Current management of Herpes simplex infection in pregnant women and their newborn infants: What’s hot and what’s not

Current management of Herpes simplex infection in pregnant women and their newborn infants: What’s hot and what’s not

Doctors can often identify genital herpes by the typical appearance of skin lesions. The results were presented for both neonates with fever alone and those with fever and CSF pleocytosis. The doctor may choose to test for other sexually transmitted diseases (STDs) based on your symptoms, medical history, and sexual history. Is a molecular test that same thing as a PCR test (a type of Nucleic Acid Amplification Testing)? Interventions: Four clinical strategies: (1) HSV testing and empirical treatment while awaiting test results; (2) HSV testing and treatment if test results were positive for HSV or the patient had symptoms of HSV; (3) treatment alone without testing; or (4) no HSV testing or treatment unless the patient exhibited symptoms. These were subjected to testing using an MAb-based IF test and a PCR that detects the polymerase ( pol ) gene of HSV isolates. There are some importantfeatures of this test.1.

The test takes around 10 minutes to return a result. Unfortunately, not every provider knows the specifics of each test; for example, not every provider will know what the test is actually detecting and how it’s being detected. The lowest risk of neonatal transmission occurs in the setting where the mother has an active infection that was acquired before pregnancy or at stages of gestation before the onset of labour. 2 and 96.9%, respectively, for the Quanti-PATH system, 98.2 and 100. A false-negative occurs when a test reports that herpes is not present when it actually is. However, if the membranes have been ruptured for more than 6 h, the benefit of a cesarean section has not been determined. A cesarean section reduces, but does not eliminate, the risk of newborn infection (5,7).

Like the viral culture, it can give a false-negative, but the PCR test is much more accurate. Blood tests may be done to look for HSV antibodies. Antibodies are created by the immune system to fight foreign materials like viruses. Specific antibodies are made for specific viruses. If the blood tests show HSV antibodies, you are most likely infected with the virus. The main limitation of testing for HSV antibodies is that when the antibodies are present, there is no way to distinguish between HSV infection causing cold sores around the mouth versus HSV infection causing genital herpes. However, the presence of either condition places partners at risk for genital herpes transmission.

While there are no randomized trials to show definitively that this does not occur, the data available to date suggest that this is unlikely (9). However, the test is publicly available to scientists and clinicians worldwide. 4th – 6th leading cause of death. Newborns who are exposed to HSV during labour and vaginal delivery and who are asymptomatic should have HSV cultures performed at 48 h after birth. PCR finds the genetic material (DNA) of the HSV virus. Samples for HSV cultures should be taken from urine, mouth, eyes and nasopharynx. Some experts also recommend stool or rectal cultures.

The use of a single swab for the eyes followed by the mouth and nasopharynx may reduce the number of swabs. Some experts recommend weekly surveillance cultures for four to six weeks to detect active viral replication before the frank manifestations of disease. Empiric acyclovir at birth is recommended by most experts for asymptomatic infants who were delivered vaginally and whose mothers had proven or presumed primary infection. Some experts prefer waiting on the results of HSV cultures, or signs or symptoms of infection before initiating therapy. If therapy is being initiated, a cerebrospinal fluid (CSF) sample should be obtained before treatment. Acyclovir therapy is not recommended for the asymptomatic infants of mothers who had known recurrent genital lesions. If a further test is needed, additional samples from the same eye may have fewer adenoviral antigens, so if both eyes are equally affected, the second sample should be collected from the other eye.

Antiviral therapy is not routinely started for such infants who are asymptomatic, but such therapy should be initiated if culture results from the infants are positive for HSV or if HSV infection is strongly suspected. HSV may be detected by viral cultures of the oropharynx, nasopharynx, stool, blood buffy coat, CSF and urine, polymerase chain reaction (PCR) testing of CSF and blood, direct immunofluorescent antibody staining of skin lesions and enzyme immunoassays for HSV antigens. The utility of these testing modalities varies according to the type of sample that is being tested. It is very important for the clinician to speak with the virologist when cases of neonatal HSV are suspected. Virus isolation by culture remains the definitive diagnostic method for neonatal HSV infection (4,14). However, if skin lesions are present, rapid diagnostic techniques are of value, such as direct immunofluorescence for virus-infected cells and enzyme immunoassays for the presence of HSV antigens. Direct immunofluorescence staining is not reliable unless the sample was obtained from a skin lesion.

Current management of Herpes simplex infection in pregnant women and their newborn infants: What’s hot and what’s not
Cells from oropharyngeal and CSF samples are not adequate for testing by direct immunofluorescence (4). The isolation of virus from superficial cultures may represent colonization if such samples are obtained within the first 24 h after birth (4). If such cultures are positive more than 48 h after birth, they are likely to represent active viral replication and not colonization. Among exposed infants, data from prospective studies are lacking regarding the utility of regular surveillance cultures in the early diagnosis of neonatal HSV infection. An approach that is favoured by some experts is weekly cultures for the first four to six weeks of life as a guide to the need for acyclovir therapy (15). While HSV cultures may be positive in infants with disseminated disease, in patients with localized CNS disease, CSF cultures are usually negative. For patients with localized CNS disease, PCR is an important diagnostic test.

CSF DNA HSV PCR has obviated the need for brain biopsies in infants with presumed HSV CNS disease. However, since there is no commercially available HSV DNA PCR assay, the results of this test vary across laboratories (16–18). Due to this variability, caution should be exercised when using a negative CSF HSV PCR, to rule out HSV encephalitis, particularly if this decision is based on the results of a single lumbar puncture done in the early stages of the illness. More than one needle stick may be needed. It has been well established that neonatal HSV CNS infection may occur despite the finding of ‘normal’ CSF cell counts and biochemical features, particularly during the early stages of infection. Thus, CSF HSV DNA PCR testing should still be performed even if the above parameters are normal. Serological testing using HSV immunoglobulin M is usually not useful in the diagnosis of neonatal HSV infection.

Each of the specific laboratory tests for HSV has important limitations. Thus, the results of these tests should be interpreted with careful consideration of the clinical picture and the results of general laboratory tests that may be consistent with HSV infection. These tests include electroencephalography, computerized tomography or magnetic resonance imaging, liver transaminases and complete blood count. Acyclovir is the agent of choice for the treatment of neonatal HSV disease. Intravenous therapy is required, because oral acyclovir remains contraindicated for the treatment of HSV infections in neonates (19). The specialist commentator noted that even if they have a positive test using AdenoPlus, patients also need to be checked by a healthcare professional with a slit lamp if they have a lot of pain, blurred vision or sensitivity to bright lights (photophobia) because they might need topical steroid treatment. Recent data support the use of high-dose acyclovir (60 mg/kg/day in three divided doses) for the treatment of neonatal HSV.

Data from the National Institute of Allergy and Infectious Diseases Collaborative Study suggest that mortality and morbidity were lower in infants who were treated with higher doses of acyclovir (20). Current data indicate that a 21 days duration of acyclovir rather than 14 days should be used to treat CNS and disseminated disease. The longer duration of therapy should always be used unless CNS infection is definitively ruled out. A repeat lumber puncture is recommended at the end of the treatment of CNS disease. Given an association between late sequelae and recurrent HSV skin lesions, questions have arisen regarding the role of long term suppressive therapy with oral acyclovir. Administration of oral acyclovir as suppressive therapy can prevent recurrences of HSV after SEM disease (21). However, data are lacking regarding whether the suppression of cutaneous recurrences with oral acyclovir will result in a reduction in the incidence of late neurological sequelae (21).

Because there is the potential for significant neurological sequelae among survivors of neonatal HSV infection (2), careful follow-up of affected neonates is critical. They should have a structured follow-up program that allows for neurodevelopmental, ophthalmological and hearing assessments. While relapses may occur after cessation of therapy, the optimal management of these recurrences is unclear. Infants with HSV infection should be followed and evaluated for recurrent disease and neurological sequelae. Such sequelae are most likely to occur among infants who were diagnosed with CNS or disseminated disease. Recurrent skin lesions are frequent in infants with neonatal HSV and may be associated with CNS sequelae if they occur during the first six months of life. Finally, there are important infection control procedures that are required in the management of infants with neonatal HSV.

Health care providers should work closely with their local infection control personnel to ensure that appropriate procedures are in place based on the most up to date guidelines. Close collaboration with the infection control team is required in the management of different clinical scenarios, including but not limited to neonates with HSV, neonates exposed during delivery, and women who are intrapartum or postpartum and who have active HSV lesions. This period is called the window period or seroconversion period. Arvin AM, Whitley RJ. Herpes simplex virus infections. In: Remington JS, Klein JO, editors. Infectious Diseases of the Fetus and Newborn.

5th ed. Philadelphia: WB Saunders Co; 2001. pp. 425–46. 19. American Academy of Pediatrics . Herpes simplex.

In: Pickering LK, editor. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village: American Academy of Pediatrics; 2000. pp. 309–18.

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