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This article is intended for primary care clinicians, dermatologists, and other specialists caring for children with eczema herpeticum.
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CME Released: 11/16/2011
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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.
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
