title: Impact of an Institutional Guideline on the Care of Neonates at Risk for Herpes Simplex Virus in the Emergency Department.
abstract: OBJECTIVE
  Herpes simplex virus (HSV) is rare in neonates but carries significant morbidity and mortality in that group. Emergency department (ED) clinicians have little guidance to decide when to test for HSV and give acyclovir. We created an institutional guideline to provide guidance in patients younger than 6 weeks. Our objective was to evaluate whether guideline implementation affected the ED's decision to test for HSV, and ED use of HSV polymerase chain reactions (PCRs) and acyclovir.
  
  
  METHODS
  We reviewed charts for patients 1 year before implementation and 1 year after implementation of our guideline. Inclusion criteria were younger than 60 days, admitted through the ED, symptom onset younger than 6 weeks, and any one of the following criteria: (1) ED blood culture obtained, (2) ED or inpatient HSV PCR obtained, and (3) ED or inpatient acyclovir treatment. Premature patients and transfer patients were excluded. We compared whether the decision to initiate HSV testing, ED use of HSV PCRs, serum alanine aminotransferase, and acyclovir use changed post-guideline implementation.
  
  
  RESULTS
  We reviewed 173 charts pre-implementation and 129 post-implementation. We found a significant decrease in ED testing for HSV among patients who did not meet guideline criteria (P < 0.01). We saw an improvement in the use of alanine aminotransferase among patients who met criteria for testing (P = 0.02), but no change in the use of HSV PCRs or acyclovir use among tested patients.
  
  
  CONCLUSIONS
  Guideline implementation reduced HSV evaluations in low-risk patients, but did not improve test utilization or acyclovir administration among those tested. Additional work is needed to improve guideline utilization.
authors: From the Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.
authors: Fahd A
authors: FA
authors: Ahmad
authors: Gregory A
authors: GA
authors: Storch
authors: Aaron S
authors: AS
authors: Miller
mesh_terms: D000212:Acyclovir / Q000008:administration & dosage / Q000627:therapeutic use; D000410:Alanine Transaminase / Q000097:blood; D000998:Antiviral Agents / Q000008:administration & dosage / Q000627:therapeutic use; D003657:Decision Making / Q000502:physiology; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D017408:Guidelines as Topic / Q000592:standards*; D006561:Herpes Simplex / Q000097:blood / Q000134:cerebrospinal fluid / Q000175:diagnosis* / Q000453:epidemiology; D006801:Humans; D007231:Infant, Newborn; D007902:Length of Stay / Q000639:trends; D008297:Male; D065228:Non-Randomized Controlled Trials as Topic; D016133:Polymerase Chain Reaction; D010818:Practice Patterns, Physicians'; D018139:Simplexvirus / Q000235:genetics* / Q000302:isolation & purification
chemical_list: D000998:Antiviral Agents; D000410:Alanine Transaminase; D000212:Acyclovir