Current Practice Patterns Regarding Diagnostic Investigations and Empiric Use of Acyclovir by Canadian Pediatric Emergency Physicians in Febrile Neonates

Objective: The aim of this study was to assess current attitudes and approaches to the febrile neonate in terms of diagnostic investigations and empiric treatment of suspected herpes simplex virus (HSV) infection. Methods: Between March 2010 and November 2010, a survey describing a hypothetical case of a febrile neonate presenting to the ED without clear signs of an HSV infection was sent to tertiary care pediatric emergency physicians across Canada. Participants were asked multiple choice and open-ended questions to obtain information about their choice of investigations, empiric treatment, and impression of the likelihood of HSV in the case. Survey data were analyzed using univariate statistics. Results: Blood culture (98.6%), complete blood count (99.3%), lumbar puncture (81.2%), and nasopharyngeal swabs for respiratory viruses (61.6%) were most commonly performed by the 139 respondents, whereas 33% reported they would send cerebrospinal fluid for HSV polymerase chain reaction. Most (76%) would administer empiric antibiotics, whereas 5.8% included acyclovir to their treatment regimen. Greater than 50% included positive maternal history as an important factor in determining a febrile neonate's risk of HSV infection. Thirty-four percent reported that the wellness of the child, the presence of skin changes (37%), and the presence of any worrisome neurologic sign or symptom (37%) would influence their decision for investigations and empiric administration of acyclovir. Conclusions: Canadian pediatric emergency physicians are aware of risk factors for neonatal HSV infection and tailor their history and diagnostic investigations toward the diagnosis of HSV infection, but very few empirically administer acyclovir. Examination of future Canadian HSV guidelines for this patient population is warranted.