Why are young infants tested for herpes simplex virus?
Kara L Davis1, Samir S Shah, Gary Frank
1Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA.
Insights
Physicians ordered herpes simplex virus (HSV) PCR tests in infants for seizures or other PCR tests, not typical infection signs. The low yield suggests careful consideration of widespread testing in this population.
Area of Science:
- Pediatric Infectious Diseases
- Clinical Virology
- Diagnostic Microbiology
Background:
- Polymerase chain reaction (PCR) is the preferred method for detecting herpes simplex virus (HSV) genome in cerebrospinal fluid (CSF).
- The effectiveness of HSV PCR testing in infants presenting with sepsis symptoms is not well-established.
Purpose of the Study:
- To determine factors influencing physician decisions to order HSV PCR in infants undergoing lumbar puncture.
- To assess the impact of HSV PCR testing on patient management in this demographic.
Main Methods:
- A case-control study was conducted over five years at a children's hospital.
- Infants aged 0-60 days with lumbar punctures were divided into cases (HSV PCR ordered) and controls (HSV PCR not ordered).
Main Results:
- Seizures, concurrent enteroviral PCR testing, and ordering hepatic transaminases were associated with ordering HSV PCR.
- Herpes simplex virus infection was diagnosed in 3.4% of cases.
- Healthcare resource utilization for PCR testing was significant.
Conclusions:
- Physician decisions to order HSV PCR were linked to seizures, enteroviral PCR, and hepatic transaminase tests, not traditional neonatal infection indicators.
- The diagnostic yield of HSV PCR in this infant population was low.
- Clinicians must balance early diagnosis benefits against the costs of extensive testing.
Background:
The polymerase chain reaction (PCR)-based test to detect herpes simplex virus (HSV) genome in cerebrospinal fluid (CSF) has become the test of choice for diagnosing this infection. The utility of this test in young infants undergoing sepsis evaluations is unknown.
Objectives:
We sought to identify the factors that prompted physicians to include HSV PCR in their evaluation of young infants undergoing lumbar puncture. In addition, the impact of ordering this test on patient management was assessed.
Methods:
This case-control study included infants 0 to 60 days who were evaluated by lumbar puncture at the Alfred I. duPont Hospital for Children over a 5-year period. Case patients had CSF HSV PCR ordered as part of their evaluation and control patients did not.
Results:
Eighty-eight case patients and 83 control patients were identified. The median patient age was 12 days and most patients (55%) were male. Both groups were similar in demographics. Herpes simplex virus infection was diagnosed by PCR in 3.4% of cases. The occurrence of a seizure (adjusted odds ratio [OR], 8.3; 95% confidence interval [CI], 1.7-41.0), the performance of CSF enteroviral PCR testing (adjusted OR, 4.7; 95% CI, 1.4-15.8), and the decision to obtain hepatic transaminases (adjusted OR, 5.6; 95% CI, 2.7-11.8) were associated with the decision to perform CSF HSV PCR testing. Use of health care resources associated with PCR testing was considerable.
Discussion:
The occurrence of a seizure, the performance of CSF enteroviral PCR testing, and the decision to obtain hepatic transaminases were independently associated with the decision to perform CSF HSV PCR testing. Features traditionally associated with neonatal HSV infection, such as elevated numbers of CSF white blood cells or red blood cells, did not appear to influence the decision to perform CSF HSV PCR testing. The yield of testing in this population was low. Clinicians should weigh the benefits of early diagnosis in a few patients against the consequences of excessive testing in this population.
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