Article Title: Brower LH, Wilson PM, Murtagh-Kurowski E, et al. Evaluation for Neonatal HSV in Infants Undergoing Workup for Serious Bacterial Infection: A 5-Year Retrospective Review. Hospital Pediatrics, June 2020.
Fellow: Sarah Schneider, MD, UC San Diego/Rady Children’s Hospital
Brief Summary: Determining which febrile infants warrant HSV testing and empiric treatment continues to be a major clinical gap. The intent of this retrospective study was to describe characteristics of infants who underwent empirical testing and treatment of HSV, as well as characteristics of patients ultimately diagnosed with HSV. The study included 1633 infants (age 0-60 days), and found that compared with those without HSV, HSV-positive infants (n=19) were younger (< 28 days), more likely to have mother with HSV symptoms, and more likely to present with non-specific symptoms (neurologic symptoms, ill appearance, or difficulty breathing). Interestingly, HSV-positive infants were less likely to be febrile on presentation, which highlights the difficulty in using fever as diagnostic criteria.
Article Strengths: This was a large descriptive study from a tertiary children’s hospital with detailed EMR extraction to try and address an important clinical care gap. The specific details of all patients diagnosed with HSV are informative and provided typical and nonspecific clinical features to alert physicians to evaluate and treat for neonatal HSV. The article discussed variability with adherence to recommended HSV testing guidelines, underscoring the need for clinical decision support based on high-risk features of presentation and published diagnostic recommendations. The authors developed a clinical pathway from these results and published in a separate QI article titled: Using Quality Improvement to implement a Standardized Approach to Neonatal Herpes Simplex Virus (DOI: https://doi.org/10.1542/peds.2018-0262).
Limitations: Given the retrospective study design, data was limited to what was recorded in the electronic medical record and was unable to analyze physician thought process regarding decision to undergo HSV testing and treatment. The study was only single center with a low incidence of disease, only 19 patients over a five year period, so it is challenging to generalize the patient population to all neonates with HSV. Neonatal HSV diagnosis can be limited by sensitivity and specificity of HSV PCR testing, with risk of false negative especially.
Major Takeaway: Clinical presentation of neonatal HSV can be extremely variable and non-specific, and can present in absence of fever. Work-up and empiric treatment for HSV is generally at the discretion of the treating physician, but should be considered in infants < 28 days of age presenting with nonspecific symptoms such as poor feeding, neurologic symptoms, or difficulty breathing. Clinical decision support can potentially help to guide testing and alert physicians to the diagnosis sooner, but with non-specific symptoms physicians must also be cautious to avoid over testing and treatment.
Impact on Practice: While it is important to understand risk factors and the variety in clinical presentation of neonatal HSV, clinicians are still challenged by who they should test and empirically treat. This article helps to provide some framework for testing and risk stratification, but there is still no generalizable guideline. Through implementation of clinical pathways and continued research on this topic, we will hopefully learn more and continue to prevent significant morbidity and mortality of neonatal HSV.
Fellow: Sarah Schneider, MD, UC San Diego/Rady Children’s Hospital
Brief Summary: Determining which febrile infants warrant HSV testing and empiric treatment continues to be a major clinical gap. The intent of this retrospective study was to describe characteristics of infants who underwent empirical testing and treatment of HSV, as well as characteristics of patients ultimately diagnosed with HSV. The study included 1633 infants (age 0-60 days), and found that compared with those without HSV, HSV-positive infants (n=19) were younger (< 28 days), more likely to have mother with HSV symptoms, and more likely to present with non-specific symptoms (neurologic symptoms, ill appearance, or difficulty breathing). Interestingly, HSV-positive infants were less likely to be febrile on presentation, which highlights the difficulty in using fever as diagnostic criteria.
Article Strengths: This was a large descriptive study from a tertiary children’s hospital with detailed EMR extraction to try and address an important clinical care gap. The specific details of all patients diagnosed with HSV are informative and provided typical and nonspecific clinical features to alert physicians to evaluate and treat for neonatal HSV. The article discussed variability with adherence to recommended HSV testing guidelines, underscoring the need for clinical decision support based on high-risk features of presentation and published diagnostic recommendations. The authors developed a clinical pathway from these results and published in a separate QI article titled: Using Quality Improvement to implement a Standardized Approach to Neonatal Herpes Simplex Virus (DOI: https://doi.org/10.1542/peds.2018-0262).
Limitations: Given the retrospective study design, data was limited to what was recorded in the electronic medical record and was unable to analyze physician thought process regarding decision to undergo HSV testing and treatment. The study was only single center with a low incidence of disease, only 19 patients over a five year period, so it is challenging to generalize the patient population to all neonates with HSV. Neonatal HSV diagnosis can be limited by sensitivity and specificity of HSV PCR testing, with risk of false negative especially.
Major Takeaway: Clinical presentation of neonatal HSV can be extremely variable and non-specific, and can present in absence of fever. Work-up and empiric treatment for HSV is generally at the discretion of the treating physician, but should be considered in infants < 28 days of age presenting with nonspecific symptoms such as poor feeding, neurologic symptoms, or difficulty breathing. Clinical decision support can potentially help to guide testing and alert physicians to the diagnosis sooner, but with non-specific symptoms physicians must also be cautious to avoid over testing and treatment.
Impact on Practice: While it is important to understand risk factors and the variety in clinical presentation of neonatal HSV, clinicians are still challenged by who they should test and empirically treat. This article helps to provide some framework for testing and risk stratification, but there is still no generalizable guideline. Through implementation of clinical pathways and continued research on this topic, we will hopefully learn more and continue to prevent significant morbidity and mortality of neonatal HSV.