Testing and Empiric Treatment for Neonatal Herpes Simplex Virus: Challenges and Opportunities for Improving the Value of Care.

A 6-day-old boy presents to the emergency department with 1 day of fever and decreased intake. He has no rash, is mildly dehydrated but not ill-appearing, and has normal mental status. An evaluation for serious bacterial infection is performed, but the lumbar puncture is not successful. He receives ampicillin and gentamicin and is admitted to the inpatient unit. The resident team successfully reattempts the lumbar puncture, with 6 white blood cells and >1000 red blood cells. Herpes simplex virus testing of the cerebrospinal fluid and mucous membranes is sent, the patient is started on acyclovir, and his gentamicin is changed to cefotaxime to minimize exposure to nephrotoxic medications. On day 2 of hospitalization, the team notes that his creatinine has increased since admission. This prompts initiation of intravenous fluids and repeat laboratory testing. The parents ask about the potential impact on his future kidney function. The herpes simplex virus testing and all cultures are negative; however, discharge is delayed as repeat creatinine measurements are performed to ensure the creatinine is decreasing. Neonatal herpes simplex virus (HSV) infections are rare, with an incidence of 9.6 per 100 000 births1 and a prevalence of 0.2% to 0.3% in febrile neonates.2 However, neonatal HSV infections are associated with high mortality and, among survivors, long-term morbidity.3,4 In the absence of multicenter trials and decision rules, clinicians must rely on findings from published case series, which emphasize that no combination of presenting signs and symptoms can reliably identify all neonates with HSV infection.5–11 The variability in presentation has given rise to multiple proposed approaches to empiric testing and treatment and, consequently, substantial variation in the factors that prompt HSV testing, sometimes without clear correlation with known risk factors.12–15 It is important to address this …