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

Fluorescent octahydrophenazines as novel inhibitors against herpes simplex viruses

A new series of racemic fluorescent octahydrophenazines (rac-PZ1-11) have been designed and synthesized via the efficient nucleophilic aromatic substitution (SNAr) of tetrafluorobenzenedinitriles (1a-c) and racemic cyclohexane-1,2-diamines (rac-2a and b). The bioactivities of these racemic rac-PZs (20 μM) against herpes simplex virus type-1 (HSV-1) were evaluated by the relative cell viability of Vero cells infected with HSV-1. It was found that rac-PZ3 shows much higher anti-HSV-1 activity than others, with EC50 = 9.2 ± 1.4 μM. Further investigation into the anti-HSV activities of rac-PZ3 and its enantiomers RR- and SS-PZ3 indicates that rac-PZ3 can also efficiently inhibit HSV-2 and even ACV-resistant HSV-2 (EC50 = 11.0 ± 2.3 and 14.9 ± 2.8 μM, respectively), SS-PZ3 has better activities against HSV-1, HSV-2 and ACV-resistant HSV-2 (EC50 = 4.1 ± 1.1, 5.8 ± 1.0 and 7.9 ± 1.2 μM, respectively), but RR-PZ3 has almost no antiviral activities. The primary mechanism study indicates that rac-PZ3 efficiently reverses the HSV-1/2-induced cytopathic effect and suppresses the expression of viral mRNA and proteins. In addition, rac-, RR- and SS-PZ3 possess excellent fluorescence properties with almost the same emission wavelength and high fluorescence quantum yields (ΦF = 90.3-92.3 % in cyclohexane solutions and 54.4-57.3 % in solids) and can target endoplasmic reticulum and cell membrane. The efficient anti-HSV bioactivities and excellent fluorescence of PZ3 prove its potential applications in antiviral therapy and biological imaging.

Neonatal herpes: case series in two obstetric centres over a 10-year period (2013-2023), France

Neonatal herpes simplex virus (HSV) infection (HSV infection in infants less than 6 weeks of age) is rare but mortality and morbidity rates are high after disseminated disease and encephalitis. In France, the epidemiology is poorly described, and two decades ago, incidence was estimated to be 3 per 100,000 live births a year. We describe determinants, epidemiologic and clinical characteristics of neonatal HSV infection in a managed-care population attending in two major obstetric and paediatric centres, Paris, France, over a 10-year period. This retrospective case series study was conducted from 2013 to 2023, in infants less than 42 days of age who had virologically confirmed HSV infection. We report an overall rate of neonatal herpes of 5.5 per 100,000 live births a year and an incidence of symptomatic cases of 1.2 per 100,000 live births a year. HSV-1 was the major serotype involved (84.2%) and post-natal acquisition through the orolabial route reached 63.2%. All neonates who had neonatal HSV PCR screening (owing to clinical signs in parents) and who received prompt acyclovir treatment remained asymptomatic. Symptomatic forms accounted for 21.1% cases of the total and mortality was high (62.5% of symptomatic forms).   Conclusion: This case series confirms that neonates at risk for HSV disease and poor outcome are those born to HSV-seronegative mothers, preterm infants, and those who received acyclovir after onset of symptoms (mainly because mothers did not present evidence of acute HSV infection). Our study confirms the major role of HSV-1 and the frequency of its early post-natal acquisition. What is known: • Neonatal herpes simplex virus infection is rare but motality and morbidity rates are high after disseminted disease and encephalitis. National recommendations exist worldwide but mangement of this disease is not always easy. What is new: • As in France epidemiology of neonatal herpes is poorly described, our report is potentially an important addition to the existing literature. Moreover, we describe local practice that may be useful to physicians.

Seroprevalence of Herpes Simplex Virus Types 1 and 2 among Pregnant Women in South-Western Romania

BACKGROUND

Pregnancy-related infections with the human herpes simplex virus (HSV) strains HSV-1 and HSV-2 are particularly noteworthy. There are numerous reported examples of intrapartum transmission of herpes infection, notwithstanding the extreme rarity of intrauterine transfer from mother to fetus. The purpose of this study was to evaluate the seroprevalence of HSV-1 and HSV-2 antibodies in pregnant women in the western region of Romania.

METHODS

Pregnant women who presented for routine pregnancy monitoring at Romania's County Clinical Emergency Hospital in Craiova between 2013 and 2016 and 2019 and 2022 were included in the study. In order to find anti-HSV-1/2 IgG antibodies, we conducted serological testing on the patients and gathered demographic information from them.

RESULTS

HSV-1 seroprevalence was shown to have declined in rural areas and increased in urban areas, with values between 2013 and 2016 being 89.30% and those between 2019 and 2022 being 84.96%, respectively. Women over 35 who were pregnant had the highest seroprevalence. The seroprevalence of HSV-2 decreased from 16.16% in 2013-2016 to 12.43% in 2019-2022, and both rural and urban areas continued to experience this declining trend. Similarly, pregnant women over 35 years old had the highest frequency of HSV-1 infections.

CONCLUSIONS

Establishing educational programs and other actions to reduce the transmission rate and ultimately the prevalence of the disease can be made easier with knowledge about the seroprevalence of HSV-1 and HSV-2 infections.

The Evaluation and Treatment of an Infant Exposed to Nongenital HSV-2: A Case Report

BACKGROUND

Pregnant persons with a primary genital herpes simplex virus (HSV) infection can transfer HSV to the fetus or infant through the placenta or birth canal, which can cause significant infant morbidity or mortality. Primary nongenital infections with HSV-1 or HSV-2 in pregnant persons and the risk of infant infection are not well documented, leaving the clinician to make non-evidence-based decisions on evaluation and treatment in such presentations.

CLINICAL FINDINGS

A term newborn was delivered vaginally by a pregnant person with a nongenital HSV-2 infection. The pregnant person's rash first appeared around 32 weeks' gestation, started on their lower back, and terminated on the outer left hip. The rash improved but was still present at time of delivery, and this rash was their first known HSV outbreak.

PRIMARY DIAGNOSIS

Prenatal exposure to HSV-2.

INTERVENTIONS

Diagnostics included the pregnant person's rash surface culture, immunoglobulin G and immunoglobulin M for HSV-1 and -2; infant surface, cerebral spinal fluid (CSF), and serum HSV-1 and HSV-2 polymerase chain reactions (PCRs), infant CSF studies, blood culture, liver function tests, and treatment with intravenous acyclovir.

OUTCOMES

This infant remained clinically well during hospitalization and was discharged home at 5 days of life when CSF, surface, and serum PCRs resulted negative.

PRACTICE RECOMMENDATIONS

Risk for infant HSV infection versus parent/infant separation and exposure to invasive procedures and medications should be considered when pregnant persons present with primary versus recurrent nongenital HSV infections. Research is needed for the evaluation and treatment of infants born to pregnant persons with primary nongenital HSV infections in pregnancy.

Neonatal herpes simplex virus infection: From the maternal infection to the child outcome

This review examines the recent literature on the management of herpes simplex virus (HSV) infections in neonates. We summarized the three clinical categories of maternal HSV infection during pregnancy (primary first episode, nonprimary first episode, or recurrent episode) and the mechanisms of fetal damage. Considering when the transmission of the infection from the mother to the fetus/newborn occurs, three types of neonatal infection can be distinguished: intrauterine infection (5% of cases), postnatal infection (10% of cases), and perinatal infections (85% of cases). Neonatal presentation could range from a limited disease with skin, eye, and mouth disease to central nervous system disease or disseminated disease: the treatment with acyclovir should be tailored according to symptoms and signs of infection, and virological tests. These children need a multidisciplinary follow-up, to timely intercept any deviation from normal neurodevelopmental milestones. Prevention strategies remain a challenge, in the absence of an available vaccine against HSV.

The Many Faces of Neurological Neonatal Herpes Simplex Virus Infection

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.

Identification of oxysterol synthetic analogs as a novel class of late-stage inhibitors of herpes simplex virus 2 replication

Genital herpes, most frequently caused by herpes simplex virus 2 (HSV-2) infection, is one of the most prevalent sexually transmitted infections. The current rationale for the treatment of HSV-2 infection involves nucleoside analogs (e.g. acyclovir) to suppress reactivation. Enzymatic oxysterols are endogenous 27-carbon atoms molecules produced by enzymatic cholesterol oxidation, and recently emerged as a broad-spectrum host targeting antivirals. In this study, we screened selected members of an in-house synthesized library of oxysterol analogues for their activity against HSV-2, identifying three compounds, named PFM064, PFM067, and PFM069, endowed with 50% effective concentrations (EC₅₀) in the micromolar range, without exerting any apparent cytotoxicity. Moreover, the results obtained showed the ability of the novel derivatives to inhibit both cell-to-cell fusion induced by HSV-2, and the production of an intracellular viral progeny. Further experiments performed with PFM067 (which was selected for more-in-depth studies as the most effective synthetic analog) showed that these molecules act in a late stage of HSV-2 replicative cycle, by sequestering viral glycoproteins in the Golgi compartment, and likely inhibiting the nuclear egress of neo-synthetized viral capsids. Taken together, these results point to PFM067 as a promising chemical scaffold for the development of novel herpetic antivirals.

Neonatale Herpesinfektion mit akutem Leberversagen

Weltweit beträgt die Inzidenz neonataler Herpes-simplex-Virus(HSV)-Infektionen 10/100.000 Lebendgeburten. Schwere Infektionen bei Neonaten treten in erster Linie bei einer mütterlichen Primärinfektion während der Schwangerschaft auf. In der Literatur wird eine Mortalität unbehandelter disseminierter neonataler HSV-Infektionen bis zu 85 % beschrieben. Die frühe differenzialdiagnostische Einbeziehung einer HSV-Infektion beim kranken Neugeborenen und bei neonatalem Leberversagen sowie der niederschwellige Beginn einer hochdosierten Aciclovirtherapie sind von essenzieller Bedeutung. Dieser Fallbericht beschreibt einen Patienten mit einer schweren disseminierten HSV-Infektion und primärer Leberbeteiligung, der in unserem Zentrum behandelt wurde und ohne Lebertransplantation überlebt hat.

Evaluation and Management of an Abandoned Infant at a Quaternary Care Hospital

BACKGROUND

Infants are often brought to an emergency department (ED) for medical evaluation upon surrender or abandonment. However, no specific guidelines exist for the care of surrendered or abandoned children. We describe the case of an abandoned infant who was brought to a pediatric quaternary care hospital as a model for evaluation and management.

CASE REPORT

A 3-day-old abandoned female was brought to a quaternary care pediatric hospital ED. Given limitations in history, upon physical examination and in consultation with specialists, our team completed an extensive laboratory workup to guide initial management and treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Abandoned and surrendered infants frequently enter the medical system via the ED, and emergency physicians must be aware of best practices to evaluate and manage these patients. While each infant presentation is unique, commonalities exist. Our care may serve as a starting point by which others may base their own management. © 2022 Elsevier Inc.

Inborn Errors of Immunity in the Premature Infant: Challenges in Recognition and Diagnosis

Due to heightened awareness and advanced genetic tools, inborn errors of immunity (IEI) are increasingly recognized in children. However, diagnosing of IEI in premature infants is challenging and, subsequently, reports of IEI in premature infants remain rare. This review focuses on how common disorders of prematurity, such as sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia, can clinically overlap with presenting signs of IEI. We present four recent cases from a single neonatal intensive care unit that highlight diagnostic dilemmas facing neonatologists and clinical immunologists when considering IEI in preterm infants. Finally, we present a conceptual framework for when to consider IEI in premature infants and a guide to initial workup of premature infants suspected of having IEI.

Immunoregulatory Functions of Interferons During Genital HSV-2 Infection

Herpes simplex virus type 2 (HSV-2) infection is one of the most prevalent sexually transmitted infections that disproportionately impacts women worldwide. Currently, there are no vaccines or curative treatments, resulting in life-long infection. The mucosal environment of the female reproductive tract (FRT) is home to a complex array of local immune defenses that must be carefully coordinated to protect against genital HSV-2 infection, while preventing excessive inflammation to prevent disease symptoms. Crucial to the defense against HSV-2 infection in the FRT are three classes of highly related and integrated cytokines, type I, II, and III interferons (IFN). These three classes of cytokines control HSV-2 infection and reduce tissue damage through a combination of directly inhibiting viral replication, as well as regulating the function of resident immune cells. In this review, we will examine how interferons are induced and their critical role in how they shape the local immune response to HSV-2 infection in the FRT.

Evaluation of suspected neonatal herpes simplex virus infection in preterm versus term newborns in the neonatal intensive care unit

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.

Postnatal Exposure to Herpes Simplex Virus: To Treat or Not to Treat?

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.

Herpes Simplex Virus Serotyping in Pregnant Women With a History of Genital Herpes and an Outbreak in the Third Trimester of Pregnancy: A Cost-Effectiveness Analysis

OBJECTIVE

To estimate whether serotyping women with a history of genital herpes simplex virus (HSV) and an outbreak during the third trimester of pregnancy is cost effective compared with no serotyping.

METHODS

We designed a decision-analytic model using TreeAge Pro software to assess an approach of routine HSV serotyping in a theoretical cohort of 63,582 women (an estimate of the number of women in the United States with a history of genital HSV and an outbreak during the third trimester of pregnancy). Outcomes included mild, moderate, and severe neonatal HSV, neonatal death, costs, and quality-adjusted life-years (QALYs) for both the woman and neonate. Probabilities, utilities, and costs were derived from the literature, and we used a willingness-to-pay threshold of $100,000 per QALY. Sensitivity analyses were performed to assess the robustness of the results.

RESULTS

In our theoretical cohort, HSV serology screening resulted in 519, 8, and 15 cases of mild, moderate, and severe neonatal HSV, whereas no serology screening resulted in 745, 65, and 85 cases, respectively. Thus, HSV serology screening led to 226, 57, and 70 fewer cases of mild, moderate, and severe neonatal HSV, respectively, as well as 91 fewer neonatal deaths. Additionally, serology screening saved $61 million and gained 7,900 QALYs, making it a dominant strategy. Univariate sensitivity analysis demonstrated that serology screening was cost effective until the chance of progression from neonatal HSV infection to disease despite empiric antiviral treatment was greater than 23%.

CONCLUSION

Serology screening in pregnant women with an outbreak in the third trimester of pregnancy and a history of genital HSV resulted in improved outcomes and decreased costs.

Herpes Simplex Virus Infection in Infants: 13 Year Evaluation (2005-2017) of Laboratory Confirmed Cases in Queensland, Australia

BACKGROUND

National neonatal surveillance for herpes simplex virus (HSV) disease suggests that the incidence of HSV disease may be higher in Queensland (QLD) than in other Australian States. We sought to investigate the incidence via a retrospective 13-year evaluation of statewide laboratory data, autopsy data and linked clinical records of infants with laboratory confirmed infection.

METHODS

All positive polymerase chain reaction HSV 1 and 2 results were obtained for infants 0-3 months of age from January 1, 2005 to December 31, 2017. Clinical data were obtained from patient records and parent questionnaires were used to evaluate long-term sequelae.

RESULTS

One hundred seventy-two infants with HSV positive polymerase chain reaction results: 121 (70.3%) with HSV 1. Of 104 (60.5%) infants with signs of HSV disease, 76 (73.1%) were neonates (≤28 days of age) [incidence 9.6 (95% confidence interval, 7.0-11.5) per 100,000 live births] and 28 (26.9%) were young infants (29-90 days of age) [3.6 (95% confidence interval, 2.4-5.4) per 100,000 live births]. The annual incidence of neonatal HSV disease increased significantly in Queensland over the study period (P < 0.01). Of the 76 neonates with HSV disease, 58 (76.3%) presented with the skin, eye, mouth (SEM) disease, 17 (22.4%) with HSV encephalitis and 11 (14.5%) had disseminated disease. Young infants presented with HSV skin, eye, mouth disease (21, 75.0%) or HSV encephalitis (6, 21.4%). Death occurred in 12/104 (11.5%) infants (all neonates) with 10 attributable to HSV disease.

CONCLUSION

The incidence of neonatal HSV disease in QLD is almost 3 times the national reported incidence. Further research is being undertaken to explore reasons for this change and implications for practice.

[Herpes Simplex Virus Infection in Two Premature Infants - Diagnostic and Therapeutic Management]

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.

Congenital syphilis: Missed opportunities and the case for rescreening during pregnancy and at delivery

Two infants treated for syphilis born to at risk mothers who screened negative at their first prenatal visit but were not rescreened at delivery are described. The first presented with classic, but unrecognized, features of congenital syphilis. In the second case, possible early maternal syphilis was diagnosed soon after delivery using the treponemal first reverse-screening algorithm. Although the child's physical exam was normal and the maternal rapid plasma reagin (RPR) negative, the child was treated for syphilis because maternal confirmatory treponemal tests suggested recent seroconversion. Given the re-emergence of congenital syphilis, our report aims to demonstrate the importance of rescreening women at increased risk and improve awareness of common manifestations of the syphilis disease in the newborn. For women at increased risk, repeat syphilis testing early in the third trimester and again at delivery in communities and populations with a high prevalence of syphilis is recommended.

Economic Evaluation: Onsite HSV PCR Capabilities for Pediatric Care

Objective:

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

Project design:

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

Results:

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

Conclusions:

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

Neonatal Herpes Simplex Virus: The Long Road to Improved Outcomes

Herpes simplex virus (HSV) acquired during delivery places the neonate at risk for mortality or long-term neurodevelopmental disability. Exposure generally occurs from recurrent genital herpes infection, although primary infections result in the highest risk of neonatal disease. Neonates generally present in the second or third week of life with lesions. Encephalitis with seizures indicates the presence of central nervous system involvement, and other end organs may also be impacted. Clinical suspicion for neonatal HSV infection warrants immediate initiation of appropriate antiviral therapy. In the last 50 years, antiviral therapy has progressed from agents with prohibitive toxicity or cumbersome administration to herpes virus-specific agents that dramatically improve clinical outcomes with manageable toxicity. Multicenter clinical trials have demonstrated the superiority of high-dose intravenous acyclovir for acute therapy, followed by long-term oral suppressive therapy. This work has dramatically reduced morbidity and mortality from neonatal HSV, representing the benchmark for future clinical trials in neonatal pharmacotherapy.

Genital herpes and pregnancy: Evaluating practices and knowledge of French health care providers

BACKGROUND

Genital herpes during pregnancy is a frequent occurrence, whereas infection of newborns is rare but likely severe. In the absence of specific national guidelines from the CNGOF (French National College of Gynaecologists and Obstetricians) in France until December 2017, we supposed that knowledge of health care providers on the topic was not up to date.

OBJECTIVE

To assess health care provider knowledge of genital herpes and management practices during pregnancy, before the publication of national recommendations edited by the CNGOF.

STUDY DESIGN

A questionnaire on genital herpes during pregnancy was published on the CNGOF website and sent by e-mail to members of the French College of Fetal Ultrasound (CFEF). Questions focused on prevention and screening practices, epidemiological knowledge, and management of herpes infection during pregnancy and after birth.

RESULTS

Between April and June 2017, 354 health care providers completed the survey (263/354 (75 %) Obstetrician-Gynaecologists, 85/354 (24 %) Midwives and 6/354 (2%) General Practitioners). Overall, obstetricians were better informed about epidemiology of Herpes Simplex Virus (HSV), midwives were more familiar with neonatal risks in case of maternal primary infection but overestimated risks in case of maternal recurrence. 21 % of health care providers never prescribed antiviral prophylaxis in the third trimester if genital herpes occurred during pregnancy. Finally, most practitioners were unaware of newborn management in case of maternal genital herpes at delivery.

CONCLUSION

Management of genital herpes in pregnancy appears to be heterogeneous due to varying degrees of knowledge among French health care providers. This highlights the urgent need for national guidelines, that were published 5 months after this study. They should be broadly disseminated and adapted to the shortcomings of health professionals. It would be interesting to repeat this study later to evaluate the impact of national guidelines.

Common bacterial infections and their treatment in hospitalized pediatric patients

PURPOSE

Common bacterial infections in pediatric patients that the hospital pharmacist may encounter are reviewed, and guidance on the safe and effective use of antibiotics to treat those infections is provided.

SUMMARY

Pharmacists play a key role in evaluating and creating antibiotic treatment plans for patients with infections. Bacterial infections are a common reason for hospital admission in pediatric patients, and pharmacists working in hospitals may be consulted to provide treatment and monitoring recommendations. It is important for pharmacists to be aware of similarities and differences in adult and pediatric populations with regard to presenting signs and symptoms of bacterial infections, common causative pathogens, and antibiotic selection, dosing, and monitoring. This article reviews current approaches to treatment of common bacterial infections in pediatric patients and also provides general suggestions for antibiotic use.

CONCLUSION

Pharmacists have an opportunity to positively impact the care of pediatric patients with bacterial infections. Especially at facilities where pediatric patients are not regularly treated, pharmacists can potentially improve care through provision of recommendations for optimal antibiotic selection, dosing, and monitoring.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

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

Vertikale Übertragung des Herpes-simplex-Virus: eine Aktualisierung

Infektionen mit den Herpes-simplex-Viren (HSV)-1 und -2 haben weltweit eine hohe Prävalenz. Eine HSV-Infektion während der Schwangerschaft kann eine neonatale Herpes-Infektion verursachen, die durch eine lebenslange Infektion mit Latenz- und Reaktivierungsperioden gekennzeichnet ist. Ein Säugling kann sich in utero (5 %), peripartal (85 %) oder postnatal (10 %) mit dem HS-Virus infizieren. Herpes neonatorum ist eine seltene aber bedeutsame Infektion, die mit schwerer Morbidität und Mortalität assoziiert sein kann, insbesondere bei Dissemination oder Beteiligung des zentralen Nervensystems. Fortschritte bei Diagnose und Therapie haben zur Verringerung der Mortalität sowie, in geringerem Ausmaß, zu einem verbesserten neurologischen Outcome geführt. Dennoch sind weitere Verbesserungen wünschenswert. Dabei ist es entscheidend, Ärzte in die Lage zu versetzen, diejenigen Säuglinge, die einem erhöhten Risiko einer HSV-Infektion ausgesetzt sind, zu erkennen und die Mutter-Kind-Übertragung effektiver zu verhindern. Ein lohnendes Ziel für die Zukunft ist die Entwicklung neuer antiviraler Wirkstoffe mit höherer Wirksamkeit.

Vertical transmission of herpes simplex virus: an update

Herpes simplex virus (HSV)-1 and -2 infections are highly prevalent worldwide. HSV infection during pregnancy can result in neonatal herpes infection, which is characterized by lifelong infection with periods of latency and reactivation. HSV can be acquired by an infant during one of three periods: in utero (5 %), peripartum (85 %), or postnatal (10 %). Neonatal HSV is a rare but significant infection that may be associated with severe morbidity and mortality, especially if there is dissemination or central nervous system involvement. Diagnostic and therapeutic advances have led to a reduction in mortality and, to a lesser extent, improvement of neurodevelopmental outcomes, but further developments are still needed. It is essential to improve the clinician's ability to identify infants who are at increased risk of HSV infection and to prevent mother-to-child transmission. The development of novel antiviral agents with higher efficacy is a worthwhile aim for the future.

[The Spanish Society of Paediatric Infectious Diseases guidelines on the prevention, diagnosis and treatment of neonatal herpes simplex infections]

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.

Antiviral Drugs in Newborn and Children

This article focuses on the clinically relevant approved antiviral medications available for the treatment of infants and children. A brief overview of drug categories, mechanism of action, resistance, pharmacokinetics, and side effects is provided for the more commonly prescribed antivirals. The patient categories addressed are treatment and prophylaxis of influenza, neonatal herpes simplex virus and congenital cytomegalovirus, treatment and prophylaxis of viral disease in the immunocompromised host, and a brief introduction to the antivirals available to treat hepatitis B and hepatitis C in children.

Golden hour of neonatal life: Need of the hour

"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.

Infectious causes of microcephaly: epidemiology, pathogenesis, diagnosis, and management

Microcephaly is an important sign of neurological malformation and a predictor of future disability. The 2015-16 outbreak of Zika virus and congenital Zika infection brought the world's attention to links between Zika infection and microcephaly. However, Zika virus is only one of the infectious causes of microcephaly and, although the contexts in which they occur vary greatly, all are of concern. In this Review, we summarise important aspects of major congenital infections that can cause microcephaly, and describe the epidemiology, transmission, clinical features, pathogenesis, management, and long-term consequences of these infections. We include infections that cause substantial impairment: cytomegalovirus, herpes simplex virus, rubella virus, Toxoplasma gondii, and Zika virus. We highlight potential issues with classification of microcephaly and show how some infants affected by congenital infection might be missed or incorrectly diagnosed. Although Zika virus has brought the attention of the world to the problem of microcephaly, prevention of all infectious causes of microcephaly and appropriately managing its consequences remain important global public health priorities.

Persistent Gaps in Appropriate Use of Empiric Acyclovir in Neonates

The use of empiric acyclovir for suspected neonatal herpes simplex virus (HSV) infection has been debated for years. To identify the gap in the decision to initiate empiric acyclovir, we performed a retrospective chart review and administered a survey to pediatricians to assess current practices regarding evaluation for possible HSV infection. Seventy infants received empiric acyclovir over a 1-year period; of these, 3 infants (4.3%) had positive HSV testing. Fourteen infants were identified as "high-risk" for HSV infection; of these, 13 infants had incomplete testing. Survey results revealed uncertainty in the decision to initiate acyclovir and in the composition of complete diagnostic testing. This study confirmed the clinical uncertainty in the decision to initiate empiric acyclovir. Using this chart review and survey as a baseline, future efforts will focus on a quality improvement project to reduce empiric acyclovir use in low-risk infants and to ensure complete diagnostic evaluation in high-risk infants.

Neonatal Herpes Simplex Viral Infections and Acyclovir: An Update

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

Herpes Simplex Virus in the Neonate

Neonatal herpes simplex virus (HSV) disease is a serious, life-threatening condition that should be considered in neonates with fever, vesicular rash, culture negative sepsis, and/or seizure activity. Because signs and symptoms of neonatal HSV may closely resemble those of bacterial sepsis, a thorough history and appropriate testing are imperative to accurately confirm the diagnosis. Failure to treat vesicular lesions from HSV in the neonate leads to an approximate 75% chance of progression to disseminated disease and/or meningoencephalitis. Therefore, prompt recognition of symptoms and institution of treatment pending results of the investigation are imperative to minimize the high rates of morbidity and mortality associated with this diagnosis. [Pediatr Ann. 2017;46(2):e42-e46.].

Hemophagocytic lymphohistiocytosis caused by systemic herpes simplex virus type 1 infection: Successful treatment with dexamethasone palmitate

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory condition resulting from an uncontrolled and ineffective immune response. Here, we report a case of HLH caused by disseminated herpes simplex virus (HSV)-1 infection. The patient was initially treated with prednisolone and high-dose acyclovir. Although liver enzymes, coagulation abnormalities, and inflammatory markers were remarkably improved, the platelet count remained low. Prednisolone was therefore switched to dexamethasone palmitate. Thereafter, the platelet count normalized. Inflammatory markers normalized 30 days after admission and serum HSV-DNA became undetectable on day 41. The patient was discharged on day 91 and no developmental delay was evident at 7 months of age. These findings suggest that dexamethasone palmitate is effective for neonatal HLH.

Sexually transmitted diseases

Sexually transmitted diseases (STDs) continue to be a global epidemic with significant risk of morbidity/mortality for the fetus. STDs with prominent cutaneous findings including condylomata acuminata, genital herpes infections, and syphilis are reviewed. Important clinical cutaneous findings help aid early diagnosis and facilitate treatment. Condylomata acuminata have the potential of causing cervical cancer, anogenital cancer, and oropharyngeal cancer. Significant advances have been made in human papilloma virus vaccinations and treatment. Genital herpes infection can produce significant physical and emotional distress to the patient and significant potential harm to the fetus. Early clinical recognition of STDs and their appropriate management is critical.

Sexually transmitted diseases treatment guidelines, 2015

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

Immunization with HSV-2 gB-CCL19 Fusion Constructs Protects Mice against Lethal Vaginal Challenge

There is a lack of an HSV-2 vaccine, in part as the result of various factors that limit robust and long-term memory immune responses at the mucosal portals of viral entry. We previously demonstrated that chemokine CCL19 augmented mucosal and systemic immune responses to HIV-1 envelope glycoprotein. Whether such enhanced immunity can protect animals against virus infection remains to be addressed. We hypothesized that using CCL19 in a fusion form to direct an immunogen to responsive immunocytes might have an advantage over CCL19 being used in combination with an immunogen. We designed two fusion constructs, plasmid (p)gBIZCCL19 and pCCL19IZgB, by fusing CCL19 to the C- or N-terminal end of the extracellular HSV-2 glycoprotein B (gB) with a linker containing two (Gly4Ser)2 repeats and a GCN4-based isoleucine zipper motif for self-oligomerization. Following immunization in mice, pgBIZCCL19 and pCCL19IZgB induced strong gB-specific IgG and IgA in sera and vaginal fluids. The enhanced systemic and mucosal Abs showed increased neutralizing activity against HSV-2 in vitro. Measurement of gB-specific cytokines demonstrated that gB-CCL19 fusion constructs induced balanced Th1 and Th2 cellular immune responses. Moreover, mice vaccinated with fusion constructs were well protected from intravaginal lethal challenge with HSV-2. Compared with pgB and pCCL19 coimmunization, fusion constructs increased mucosal surface IgA(+) cells, as well as CCL19-responsive immunocytes in spleen and mesenteric lymph nodes. Our findings indicate that enhanced humoral and cellular immune responses can be achieved by immunization with an immunogen fused to a chemokine, providing information for the design of vaccines against mucosal infection by HSV-2 and other sexually transmitted viruses.

A practical guide to the diagnosis, treatment, and prevention of neonatal infections

Neonatal infections continue to cause morbidity and mortality in infants. Among approximately 400,000 infants followed nationally, the incidence rates of early-onset sepsis infection within 3 days of life are 0.98 cases per 1000 live births. Newborn infants are at increased risk for infections because they have relative immunodeficiency. This article provides evidence-based practical approaches to the diagnosis, management, and prevention of neonatal infections.

Common childhood viral infections

Infections caused by viruses are universal during childhood and adolescence. Clinicians will regularly care for children and adolescents who present with infections caused by a wide number of viral pathogens. These infections have varied presentations. Many infections may have clinical presentations that are specific to the infecting virus but present differently, based on the age and immunocompetence of the patient. Some children are directly impacted early in their lives when maternal disease results in an in utero infection (cytomegalovirus, rubella virus, or parvovirus B19). Other viruses may infect children in a predictable pattern as they grow older (rhinovirus or influenza virus). Fortunately, many viral infections frequently encountered in the past are no longer extant due to widespread immunization efforts. Recognition of these vaccine-preventable infections is important because outbreaks of some of these diseases (mumps or measles) continue to occur in the United States. Vigilance in vaccine programs against these viral agents can prevent their re-emergence. In addition, an increasing number of viral infections (herpes simplex virus, influenza virus, varicella zoster virus, or cytomegalovirus) can now be successfully treated with antiviral medications. Most viral infections in children result in self-limited illness and are treated symptomatically and infected children experience full recovery. This review will address the epidemiology, clinical presentation, diagnosis, treatment, and prevention of viral infections commonly encountered by the clinician.

Mother-to-Child Transmission of Herpes Simplex Virus

Infections with herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2), both alpha herpesviruses, are highly prevalent worldwide. Both HSV types commonly cause genital infection, which, when acquired or reactivated during pregnancy, carries with it the risk of transmission to the fetus or neonate. Women who acquire primary or first-episode genital herpes during pregnancy are at greater risk for transmitting the infection than are women with recurrent genital herpes. Because viral infection and reactivation are frequently asymptomatic, many affected women are unaware of their infection and risk of transmission to their infants. Neonatal HSV infection can have devastating long-term consequences, especially when the central nervous system (CNS) is involved. Treatment of affected neonates with intravenous acyclovir has improved outcomes but there is room for further improvement, especially in regard to CNS disease. Working with pregnant women to prevent mother-to-child transmission of HSV is an important component in reducing the overall disease burden of neonatal HSV infections.

Oral antiviral therapy for prevention of genital herpes outbreaks in immunocompetent and nonpregnant patients

BACKGROUND

Genital herpes is caused by herpes simplex virus 1 (HSV-1) or 2 (HSV-2). Some infected people experience outbreaks of genital herpes, typically, characterized by vesicular and erosive localized painful genital lesions.

OBJECTIVES

To compare the effectiveness and safety of three oral antiviral drugs (acyclovir, famciclovir and valacyclovir) prescribed to suppress genital herpes outbreaks in non-pregnant patients.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the search portal of the World Health Organization International Clinical Trials Registry Platform and pharmaceutical company databases up to February 2014. We also searched US Food and Drug Administration databases and proceedings of seven congresses to a maximum of 10 years. We contacted trial authors and pharmaceutical companies.

SELECTION CRITERIA

We selected parallel-group and cross-over randomized controlled trials including patients with recurrent genital herpes caused by HSV, whatever the type (HSV-1, HSV-2, or undetermined), with at least four recurrences per year (trials concerning human immunodeficiency virus (HIV)-positive patients or pregnant women were not eligible) and comparing suppressive oral antiviral treatment with oral acyclovir, famciclovir, and valacyclovir versus placebo or another suppressive oral antiviral treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected eligible trials and extracted data. The Risk of bias tool was used to assess risk of bias. Treatment effect was measured by the risk ratio (RR) of having at least one genital herpes recurrence. Pooled RRs were derived by conventional pairwise meta-analyses. A network meta-analysis allowed for estimation of all possible two-by-two comparisons between antiviral drugs.

MAIN RESULTS

A total of 26 trials (among which six had a cross-over design) were included. Among the 6950 randomly assigned participants, 54% (range 0 to 100%) were female, mean age was 35 years (range 26 to 45.1), and the mean number of recurrences per year was 11 (range 6.3 to 17.8). Duration of treatment was two to 12 months. Risk of bias was considered high for half of the studies and unclear for the other half. A total of 14 trials compared acyclovir versus placebo, four trials compared valacyclovir versus placebo and 2 trials compared valacyclovir versus no treatment. Three trials compared famciclovir versus placebo. Two trials compared valacyclovir versus famciclovir and one trial compared acyclovir versus valacyclovir versus placebo.We analyzed data from 22 trials for the outcome: risk of having at least one clinical recurrence. We could not obtain the outcome data for four trials. In placebo-controlled trials, there was a low quality evidence that the risk of having at least one clinical recurrence was reduced with acyclovir (nine parallel-group trials, n = 2049; pooled RR 0.48, 95% confidence interval (CI) 0.39 to 0.58), valacyclovir (four trials, n = 1788; pooled RR 0.41, 95% CI 0.24 to 0.69), or famciclovir (two trials, n = 732; pooled RR 0.57, 95% CI 0.50 to 0.64). The six cross-over trials showed larger treatment effects on average than the parallel-group trials. We found evidence of a small-study effect for acyclovir placebo-controlled trials (adjusted pooled RR 0.61, 95% CI 0.49 to 0.75). In analyzing parallel-group trials by daily dose, no clear evidence was found of a dose-response relationship for any drug. In head-to-head trials, the risk of having at least one recurrence was increased with valacyclovir rather than acyclovir (one trial, n = 1345; RR 1.16, 95% CI 1.01 to 1.34) and was not significantly different from that seen with famciclovir as compared with valacyclovir (one trial, n = 320; RR 1.18, 95% CI 0.86 to 1.63).We included 16 parallel-arm trials in a network meta-analysis and we were unable to determine which of the drugs was most effective in reducing the risk of at least one clinical recurrence (after adjustment for small-study effects, pooled RR 0.83, 95% CI 0.61 to 1.11 for valacyclovir vs acyclovir; pooled RR 1.04, 95% CI, 0.71 to 1.49 for famciclovir vs acyclovir; and pooled RR 1.26, 95% CI 0.89 to 1.75 for famciclovir vs valacyclovir). Safety data were sought but were reported as total numbers of adverse events.

AUTHORS' CONCLUSIONS

Owing to risk of bias and inconsistency, there is low quality evidence that suppressive antiviral therapy with acyclovir, valacyclovir or famciclovir in pacients experiencing at least four recurrences of genital herpes per year decreases the number of pacients with at least one recurrence as compared with placebo. Network meta-analysis of the few direct comparisons and the indirect comparisons did not show superiority of one drug over another.