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Unnecessary HSV testing, treatment may increase costs, risk
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Recent data show diagnosis and treatment strategies for herpes simplex virus encephalitis tend to use a common approach for neonates even when treating beyond the neonatal period, which could lead to increased medical costs or patient risk.
James T. Gaensbauer, MD, MScPH, of the University of Colorado School of Medicine in Aurora, Colo., and colleagues evaluated the use of acyclovir in infants with herpes simplex virus (HSV) infection and children with central nervous system involvement at 15 pediatric hospitals between 1999 and 2012. Characteristics of non-neonatal patients tested for HSV encephalitis between 2007 and 2013 were analyzed to identify factors associated with potentially unnecessary testing and treatment.
James T. Gaensbauer
Overall, 743 cases of invasive HSV infection occurred. Of these, 357 (48%) were among infants aged younger than 30 days; and 386 (52%) were in children aged 30 days or older.
Use of acyclovir among patients with non-HSV infections increased from 7.6% to 15.6% during the study period. Acyclovir usage among children who did not have herpes increased from 10.8% to 14.5%; an overall increase of 34.3%. Significant overall increases occurred among all diagnosis groups, with the greatest increase in viral meningitis (120.6%); fever (69.2%); and septicemia (53.1%), according to the study authors.
Significant increases of acyclovir use occurred among children aged 0 to 29 days (60.9%), children aged 0 to 59 days (82.7%), and children aged 60 days to 1 year (43.1%). Acyclovir use decreased by 14.5% among older children aged 1 to 5 years and increased by 5.8% among children aged 5 to 13 years.
Increase in acyclovir usage occurred only in children with severity scores lower than 3, according to researchers.
Length of hospital stay was 2.1 days higher among children who did not have herpes and received acyclovir compared with those who did not.
Two children, aged 11 and 13 months, were diagnosed with HSV encephalitis during the study period. Both children met researchers’ predefined criteria for a “typical” presentation of HSV. Conversely, 4% of children who tested negative for HSV met this criteria, ie, 96% of HSV testing was performed on patients who did not have clinical features of typical HSV infection.
“Our data suggest that many unnecessary tests could be avoided by simple interventions, such as delaying an HSV [polymerase chain reaction] until [cerebrospinal fluid] cell counts have been reviewed (and confirmed as abnormal) by ordering providers; a measure that could have reduced testing in our series by up to 50%,” the researchers concluded. “In patients who are clinically unwell, but still unlikely to have HSV, a more nuanced approach to influencing clinical decision-making will be required to more comprehensively reduce testing.”
Disclosure: The researchers report no relevant financial disclosures.
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Gaensbauer JT. Pediatrics. 2014; doi:10.1542/peds.2014-0294.
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