]. HSV disease was associated with a higher mortality compared to those without disease [25% (3/12) vs. 4.4% (9/203) respectively; p = <0.05]. CONCLUSION Preterm infants evaluated and empirically treated for HSV have a higher burden of HSV infection than term infants. HSV should be considered in the management of preterm infant with a maternal history of HSV, prolonged rupture of membranes, and thrombocytopenia.
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Affiliation(s)
- Neil Fernandes
- Department of Pediatrics, Case Western Reserve University at MetroHealth Medical Center, Cleveland OH, USA
| | - Bonisha Sthapit
- Department of Pediatrics, Case Western Reserve University at MetroHealth Medical Center, Cleveland OH, USA
| | - Maroun Mhanna
- Department of Pediatrics, Case Western Reserve University at MetroHealth Medical Center, Cleveland OH, USA
| | - Nazha Abughali
- Department of Pediatrics, Case Western Reserve University at MetroHealth Medical Center, Cleveland OH, USA
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17
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Samies NL, James SH, Kimberlin DW. Neonatal Herpes Simplex Virus Disease: Updates and Continued Challenges. Clin Perinatol 2021; 48:263-274. [PMID: 34030813 DOI: 10.1016/j.clp.2021.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article defines neonatal herpes simplex virus (HSV) disease and describes the progress over the past 40 years that has revolutionized the management of HSV disease in neonates to improve their outcomes. These advancements include the introduction of acyclovir in the 1980s, polymerase chain reaction (PCR) for the detection of HSV DNA in the 1990s, and recommendations on managing infants born to mothers with active genital lesions. Despite these advancements, however, there remain high morbidity and mortality in affected neonates, with need for continued improvement. Areas of high interest include vaccine development and rapid PCR detection at time of delivery.
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Affiliation(s)
- Nicole L Samies
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Children's Harbor Building 308, 1600 7th Avenue South, Birmingham, AL 35233-1711, USA.
| | - Scott H James
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Children's Harbor Building 308, 1600 7th Avenue South, Birmingham, AL 35233-1711, USA
| | - David W Kimberlin
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Children's Harbor Building 308, 1600 7th Avenue South, Birmingham, AL 35233-1711, USA
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18
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Abstract
Neonatal herpes simplex virus (HSV) infection carries significant morbidity and mortality. In contrast to perinatal exposure, there are no clear guidelines for the management of postnatal HSV exposure. This review focuses on the risk of HSV infection following postnatal exposure and suggests an approach to management. While many infants are protected by transplacentally transferred maternal anti-HSV antibodies, infants of seronegative mothers with significant postnatal HSV exposure may be at risk of severe disease. Individual risk assessment, appropriate investigations, and empiric acyclovir treatment should be considered in postnatally exposed newborns, even if asymptomatic. In all cases, close clinical follow-up is indicated, as well as education of families on the symptoms of neonatal HSV disease. Finally, measures to reduce the risk of postnatal HSV infection should be considered, such as discouraging individuals, particularly those with a history of recurrent cold sores, from kissing newborns.
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19
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Haase R, Seliger G, Baier J. [Herpes Simplex Virus Infection in Two Premature Infants - Diagnostic and Therapeutic Management]. Z Geburtshilfe Neonatol 2021; 225:441-444. [PMID: 33530114 DOI: 10.1055/a-1345-9835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Herpes simplex virus type 1 or 2 (HSV 1/2)-related infections in neonates are rare but associated with high morbidity and mortality, especially if specific treatment is delayed. Due to immaturity of the immunological system, premature infants are particularly at risk. In addition, symptoms of neonatal HSV infections may imitate prematurity-related problems, such as sepsis. So, a thorough patient's history and appropriate diagnostic measures are important to confirm the diagnosis. We present 2 premature infants with systemic HSV infections and discuss diagnostic and therapeutic management. Both were treated with intravenous acyclovir followed by enteral aciclovir suppressive therapy.
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Affiliation(s)
- Roland Haase
- Abteilung für Neonatologie und Pädiatrische Intensivmedizin, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland.,Klinik für Neonatologie und Kinderintensivmedizin, St. Elisabeth & St. Barbara Krankenhaus, Halle (Saale), Deutschland
| | - Gregor Seliger
- Universitätsklinik und Poliklinik für Geburtshilfe und Pränatalmedizin, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Jan Baier
- Abteilung für Neonatologie und Pädiatrische Intensivmedizin, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
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20
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Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada T, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda H, Abe T, Andoh K, Iida Y, Ishihara T, Ide K, Ito K, Ito Y, Inata Y, Utsunomiya A, Unoki T, Endo K, Ouchi A, Ozaki M, Ono S, Katsura M, Kawaguchi A, Kawamura Y, Kudo D, Kubo K, Kurahashi K, Sakuramoto H, Shimoyama A, Suzuki T, Sekine S, Sekino M, Takahashi N, Takahashi S, Takahashi H, Tagami T, Tajima G, Tatsumi H, Tani M, Tsuchiya A, Tsutsumi Y, Naito T, Nagae M, Nagasawa I, Nakamura K, Nishimura T, Nunomiya S, Norisue Y, Hashimoto S, Hasegawa D, Hatakeyama J, Hara N, Higashibeppu N, Furushima N, Furusono H, Matsuishi Y, Matsuyama T, Minematsu Y, Miyashita R, Miyatake Y, Moriyasu M, Yamada T, Yamada H, Yamamoto R, Yoshida T, Yoshida Y, Yoshimura J, Yotsumoto R, Yonekura H, Wada T, Watanabe E, Aoki M, Asai H, Abe T, Igarashi Y, Iguchi N, Ishikawa M, Ishimaru G, Isokawa S, Itakura R, Imahase H, Imura H, Irinoda T, Uehara K, Ushio N, Umegaki T, Egawa Y, Enomoto Y, Ota K, Ohchi Y, Ohno T, Ohbe H, Oka K, Okada N, Okada Y, Okano H, Okamoto J, Okuda H, Ogura T, Onodera Y, Oyama Y, Kainuma M, Kako E, Kashiura M, Kato H, Kanaya A, Kaneko T, Kanehata K, Kano K, Kawano H, Kikutani K, Kikuchi H, Kido T, Kimura S, Koami H, Kobashi D, Saiki I, Sakai M, Sakamoto A, Sato T, Shiga Y, Shimoto M, Shimoyama S, Shoko T, Sugawara Y, Sugita A, Suzuki S, Suzuki Y, Suhara T, Sonota K, Takauji S, Takashima K, Takahashi S, Takahashi Y, Takeshita J, Tanaka Y, Tampo A, Tsunoyama T, Tetsuhara K, Tokunaga K, Tomioka Y, Tomita K, Tominaga N, Toyosaki M, Toyoda Y, Naito H, Nagata I, Nagato T, Nakamura Y, Nakamori Y, Nahara I, Naraba H, Narita C, Nishioka N, Nishimura T, Nishiyama K, Nomura T, Haga T, Hagiwara Y, Hashimoto K, Hatachi T, Hamasaki T, Hayashi T, Hayashi M, Hayamizu A, Haraguchi G, Hirano Y, Fujii R, Fujita M, Fujimura N, Funakoshi H, Horiguchi M, Maki J, Masunaga N, Matsumura Y, Mayumi T, Minami K, Miyazaki Y, Miyamoto K, Murata T, Yanai M, Yano T, Yamada K, Yamada N, Yamamoto T, Yoshihiro S, Tanaka H, Nishida O. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020). Acute Med Surg 2021; 8:e659. [PMID: 34484801 PMCID: PMC8390911 DOI: 10.1002/ams2.659] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
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21
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Engmann C, Fleming JA, Khan S, Innis BL, Smith JM, Hombach J, Sobanjo-Ter Meulen A. Closer and closer? Maternal immunization: current promise, future horizons. J Perinatol 2020; 40:844-857. [PMID: 32341454 PMCID: PMC7223555 DOI: 10.1038/s41372-020-0668-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 12/16/2022]
Abstract
This state-of-the art manuscript highlights our current understanding of maternal immunization-the practice of vaccinating pregnant women to confer protection on them as well as on their young infants, and thereby reduce vaccine-preventable morbidity and mortality. Advances in our understanding of the immunologic processes that undergird a normal pregnancy, studies from vaccines currently available and recommended for pregnant women, and vaccines for administration in special situations are beginning to build the case for safe scale-up of maternal immunization. In addition to well-known diseases, new diseases are emerging which pose threats. Several new vaccines are currently under development and increasingly include pregnant women. In this manuscript, targeted at clinicians, vaccinologists, scientists, public health practitioners, and policymakers, we also outline key considerations around maternal immunization introduction and delivery, discuss noninfectious horizons for maternal immunization, and provide a framework for the clinician faced with immunizing a pregnant woman.
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Affiliation(s)
- Cyril Engmann
- Maternal, Newborn, Child Health and Nutrition, PATH, Seattle, WA, USA.
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.
- Department of Global Health, University of Washington School of Public Health, Seattle, WA, USA.
| | | | - Sadaf Khan
- Maternal, Newborn, Child Health and Nutrition, PATH, Seattle, WA, USA
| | - Bruce L Innis
- Center for Vaccine Innovation and Access, PATH, Seattle, WA, USA
| | - Jeffrey M Smith
- Maternal, Newborn and Child Health, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Joachim Hombach
- Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
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22
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Brower LH, Wilson PM, Murtagh-Kurowski E, Courter JD, Shah SS, Schondelmeyer AC. Evaluation for Neonatal HSV in Infants Undergoing Workup for Serious Bacterial Infection: A 5-Year Retrospective Review. Hosp Pediatr 2020; 10:463-470. [PMID: 32385054 PMCID: PMC7374942 DOI: 10.1542/hpeds.2020-0033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
| | | | - Eileen Murtagh-Kurowski
- Emergency Medicine, and
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Samir S Shah
- Divisions of Hospital Medicine
- Infectious Diseases, Department of Pediatrics and
| | - Amanda C Schondelmeyer
- Divisions of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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23
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Ramgopal S, Noorbakhsh KA, Pruitt CM, Aronson PL, Alpern ER, Hickey RW. Outcomes of Young Infants with Hypothermia Evaluated in the Emergency Department. J Pediatr 2020; 221:132-137.e2. [PMID: 32446472 DOI: 10.1016/j.jpeds.2020.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/11/2020] [Accepted: 03/02/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To assess the prevalence of serious infections and mortality among infants ≤90 days of age presenting to the emergency department with hypothermia. STUDY DESIGN We performed a cross-sectional cohort study of infants ≤90 days presenting to any of 40 EDs in the Pediatric Health Information Systems between January 1, 2009, and December 31, 2018. Infants with an International Classification of Diseases, ninth or tenth edition, admission/discharge diagnosis code of hypothermia were included. We determined the prevalence of serious bacterial infection (urinary tract infection, bacteremia, and/or bacterial meningitis), pneumonia, herpes simplex virus (HSV) infection, and emergency department/hospital mortality. RESULTS We included 3565 infants (1633 male [50.9%] and 3225 ≤30 days of age [90.5%]). Most (65.0%) presented in the first week of life. There were 389 infants (10.8%) with a complex chronic condition. The prevalence of serious bacterial infection was 8.0% (n = 284), including 2.4% (n = 87) with urinary tract infection, 5.6% (n = 199) with bacteremia, and 0.3% (n = 11) with bacterial meningitis. There were 7 patients (0.2%) with neonatal HSV and 9 (0.3%) with pneumonia; 0.2% (n = 6) died. The presence of a complex chronic condition was associated with the presence of serious bacterial infection (P < .001) and was present in 3 of 6 patients who died. In a sensitivity analysis including patients with any diagnosis code of hypothermia (n = 8122), 14.9% had serious bacterial infection, 0.6% had HSV, and 3.3% had pneumonia; 2.0% died. CONCLUSIONS Of infants with hypothermia ≤90 days of age, 8.3% had serious bacterial infections or HSV. Compared with literature from febrile infants, hypothermia is associated with a high mortality rate. Complex chronic conditions were particularly associated with poor outcomes. Additional research is required to risk stratify young infants with hypothermia.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Kathleen A Noorbakhsh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Paul L Aronson
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT; Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
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24
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Patel CD, Backes IM, Taylor SA, Jiang Y, Marchant A, Pesola JM, Coen DM, Knipe DM, Ackerman ME, Leib DA. Maternal immunization confers protection against neonatal herpes simplex mortality and behavioral morbidity. Sci Transl Med 2020; 11:11/487/eaau6039. [PMID: 30971454 DOI: 10.1126/scitranslmed.aau6039] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/30/2018] [Accepted: 01/15/2019] [Indexed: 12/11/2022]
Abstract
Neonatal herpes simplex virus (nHSV) infections cause devastating morbidity and mortality in infants. Most nHSV cases are associated with primary maternal infection, consistent with the hypothesis that maternal immunity is protective. In humans, we found HSV-specific neutralizing antibodies in newborns of immune mothers, indicating that placentally transferred HSV-specific antibody is protective. Using a murine model, we showed that passive administration of HSV-specific antibody to dams prevented disseminated infection and mortality in pups. Maternal immunization with an HSV-2 replication-defective vaccine candidate, dl5-29, led to transfer of HSV-specific antibodies into neonatal circulation that protected against nHSV neurological disease and death. Furthermore, we observed considerable anxiety-like behavior in adult mice that had been infected with low doses of HSV as neonates, despite a notable lack of signs of infection. This phenotype suggests that nHSV infection can have an unsuspected and permanent impact on behavior. These behavioral sequelae of nHSV were prevented by maternal immunization with dl5-29, demonstrating an unexpected benefit of immunization. These findings also support the general concept that maternal immunization can prevent neurotropic neonatal infections and associated morbidity and mortality.
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Affiliation(s)
- Chaya D Patel
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA.,Guarini School of Graduate and Advanced Studies at Dartmouth, Hanover, NH 03755, USA
| | - Iara M Backes
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA.,Thayer School of Engineering, Dartmouth College, Hanover, NH 03755, USA
| | - Sean A Taylor
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Yike Jiang
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA
| | - Arnaud Marchant
- Institute for Medical Immunology, Université libre de Bruxelles, Charleroi B-6041, Belgium
| | - Jean M Pesola
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA 02115, USA
| | - Donald M Coen
- Department of Biological Chemistry and Molecular Pharmacology, Harvard Medical School, Boston, MA 02115, USA
| | - David M Knipe
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, MA 02115, USA
| | | | - David A Leib
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA.
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25
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Downes KJ, Boge CLK, Baro E, Wharton GT, Liston KM, Haltzman BL, Emerson HM, Doe E, Fulchiero R, Tran V, Yen L, Lieu P, Van Driest SL, Grisso AG, Aka IT, Hale J, Gillon J, Pingel JS, Coffin SE, McMahon AW. Acute Kidney Injury During Treatment with Intravenous Acyclovir for Suspected or Confirmed Neonatal Herpes Simplex Virus Infection. J Pediatr 2020; 219:126-132.e2. [PMID: 32037154 PMCID: PMC7096264 DOI: 10.1016/j.jpeds.2019.12.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/22/2019] [Accepted: 12/26/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To describe the epidemiology of and risk factors associated with acute kidney injury (AKI) during acyclovir treatment in neonates and infants. STUDY DESIGN We conducted a multicenter (n = 4), retrospective cohort study of all hospitalized infants age <60 days treated with intravenous acyclovir (≥1 dose) for suspected or confirmed neonatal herpes simplex virus disease from January 2011 to December 2015. Infants with serum creatinine measured both before acyclovir (baseline) and during treatment were included. We classified AKI based on changes in creatinine according to published neonatal AKI criteria and performed Cox regression analysis to evaluate risk factors for AKI during acyclovir treatment. RESULTS We included 1017 infants. The majority received short courses of acyclovir (median, 5 doses). Fifty-seven infants (5.6%) developed AKI during acyclovir treatment, with an incidence rate of AKI at 11.6 per 1000 acyclovir days. Cox regression analysis identified having confirmed herpes simplex virus disease (OR, 4.35; P = .002), receipt of ≥2 concomitant nephrotoxic medications (OR, 3.07; P = .004), receipt of mechanical ventilation (OR, 5.97; P = .001), and admission to an intensive care unit (OR, 6.02; P = .006) as risk factors for AKI during acyclovir treatment. CONCLUSIONS Among our cohort of infants exposed to acyclovir, the rate of AKI was low. Sicker infants and those exposed to additional nephrotoxic medications seem to be at greater risk for acyclovir-induced toxicity and warrant closer monitoring.
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Affiliation(s)
- Kevin J. Downes
- Division of Infectious Disease, Department of Pediatrics, Children’s Hospital of Philadelphia, Research Institute,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Craig L. K. Boge
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute
| | - Elande Baro
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Gerold T. Wharton
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, MD
| | - Kellie M. Liston
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute
| | - Brittany L. Haltzman
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute
| | - Hannah M. Emerson
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute
| | - Edwin Doe
- Neonatal Intensive Care, Inova Children’s Hospital, Falls Church, VA
| | - Rosanna Fulchiero
- Neonatal Intensive Care, Inova Children’s Hospital, Falls Church, VA
| | - Van Tran
- Neonatal Intensive Care, Inova Children’s Hospital, Falls Church, VA
| | - Lilly Yen
- Department of Pharmacy, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Phuong Lieu
- Department of Pharmacy, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Sara L. Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Alison G. Grisso
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Ida T. Aka
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Jennifer Hale
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica Gillon
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Julie S. Pingel
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Susan E. Coffin
- Division of Infectious Disease, Department of Pediatrics, Children’s Hospital of Philadelphia, Research Institute,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Ann W. McMahon
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, MD
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26
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Abstract
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.
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27
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Economic Evaluation: Onsite HSV PCR Capabilities for Pediatric Care. Pediatr Qual Saf 2020; 5:e266. [PMID: 32426632 PMCID: PMC7190250 DOI: 10.1097/pq9.0000000000000266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 01/30/2020] [Indexed: 02/05/2023] Open
Abstract
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.
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28
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Brower LH, Wilson PM, Murtagh Kurowski E, Haslam D, Courter J, Goyal N, Durling M, Shah SS, Schondelmeyer A. Using Quality Improvement to Implement a Standardized Approach to Neonatal Herpes Simplex Virus. Pediatrics 2019; 144:peds.2018-0262. [PMID: 31345997 DOI: 10.1542/peds.2018-0262] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Neonatal herpes simplex virus (HSV) infections are associated with high mortality and long-term morbidity. However, incidence is low and acyclovir, the treatment of choice, carries risk of toxicity. We aimed to increase the percentage of patients 0 to 60 days of age who are tested and treated for HSV in accordance with local guideline recommendations from 40% to 80%. METHODS This quality improvement project took place at 1 freestanding children's hospital. Multiple plan-do-study-act cycles were focused on interventions aimed at key drivers including provider buy-in, guideline availability, and accurate identification of high-risk patients. A run chart was used to track the effect of interventions on the percentage managed per guideline recommendations over time by using established rules for determining special cause. Pre- and postimplementation acyclovir use was compared by using a χ2 test. In HSV-positive cases, delayed acyclovir initiation, defined as >1 day from presentation, was tracked as a balancing measure. RESULTS The median percentage of patients managed according to guideline recommendations increased from 40% to 80% within 8 months. Acyclovir use decreased from 26% to 7.9% (P < .001) in non-high-risk patients but did not change significantly in high-risk patients (73%-83%; P = .15). There were no cases of delayed acyclovir initiation in HSV-positive cases. CONCLUSIONS Point-of-care availability of an evidence-based guideline and interventions targeted at provider engagement improved adherence to a new guideline for neonatal HSV management and decreased acyclovir use in non-high-risk infants. Further study is necessary to confirm the safety of these recommendations in other settings.
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Affiliation(s)
- Laura H Brower
- Divisions of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Paria M Wilson
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Pediatric Emergency Medicine.,Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eileen Murtagh Kurowski
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Pediatric Emergency Medicine.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David Haslam
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Infectious Diseases, and
| | - Joshua Courter
- Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Neera Goyal
- Divisions of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of External Primary Care, Nemours/Alfred I duPont Hospital for Children, Wilmington, Delaware.,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | | | - Samir S Shah
- Divisions of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Infectious Diseases, and
| | - Amanda Schondelmeyer
- Divisions of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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29
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Aronson PL, Cruz AT, Freedman SB, Balamuth F, Grether-Jones KL, Lyons TW, Fleming AH, Louie J, Mistry RD, Garro AC, Shah SS, Nigrovic LE. Association of Herpes Simplex Virus Testing with Hospital Length of Stay for Infants ≤60 Days of Age Undergoing Evaluation for Meningitis. J Hosp Med 2019; 14:492-495. [PMID: 31112493 PMCID: PMC6686736 DOI: 10.12788/jhm.3202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although neonatal herpes simplex virus (HSV) causes significant morbidity, utilization of the cerebrospinal fluid (CSF) HSV polymerase chain reaction (PCR) test remains variable. Our objective was to examine the association of CSF HSV PCR testing with length of stay (LOS) in a 20-center retrospective cohort of hospitalized infants aged ≤60 days undergoing evaluation for meningitis after adjustment for patient-level factors and clustering by center. Of 20,496 eligible infants, 7,399 (36.1%) had a CSF HSV PCR test performed, and 46 (0.6% of those tested) had a positive test. Infants who had a CSF HSV PCR test performed had a 23% longer hospital LOS (incident rate ratio 1.23; 95% CI: 1.14-1.33). Targeted CSF HSV PCR testing may mitigate the impact on LOS for low-risk infants.
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Affiliation(s)
- Paul L Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Corresponding Author: Paul L Aronson, MD, MHS; E-mail: ; Telephone: 203-785-3849
| | - Andrea T Cruz
- Sections of Pediatric Emergency Medicine and of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Fran Balamuth
- Division of Emergency Medicine
- Center for Pediatric Clinical Effectiveness, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kendra L Grether-Jones
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Todd W Lyons
- Division of Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alesia H Fleming
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey Louie
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Rakesh D Mistry
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Aris C Garro
- Section of Emergency Medicine, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Samir S Shah
- Divisions of Infectious Diseases
- Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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30
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Abstract
Herpes simplex virus (HSV) is a common and often benign infection in humans; although it less commonly affects newborns, infection in this age group can be devastating. Newborns often present with nonspecific clinical findings, making timely and accurate diagnosis of infection critical. A wide variety of tests are available for detecting herpes simplex virus infection, but only a subset are useful and validated in the newborn population. The current review summarizes available diagnostic testing for neonatal disease, including discussing limitations, unmet needs, and emerging data on molecular testing methods.
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Affiliation(s)
- William J Muller
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Xiaotian Zheng
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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31
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Mahant S, Hall M, Schondelmeyer AC, Berry JG, Kimberlin DW, Shah SS. Neonatal Herpes Simplex Virus Infection Among Medicaid-Enrolled Children: 2009-2015. Pediatrics 2019; 143:e20183233. [PMID: 30923058 PMCID: PMC6565359 DOI: 10.1542/peds.2018-3233] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To examine the incidence, mortality, and health care use related to neonatal herpes simplex virus (HSV) infection. METHODS A retrospective longitudinal cohort study using a multistate Medicaid claims database. We identified neonates hospitalized with HSV infection from 2009 to 2015 by using discharge diagnosis codes and managed them for 6 months after discharge. Incidence rates were corrected for the imperfect sensitivity and specificity of thediagnosis codes for identifying HSV infection. RESULTS Of 2 107 124 births from 2009 to 2015, 900 neonates were identified with HSV infection, with a corrected incidence rate of 4.5 (95% confidence interval [CI]: 4.2-4.8) per 10 000 births. The yearly disease incidence increased by 56%, from 3.4 (95% CI: 2.8-4.2) per 10 000 births (or 1 in 2941 births) in 2009 to 5.3 (95% CI: 4.6-6.1) per 10 000 births (or 1 in 1886 births) in 2015 (P < .001). Of the 900 neonates with HSV infection, 54 (6.0% [95% CI: 4.4%-7.6%]) died during the index hospitalization; there was no increase in the yearly mortality rate. Of the 692 (81.2%) infants with follow-up data, 316 (45.7%) had an emergency department visit, and 112 (16.2%) had a hospital readmission. Total payments at 6 months amounted to $60 620 431, a median of $87 602 per case of neonatal HSV infection. CONCLUSIONS We observed an increase in neonatal HSV infection incidence over a recent 7-year period in a Medicaid population. Associated health care use and payments were substantial. Public health interventions targeting disease prevention and early diagnosis are needed.
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Affiliation(s)
- Sanjay Mahant
- Division of Pediatric Medicine, Department of Pediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada;
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - David W Kimberlin
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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32
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Gaensbauer J, Grubenhoff JA. Neonatal Herpes Simplex Virus Infections: New Data, Old Conundrum. Pediatrics 2019; 143:peds.2019-0159. [PMID: 30923057 DOI: 10.1542/peds.2019-0159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- James Gaensbauer
- Denver Health Medical Center, Denver, Colorado; .,Children's Hospital Colorado, Aurora, Colorado; and.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Joseph A Grubenhoff
- Children's Hospital Colorado, Aurora, Colorado; and.,Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
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33
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Bårnes GK, Gudina EK, Berhane M, Abdissa A, Tesfaw G, Abebe G, Feruglio SL, Caugant DA, Jørgensen HJ. New molecular tools for meningitis diagnostics in Ethiopia - a necessary step towards improving antimicrobial prescription. BMC Infect Dis 2018; 18:684. [PMID: 30572843 PMCID: PMC6302510 DOI: 10.1186/s12879-018-3589-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 12/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Meningitis remains a top cause of premature death and loss of disability-adjusted life years in low-income countries. In resource-limited settings, proper laboratory diagnostics are often scarce and knowledge about national and local epidemiology is limited. Misdiagnosis, incorrect treatment and overuse of antibiotics are potential consequences, especially for viral meningitis. METHODS A prospective study was conducted over three months in a teaching hospital in Ethiopia with limited laboratory resources. Cerebrospinal fluid (CSF) samples from patients with suspected meningitis were analysed using a multiplex PCR-based system (FilmArray, BioFire), in addition to basic routine testing with microscopy and culture. Clinical data, as well as information on treatment and outcome were collected. RESULTS Two hundred and eighteen patients were included; 117 (54%) neonates (0-29 days), 63 (29%) paediatrics (1 month-15 years) and 38 (17%) adults (≥16 years). Of 218 CSF samples, 21 (10%) were PCR positive; 4% in neonates, 14% in paediatrics and 18% in adults. Virus was detected in 57% of the PCR positive samples, bacteria in 33% and fungi in 10%. All CSF samples that were PCR positive for a bacterial agent had a white cell count ≥75 cells/mm3 and/or turbid appearance. The majority (90%) of patients received more than one antibiotic for treatment of the meningitis episode. There was no difference in the mean number of different antibiotics received or in the cumulative number of days with antibiotic treatment between patients with a microorganism detected in CSF and those without. CONCLUSIONS A rapid molecular diagnostic system was successfully implemented in an Ethiopian setting without previous experience of molecular diagnostics. Viral meningitis was diagnosed for the first time in routine clinical practice in Ethiopia, and viral agents were the most commonly detected microorganisms in CSF. This study illustrates the potential of rapid diagnostic tests for reducing antibiotic usage in suspected meningitis cases. However, the cost of consumables for the molecular diagnostic system used in this study limits its use in low-income countries.
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Affiliation(s)
- Guro K Bårnes
- Division for Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | | | | | - Getnet Tesfaw
- Institute of Health, Jimma University, Jimma, Ethiopia
| | - Gemeda Abebe
- Institute of Health, Jimma University, Jimma, Ethiopia.,Mycobacteriology Research Center, Jimma University, Jimma, Ethiopia
| | - Siri Laura Feruglio
- Division for Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Dominique A Caugant
- Division for Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway. .,Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Hannah Joan Jørgensen
- Division for Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway.,Norwegian Veterinary Institute, Oslo, Norway
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Lyons TW, Cruz AT, Freedman SB, Nigrovic LE. Accuracy of Herpes Simplex Virus Polymerase Chain Reaction Testing of the Blood for Central Nervous System Herpes Simplex Virus Infections in Infants. J Pediatr 2018; 200:274-276.e1. [PMID: 29784511 DOI: 10.1016/j.jpeds.2018.04.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 11/26/2022]
Abstract
There were 1038 infants with herpes simplex virus polymerase chain reaction testing performed of blood and cerebrospinal fluid specimens. There were 21 (2.0%) with a positive cerebrospinal fluid PCR, of whom 16 also had a positive blood PCR (sensitivity 76%; 95% CI, 53%-92%). Blood PCR cannot exclude herpes simplex virus central nervous system infection.
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Affiliation(s)
- Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | - Andrea T Cruz
- Sections of Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine, Houston, TX
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Baquero Artigao F, Prieto Tato LM, Ramos Amador JT, Alarcón Allen A, de la Calle M, Frick MA, Goncé Mellgren A, González Tomé MI, Moreno Pérez D, Noguera Julian A. The Spanish Society of Paediatric Infectious Diseases guidelines on the prevention, diagnosis and treatment of neonatal herpes simplex infections. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2018.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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[The Spanish Society of Paediatric Infectious Diseases guidelines on the prevention, diagnosis and treatment of neonatal herpes simplex infections]. An Pediatr (Barc) 2018; 89:64.e1-64.e10. [PMID: 29453157 DOI: 10.1016/j.anpedi.2018.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 01/03/2018] [Indexed: 11/17/2022] Open
Abstract
Neonatal herpes simplex virus infections are rare, but are associated with significant morbidity and mortality. Most newborns acquire herpes simplex virus infection in the peripartum period. For peripartum transmission to occur, women must be shedding the virus in their genital tracts symptomatically or asymptomatically around the time of delivery. There are evidence-based interventions in pregnancy to prevent the transmission to the newborn. Caesarean section should be performed in the presence of herpetic lesions, and antiviral prophylaxis in the last weeks of pregnancy is recommended to suppress genital tract herpes simplex virus at the time of delivery. The diagnosis and early treatment of neonatal herpes simplex virus infections require a high index of suspicion, especially in the absence of skin lesions. It is recommended to rule out herpes simplex virus infections in those newborns with mucocutaneous lesions, central nervous system involvement, or septic appearance. The prognosis of newborns with skin, eye, and/or mouth disease in the high-dose acyclovir era is very good. Antiviral treatment not only improves mortality rates in disseminated and central nervous system disease, but also improves the rates of long-term neurodevelopmental impairment in the cases of disseminated disease. Interestingly, a 6-month suppressive course of oral acyclovir following the acute infection has improved the neurodevelopmental prognosis in patients with CNS involvement.
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During the Emergency Department Evaluation of a Well-Appearing Neonate with Fever, Should Empiric Acyclovir Be Initiated? J Emerg Med 2018; 54:261-265. [DOI: 10.1016/j.jemermed.2017.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 10/17/2017] [Indexed: 11/18/2022]
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Cruz AT, Freedman SB, Kulik DM, Okada PJ, Fleming AH, Mistry RD, Thomson JE, Schnadower D, Arms JL, Mahajan P, Garro AC, Pruitt CM, Balamuth F, Uspal NG, Aronson PL, Lyons TW, Thompson AD, Curtis SJ, Ishimine PT, Schmidt SM, Bradin SA, Grether-Jones KL, Miller AS, Louie J, Shah SS, Nigrovic LE. Herpes Simplex Virus Infection in Infants Undergoing Meningitis Evaluation. Pediatrics 2018; 141:peds.2017-1688. [PMID: 29298827 PMCID: PMC5810597 DOI: 10.1542/peds.2017-1688] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2017] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Stephen B. Freedman
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dina M. Kulik
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Pamela J. Okada
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alesia H. Fleming
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Joanna E. Thomson
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - David Schnadower
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Joseph L. Arms
- Department of Pediatrics, Children’s Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Prashant Mahajan
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
| | - Aris C. Garro
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Christopher M. Pruitt
- Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Fran Balamuth
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil G. Uspal
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Todd W. Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Amy D. Thompson
- Departments of Pediatrics and Emergency Medicine, Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Sarah J. Curtis
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Paul T. Ishimine
- Department of Emergency Medicine, University of California San Diego School of Medicine, San Diego, California
| | - Suzanne M. Schmidt
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stuart A. Bradin
- Department of Pediatrics, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | - Kendra L. Grether-Jones
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Aaron S. Miller
- Department of Pediatrics, Saint Louis University School of Medicine, St Louis, Missouri; and
| | - Jeffrey Louie
- Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
| | - Samir S. Shah
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Lee CK, Chiu L, Yan G, Chew KL, Yan B, Jureen R, Loh TP. False negative results caused by erroneous automated result interpretation algorithm on the FilmArray 2.0 instrument. ACTA ACUST UNITED AC 2017; 56:e43-e45. [DOI: 10.1515/cclm-2017-0518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 07/01/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Chun Kiat Lee
- Department of Laboratory Medicine , Molecular Diagnosis Centre, National University Health System , 5, Lower Kent Ridge Road , 119074, Singapore , Singapore , Phone: +65-6772-4175, Fax: +65-6772-4407, E-mail:
| | - Lily Chiu
- Department of Laboratory Medicine , National University Health System , Singapore , Singapore
| | - Gabriel Yan
- Department of Medicine , National University Health System , Singapore , Singapore
| | - Ka Lip Chew
- Department of Laboratory Medicine , National University Health System , Singapore , Singapore
| | - Benedict Yan
- Department of Laboratory Medicine , National University Health System , Singapore , Singapore
| | - Roland Jureen
- Department of Laboratory Medicine , National University Health System , Singapore , Singapore
| | - Tze Ping Loh
- Department of Laboratory Medicine , National University Health System , Singapore , Singapore
- Biomedical Institute for Global Health Research and Technology, National University of Singapore , Singapore , Singapore
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40
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Impact of an Institutional Guideline on the Care of Neonates at Risk for Herpes Simplex Virus in the Emergency Department. Pediatr Emerg Care 2017; 33:396-401. [PMID: 26308608 DOI: 10.1097/pec.0000000000000498] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Herpes simplex virus (HSV) is rare in neonates but carries significant morbidity and mortality in that group. Emergency department (ED) clinicians have little guidance to decide when to test for HSV and give acyclovir. We created an institutional guideline to provide guidance in patients younger than 6 weeks. Our objective was to evaluate whether guideline implementation affected the ED's decision to test for HSV, and ED use of HSV polymerase chain reactions (PCRs) and acyclovir. METHODS We reviewed charts for patients 1 year before implementation and 1 year after implementation of our guideline. Inclusion criteria were younger than 60 days, admitted through the ED, symptom onset younger than 6 weeks, and any one of the following criteria: (1) ED blood culture obtained, (2) ED or inpatient HSV PCR obtained, and (3) ED or inpatient acyclovir treatment. Premature patients and transfer patients were excluded. We compared whether the decision to initiate HSV testing, ED use of HSV PCRs, serum alanine aminotransferase, and acyclovir use changed post-guideline implementation. RESULTS We reviewed 173 charts pre-implementation and 129 post-implementation. We found a significant decrease in ED testing for HSV among patients who did not meet guideline criteria (P < 0.01). We saw an improvement in the use of alanine aminotransferase among patients who met criteria for testing (P = 0.02), but no change in the use of HSV PCRs or acyclovir use among tested patients. CONCLUSIONS Guideline implementation reduced HSV evaluations in low-risk patients, but did not improve test utilization or acyclovir administration among those tested. Additional work is needed to improve guideline utilization.
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41
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Harris JB, Holmes AP. Neonatal Herpes Simplex Viral Infections and Acyclovir: An Update. J Pediatr Pharmacol Ther 2017; 22:88-93. [PMID: 28469532 DOI: 10.5863/1551-6776-22.2.88] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Neonatal herpes simplex virus (HSV) infections have high morbidity and mortality rates. Optimization of treatment and prevention strategies are imperative to improve the care and outcomes of neonates infected with HSV. Management of HSV includes reducing neonatal transmission, treating acute infections, and limiting adverse neurodevelopmental outcomes and future cutaneous outbreaks after acute infections. Transmission risk may be affected by route of delivery and maternal suppressive therapy. Neonatal HSV infections are divided into 3 categories: localized skin, eyes, or mouth; localized central nervous system; or disseminated infections. Parenteral acyclovir, the pharmacologic agent of choice, is used when treating each type of infection. However, dosage strategies and durations of therapy may vary based on disease state severity, presentation, and patient characteristics. Oral acyclovir may be used as suppressive therapy after acute treatment completion in specific neonatal populations, reducing long-term adverse neurodevelopmental outcomes and future skin eruptions. The mortality rate remains high even with treatment.
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Bittencourt MDJS, Freitas LKM, Drago MG, Carvalho AH, Nascimento BAMD. Cutaneous neonatal herpes simplex virus infection type 2: a case report. An Bras Dermatol 2017; 91:216-8. [PMID: 27192523 PMCID: PMC4861571 DOI: 10.1590/abd1806-4841.20163870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 10/13/2014] [Indexed: 11/22/2022] Open
Abstract
Neonatal herpes is a serious condition. Newborns can be contaminated in utero via
transplacental hematogenic transmission, upon delivery (the most frequent
route), or during the postnatal period (indirect transmission). Optimal
management requires prompt and accurate recognition, particularly in newborns,
in order to prevent complications. Acyclovir is the treatment of choice, but its
implementation is often delayed while awaiting test results, such as PCR and
serology. Cytology for diagnostic purposes is rarely used in dermatology,
despite the quick and reliable results. We report a case of neonatal herpes
caused by type 2 herpes simplex virus diagnosed by cytology.
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2017. Other selected articles can be found online at http://ccforum.com/series/annualupdate2017 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .
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Affiliation(s)
- Adrienne G. DePorre
- Children’s Mercy Hospital, Department of Pediatrics, Division of Hospital Medicine, 2401 Gillham Rd, MO 64108 Kansas City, USA
- Department of Pediatrics, University of Missouri—Kansas City, MO 64108 Kansas City, USA
| | - Paul L. Aronson
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Yale School of Medicine, 100 York St, Suite 1F, New Haven, CT 06511 USA
| | - Russell J. McCulloh
- Children’s Mercy Hospital, Department of Pediatrics, Division of Hospital Medicine, 2401 Gillham Rd, MO 64108 Kansas City, USA
- Department of Pediatrics, University of Missouri—Kansas City, MO 64108 Kansas City, USA
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Multicenter Evaluation of BioFire FilmArray Meningitis/Encephalitis Panel for Detection of Bacteria, Viruses, and Yeast in Cerebrospinal Fluid Specimens. J Clin Microbiol 2016; 54:2251-61. [PMID: 27335149 DOI: 10.1128/jcm.00730-16] [Citation(s) in RCA: 363] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 06/14/2016] [Indexed: 11/20/2022] Open
Abstract
Rapid diagnosis and treatment of infectious meningitis and encephalitis are critical to minimize morbidity and mortality. Comprehensive testing of cerebrospinal fluid (CSF) often includes Gram stain, culture, antigen detection, and molecular methods, paired with chemical and cellular analyses. These methods may lack sensitivity or specificity, can take several days, and require significant volume for complete analysis. The FilmArray Meningitis/Encephalitis (ME) Panel is a multiplexed in vitro diagnostic test for the simultaneous, rapid (∼1-h) detection of 14 pathogens directly from CSF specimens: Escherichia coli K1, Haemophilus influenzae, Listeria monocytogenes, Neisseria meningitidis, Streptococcus pneumoniae, Streptococcus agalactiae, cytomegalovirus, enterovirus, herpes simplex virus 1 and 2, human herpesvirus 6, human parechovirus, varicella-zoster virus, and Cryptococcus neoformans/Cryptococcus gattii We describe a multicenter evaluation of 1,560 prospectively collected CSF specimens with performance compared to culture (bacterial analytes) and PCR (all other analytes). The FilmArray ME Panel demonstrated a sensitivity or positive percentage of agreement of 100% for 9 of 14 analytes. Enterovirus and human herpesvirus type 6 had agreements of 95.7% and 85.7%, and L. monocytogenes and N. meningitidis were not observed in the study. For S. agalactiae, there was a single false-positive and false-negative result each, for a sensitivity and specificity of 0 and 99.9%, respectively. The specificity or negative percentage of agreement was 99.2% or greater for all other analytes. The FilmArray ME Panel is a sensitive and specific test to aid in diagnosis of ME. With use of this comprehensive and rapid test, improved patient outcomes and antimicrobial stewardship are anticipated.
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Huang FK, Chen HL, Yang PH, Lin HC. Bird's Eye View of a Neonatologist: Clinical Approach to Emergency Neonatal Infection. Pediatr Neonatol 2016; 57:167-73. [PMID: 26701838 DOI: 10.1016/j.pedneo.2015.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 04/21/2015] [Accepted: 06/01/2015] [Indexed: 10/22/2022] Open
Abstract
Though the incidence of neonatal infection in term and near-term infants is relatively low, incidence of infection in preterm very low birth weight infants is as high as 20-30% and may result in neurodevelopmental impairment or mortality. Pediatricians should be familiar with recognition and emergency management of life-threatening neonatal infections, such as congenital pneumonia, early onset sepsis, late onset sepsis, bacterial and fungal meningitis, disseminated neonatal herpes simplex virus (HSV), and HSV meningoencephalitis. For the pediatrician, it is logical to approach the management of these infections by time of onset, i.e., early versus late onset of infection. Perinatal risk factors and simple laboratory tests, such as total white blood-cell count, immature/total ratio, and C-reactive protein are helpful in guiding the decision of antibiotics therapy. Successful management of these critical infections depends upon early diagnosis and timely administration of adequate antibiotics. Empiric antibiotic therapy must cover the most likely pathogens according to the risk factors of each individual neonate, and therapy duration is dependent upon culture results, clinical course, and the microorganism. Future research may focus on developing a practical neonatal sepsis score system based on risk factors and common biomarkers, which are readily available at bedside to make early accurate decisions and achieve better outcomes.
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Affiliation(s)
- Fu-Kuei Huang
- Department of Pediatrics, China Medical University Children Hospital, Taichung, Taiwan
| | - Hsiu-Lin Chen
- Department of Pediatrics of Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Peng-Hong Yang
- Department of Neonatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hung-Chih Lin
- Department of Pediatrics, China Medical University Children Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan.
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Abstract
The incidence and likely causes of fever of unknown origin (FUO) have changed over the last few decades, largely because enhanced capabilities of laboratory testing and imaging have helped confirm earlier diagnoses. History and examination are still of paramount importance for cryptogenic infections. Adolescents who have persisting nonspecific complaints of fatigue sometimes are referred to Pediatric Infectious Diseases consultants for FUO because the problem began with an acute febrile illness or measured temperatures are misidentified as "fevers". A thorough history that reveals myriad symptoms when juxtaposed against normal findings on examination and simple laboratory testing can suggest a diagnosis of "fatigue of deconditioning". "Treatment" is forced return to school, and reconditioning. The management of patients with acute onset of fever without an obvious source or focus of infection is dependent on age. Infants under one month of age are at risk for serious and rapidly progressive bacterial and viral infections, and yet initially can have fever without other observable abnormalities. Urgent investigation and pre-emptive therapies usually are prudent. By two months of age, clinical judgment best guides management. Between one and two months of age, a decision to investigate or not depends on considerations of the height and duration of fever, the patient's observable behavior/interaction, knowledge of concurrent family illnesses, and likelihood of close observation and follow up. Children 6 months-36 months of age with acute onset of fever who appear well and have no observable focus of infection can be evaluated clinically, without laboratory investigation or antibiotic therapy, unless risk factors elevate the likelihood of urinary tract infection.
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Curfman AL, Glissmeyer EW, Ahmad FA, Korgenski EK, Blaschke AJ, Byington CL, Miller AS. Initial Presentation of Neonatal Herpes Simplex Virus Infection. J Pediatr 2016; 172:121-126.e1. [PMID: 26960921 DOI: 10.1016/j.jpeds.2016.02.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 01/25/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To inform the decision to test and empirically treat for herpes simplex virus (HSV) by describing the initial clinical presentation and laboratory findings of infants with a confirmed diagnosis of neonatal HSV. STUDY DESIGN This is a retrospective case series performed at 2 pediatric tertiary care centers. Infants who developed symptoms prior to 42 days of age with laboratory confirmed HSV from 2002 through 2012 were included. We excluded infants <34 weeks gestation, those who developed illness before discharge from their birth hospital, and those who developed symptoms after 42 days of age. RESULTS We identified 49 infants with HSV meeting these criteria. Most infants (43/49, 88%) came to medical attention at ≤28 days. Of 49 infants, 22 (45%) had disseminated, 16 (33%) central nervous system, and 10 (20%) skin, eye, mouth HSV disease. Eight infants (16%) had nonspecific presentations without the classic signs of seizure, vesicular rash, or critical illness (intensive care admission). All infants with nonspecific presentation were ≤14 days, had cerebrospinal fluid pleocytosis, or both. CONCLUSIONS The majority of infants with HSV (84%) presented with seizure, vesicular rash, or critical illness. A subset of patients (16%) lacked classic signs at hospitalization; most manifested signs suggestive of HSV within 24 hours. Further studies are needed to validate the risk factors identified in this study including age <14 days and cerebrospinal fluid pleocytosis at presentation.
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Affiliation(s)
- Alison L Curfman
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO.
| | - Eric W Glissmeyer
- Department of Pediatrics, University of Utah, Salt Lake City, UT; Institute for Health Care Delivery Research, Intermountain Healthcare, Salt Lake City, UT
| | - Fahd A Ahmad
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - E Kent Korgenski
- Department of Pediatrics, University of Utah, Salt Lake City, UT; Pediatric Clinical Program, Intermountain Healthcare, Salt Lake City, UT
| | - Anne J Blaschke
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Aaron S Miller
- Department of Pediatrics, St. Louis University School of Medicine, St. Louis, MO
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Brower L, Schondelmeyer A, Wilson P, Shah SS. Testing and Empiric Treatment for Neonatal Herpes Simplex Virus: Challenges and Opportunities for Improving the Value of Care. Hosp Pediatr 2016; 6:108-11. [PMID: 26740558 DOI: 10.1542/hpeds.2015-0166] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | - Paria Wilson
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Enioutina EY, Constance JE, Stockmann C, Linakis MW, Yu T, Rower JE, Balch AH, Sherwin CM. Pharmacokinetic considerations in the use of antivirals in neonates. Expert Opin Drug Metab Toxicol 2015; 11:1861-78. [PMID: 26535960 DOI: 10.1517/17425255.2015.1108963] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Neonatal patients, because of the inability of their immune system to properly respond to microbial challenge, are highly susceptible to viral infections. Immunoglobulins, monoclonal antibody and antiviral drugs are used for prophylaxis and treatment of viral diseases in neonates. Neonates and, especially, preterm infants differ in drug absorption, distribution, metabolism and excretion from adults and older children. AREAS COVERED This review will evaluate deficiencies of neonatal immune responses to microbial challenge that predispose newborns to viral infections, clinical manifestations and the treatment of viral diseases in neonates. We focus on published studies describing antiviral drug pharmacokinetics in neonates and make recommendations on the dosing of these drugs, allowing achievement of maximal clinical benefits in neonates. EXPERT OPINION While some efforts were undertaken to study pharmacokinetics and pharmacodynamics of antiviral drugs, much more needs to be done. Current data indicate that the pharmacokinetics of antiviral drugs may vary significantly depending on gestational age, maturation processes of drug-metabolizing enzymes and renal clearance. Specifics of pharmacokinetics of antiviral drugs need to be taken into consideration when they are prescribed to neonates and infants.
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Affiliation(s)
- Elena Yu Enioutina
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA.,b Division of Microbiology and Immunology, Department of Pathology , University of Utah School of Medicine , 15 North Medical Drive East, Salt Lake City , UT 84112 , USA
| | - Jonathan E Constance
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Chris Stockmann
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Matthew W Linakis
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Tian Yu
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Joseph E Rower
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Alfred H Balch
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
| | - Catherine M Sherwin
- a Division of Clinical Pharmacology, Department of Pediatrics , University of Utah School of Medicine , 295 Chipeta Way, Salt Lake City , UT 84108 , USA
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Miller AS, Bennett JS. Challenges in the care of young infants with suspected neonatal herpes simplex virus. Hosp Pediatr 2015; 5:106-8. [PMID: 25646205 DOI: 10.1542/hpeds.2014-0095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Aaron S Miller
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey S Bennett
- Department of Pediatrics, University of Kentucky, Lexington, Kentucky
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