During the Emergency Department Evaluation of a Well-Appearing Neonate with Fever, Should Empiric Acyclovir Be Initiated?

During the Emergency Department Evaluation of a Well-Appearing Neonate with Fever, Should Empiric Acyclovir Be Initiated?

Bruno Eric; Pillus David; Cheng David; Vilke Gary; Pokrajac Nicholas

The Journal of emergency medicine

2018

2018-02

BACKGROUND: Herpes simplex virus (HSV) infection represents significant morbidity and mortality in the neonatal period. Although clear guidelines exist on the evaluation and management of the otherwise well-appearing febrile neonate pertaining to occult serious bacterial infections, there is no standardized approach regarding when to initiate testing and treatment for HSV infection. It is vital we establish a unified guideline based on available clinical research to aid in our decision to evaluate and initiate therapy for this disease. METHODS: A PubMed search was performed using the keywords "neonate AND fever AND HSV" and "neonate AND fever AND acyclovir." The time period for the search was May 1982 to May 2016. Identified articles underwent further selection based on relevance to the clinical question. Selected articles then underwent detailed review and structured analysis. RESULTS: Our search identified 93 articles, of which 18 were found to be relevant to our clinical question. Recommendations were then made based on thorough review and analysis of the selected articles. CONCLUSIONS: Neonatal HSV infection carries significant morbidity and mortality if left untreated. High-quality clinical evidence on when to evaluate and treat for possible HSV infection is lacking. Based on available research, HSV infection in the febrile neonate should be strongly considered if age is \textless 21 days, or if presenting with concerning clinical features. If testing is performed, empiric treatment with high-dose acyclovir should be initiated. Additional research is needed to further clarify which cases mandate evaluation and treatment for HSV, and to better define treatment protocols.

acyclovir; Acyclovir – Therapeutic Use; Acyclovir/*therapeutic use; Antiviral Agents – Therapeutic Use; Antiviral Agents/therapeutic use; Decision Making; febrile neonate; Female; Ferrans and Powers Quality of Life Index; Fever – Etiology; Fever/etiology; Guidelines as Topic/standards; Herpes Simplex – Complications; Herpes Simplex – Diagnosis; Herpes Simplex – Drug Therapy; herpes simplex virus; Herpes Simplex/complications/diagnosis/*drug therapy; Herpesviruses; HSV; Humans; Infant; Infectious – Diagnosis; Infectious/diagnosis; Male; neonatal fever; Newborn; Practice Guidelines – Standards; Pregnancy Complications; Scales; Simplexvirus/pathogenicity

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