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Pediatrics. 2019 Aug;144(2). pii: e20180262. doi: 10.1542/peds.2018-0262.

Using Quality Improvement to Implement a Standardized Approach to Neonatal Herpes Simplex Virus.

Author information

Divisions of Hospital Medicine.
Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
Pediatric Emergency Medicine.
Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Infectious Diseases, and.
Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Division of External Primary Care, Nemours/Alfred I duPont Hospital for Children, Wilmington, Delaware.
Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; and.



Neonatal herpes simplex virus (HSV) infections are associated with high mortality and long-term morbidity. However, incidence is low and acyclovir, the treatment of choice, carries risk of toxicity. We aimed to increase the percentage of patients 0 to 60 days of age who are tested and treated for HSV in accordance with local guideline recommendations from 40% to 80%.


This quality improvement project took place at 1 freestanding children's hospital. Multiple plan-do-study-act cycles were focused on interventions aimed at key drivers including provider buy-in, guideline availability, and accurate identification of high-risk patients. A run chart was used to track the effect of interventions on the percentage managed per guideline recommendations over time by using established rules for determining special cause. Pre- and postimplementation acyclovir use was compared by using a χ2 test. In HSV-positive cases, delayed acyclovir initiation, defined as >1 day from presentation, was tracked as a balancing measure.


The median percentage of patients managed according to guideline recommendations increased from 40% to 80% within 8 months. Acyclovir use decreased from 26% to 7.9% (P < .001) in non-high-risk patients but did not change significantly in high-risk patients (73%-83%; P = .15). There were no cases of delayed acyclovir initiation in HSV-positive cases.


Point-of-care availability of an evidence-based guideline and interventions targeted at provider engagement improved adherence to a new guideline for neonatal HSV management and decreased acyclovir use in non-high-risk infants. Further study is necessary to confirm the safety of these recommendations in other settings.


Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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