Point-of-care availability and interventions targeted at clinician engagement may improve adherence to a new guideline for neonatal herpes simplex virus (HSV) management, according to study results published in Pediatrics.
HSV is a rare but potentially fatal neonatal infection with an estimated incidence of 9.6 per 100,000 births. The initial manifestations of neonatal HSV infection vary and usually include nonspecific signs that make early identification challenging. Delayed recognition of HSV leads to delayed acyclovir therapy (the treatment of choice), which is associated with a significant increase in odds of mortality. Testing and empirically treating every febrile neonate with acyclovir, regardless of symptomatology, is not cost effective and can lead to adverse events, including extravasation and acute kidney injury.
However, there is little guidance for clinicians on initiating testing and therapy for neonatal HSV outside of the immediate postpartum period. Therefore, in 2014 an institutional guideline for neonatal HSV was developed and made the following recommendations:
- all neonates aged <22 days should be evaluated for serious bacterial infection and have cerebrospinal fluid (CSF)-HSV-polymerase chain reaction testing performed
- only neonates presenting with high-risk features and/or abnormal CSF parameters should undergo more extensive testing and initiate empirical acyclovir therapy
This study aimed to increase the percentage of patients (aged 0 – 60 days) who are tested and treated for HSV in accordance with local guideline recommendations from 40% to 80% using quality improvement methodology.
This quality improvement project took place at 1 freestanding children’s hospital. Various “plan-do-study-act” cycles were performed and focused on interventions aimed at key drivers, including guideline availability, specifically via electronic health records; accurate identification of high-risk patients; and provider buy-in. A run chart was used to track the effect of interventions on percentage managed per guideline recommendations over time. Pre- and post-implementation acyclovir therapy use was compared and researchers used a balancing measure, delayed acyclovir therapy initiation in HSV-positive cases, defined as >1 day from presentation, were tracked.
Results showed that point-of-care availability of an evidence-based guideline and interventions targeted at provider engagement improved adherence to the new neonatal HSV guideline. Within 8 months, the median percentage of patients managed according to the new guideline recommendations increased from 40% to 80%. In infants not at high risk for infection, guideline adherence was 92% in infants aged >29 days compared with 69% in infants aged 0 to 28 days. Of the infants aged 0 to 28 days who did not receive guideline-adherent care, 37% received acyclovir and 57% of infants aged <22 days did not have CSF HSV testing. Further, acyclovir use decreased in non-high-risk patients from 26% to 7.9% (P <.001) but did not significantly change in high-risk patients (73% to 83%; P =.15). In addition, there were no cases of delayed acyclovir therapy initiation in HSV-positive cases.
Overall, the study authors concluded that, “Although the implementation strategies used in this [quality improvement] work are easily replicable, further multicenter work is necessary to establish the safety of these guidelines in other settings.”
Brower LH, Wilson PM, Kurowski EM, et al. Using quality improvement to implement a standardized approach to neonatal herpes simplex virus. Pediatrics. 2019;144(2):e20180262.