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CME

Delay in Drug Therapy for Eczema Herpeticum Affects Hospital Stay

  • Authors: News Author: Emma Hitt, PhD
    CME Author: Laurie Barclay, MD
  • CME Released: 11/16/2011
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 11/16/2012
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Target Audience and Goal Statement

This article is intended for primary care clinicians, dermatologists, and other specialists caring for children with eczema herpeticum.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Describe the epidemiology and outcomes of children hospitalized with eczema herpeticum, based on a multicenter, retrospective cohort study.
  2. Describe the association of delayed administration of acyclovir with outcomes in children hospitalized with eczema herpeticum, based on a multicenter, retrospective cohort study.


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Author(s)

  • Emma Hitt, PhD

    Emma Hitt is a freelance editor and writer for Medscape.

    Disclosures

    Disclosure: Emma Hitt, PhD, has disclosed no relevant financial relationships.
    Dr. Hitt does not intend to discuss off-label uses of drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.
    Dr. Hitt does not intend to discuss investigational drugs, mechanical devices, biologics, or diagnostics not approved by the FDA for use in the United States.

Editor(s)

  • Brande Nicole Martin

    CME Clinical Editor, Medscape, LLC

    Disclosures

    Disclosure: Brande Nicole Martin has disclosed no relevant financial relationships.

CME Author(s)

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC

    Disclosures

    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.


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CME

Delay in Drug Therapy for Eczema Herpeticum Affects Hospital Stay

Authors: News Author: Emma Hitt, PhD CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME Released: 11/16/2011

Valid for credit through: 11/16/2012

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Clinical Context

Atopic dermatitis occurs in approximately 15% to 30% of children. It is associated with an impaired skin barrier and increased susceptibility to bacterial and viral infection, including disseminated herpes simplex virus (eczema herpeticum). Reported mortality rates for this potentially life-threatening complication of atopic dermatitis have approached 50%.

In adult outpatients, acyclovir has been shown to be beneficial for herpes simplex virus infection. The current mortality rate and effect of delaying acyclovir in children hospitalized with eczema herpeticum have not yet been determined. The objective of this study by Aronson and colleagues was to examine the epidemiology and outcomes of children hospitalized with eczema herpeticum and to evaluate the association of delayed initiation of acyclovir on clinical outcomes.

Study Synopsis and Perspective

In hospitalized children with eczema herpeticum, early administration of acyclovir therapy decreases the length of hospitalization, according to new research.

Paul L. Aronson, MD, from the departments of emergency medicine and pediatrics at the Children's Hospital of Philadelphia in Pennsylvania, and colleagues published their findings online November 14 in Pediatrics.

According to the researchers, acyclovir therapy has not been evaluated in pediatric patients with eczema herpeticum. "In addition, the effect of timing of initiation of acyclovir in hospitalized patients with eczema herpeticum is unknown," the authors write.

The researchers sought to describe the epidemiology of eczema herpeticum in hospitalized patients, "including incidence of bacterial infection, requirement for [intensive care unit] admission, and mortality rate." They also sought to determine the effect of delaying treatment in this setting.

The study, which was conducted retrospectively from January 1, 2001, to March 31, 2010, included 1331 children aged between 2 months and 17 years from 42 tertiary care children's hospitals in the Pediatric Health Information System database.

Just less than a third of patients (30.3%) were infected with Staphylococcus aureus, 3.9% had a bloodstream infection, and 3.8% (51 patients) were admitted to the intensive care unit.

In all, 67.1% of the patients were treated with acyclovir on the first day of admission. With each day in delay of treatment, the length of hospital stay in these patients were increased by 11% (95% confidence interval [CI], 3% - 20%; P = .008), and if treatment had not been started by day 3, the length was increased by 41% (95% CI, 19% - 67%; P < .001) compared with those who started on day 1. Treatment that began between day 4 and day 7 increased the length of stay by 98% (95% CI, 60% - 145%; P < .001).

Use of topical corticosteroids on day 1 of hospitalization was not associated with a decrease in length of stay, however. No deaths were reported.

"To our knowledge, this multicenter observational study is the largest study to date in which the characteristics and outcomes of hospitalized children with eczema herpeticum are described and the first in which the association of delayed acyclovir initiation and outcomes in patients with eczema herpeticum is reported," the authors note.

They add that the median length of stay was 3 days, so the results are "clinically relevant" and that "[t]his increased [length of stay] may lead to higher costs and increased risk of health care-acquired infections."

Potential weaknesses of the trial include, but are not limited to, lack of generalizability to children with mild eczema herpeticum and possible residual confounding resulting from differences in clinical presentation explaining early vs late start of acyclovir.

"Patients clinically suspected of having eczema herpeticum should receive empiric therapy with acyclovir," conclude the authors, "because there is a statistically significant time-dependent increase in [length of stay] with every day of delay in initiating acyclovir therapy."

The study was supported by the National Institutes of Health, the Nicholas Crognale Chair for Emergency Medicine (Children's Hospital of Philadelphia), the National Institute of Allergy and Infectious Diseases, and the Robert Wood Johnson Foundation under its Physician Faculty Scholar Program. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online November 14, 2011. Abstract

Study Highlights

  • The cohort for this retrospective study consisted of 1331 children aged 2 months to 17 years hospitalized with eczema herpeticum between January 1, 2001, and March 31, 2010, at 42 tertiary care children's hospitals in the Pediatric Health Information System database.
  • Median age was 1 year.
  • The primary study endpoint was hospital length of stay.
  • The association between delayed acyclovir therapy and length of stay was examined with use of multivariable linear regression models.
  • No participants died during the study period, but 51 patients (3.8%) were admitted to the intensive care unit.
  • S aureus infection was diagnosed in 30.3% of the patients, and a bloodstream infection was present in 3.9%.
  • Median hospital length of stay was 3 days.
  • Use of topical corticosteroids on the first day of hospitalization was not associated with length of stay.
  • More than two thirds of patients (67.1%; n = 893) were given acyclovir on the first day of admission.
  • There was no difference in route of acyclovir administration between patients with early vs delayed receipt of acyclovir.
  • With each day delay in acyclovir initiation, the median hospital length of stay increased.
  • Delaying the start of acyclovir therapy by 1 day was associated with an 11% increase in length of stay (95% CI, 3% - 20%; P = .008).
  • Length of stay increased by 41% when acyclovir was started on day 3 (95% CI, 19% - 67%; P < .001) and by 98% when it was started between days 4 and 7 (95% CI, 60% - 145%; P < .001).
  • The investigators concluded that delaying acyclovir initiation was associated with increased length of stay in hospitalized children with eczema herpeticum, that use of topical corticosteroids was not associated with increased length of stay, and that mortality risk was low.
  • Early recognition of eczema herpeticum in children with atopic dermatitis is therefore important.
  • Delay in starting acyclovir may result in the spread of herpetic lesions, a prolonged course of disease, and longer hospital length of stay with higher costs and an increased risk for healthcare-acquired infections.
  • Limitations of this study include possible misclassification from discharge diagnosis coding, lack of generalizability to children with mild eczema herpeticum, inability to determine the duration of symptoms, and unmeasured confounding or residual confounding by indication.

Clinical Implications

  • In a multicenter, retrospective cohort study, rates of mortality and intensive care unit admission were low in hospitalized children with eczema herpeticum. Use of topical corticosteroids was not associated with increased hospital length of stay.
  • In a multicenter, retrospective cohort study, delaying acyclovir initiation in hospitalized children with eczema herpeticum was associated with increased length of stay. Early recognition of eczema herpeticum in children with atopic dermatitis is therefore important to reduce complications and healthcare costs.

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