I am pretty sure that perinatal HSV is not typically common beyond 3rd week, although there are case reports up to 6wks of age, so would not worry unless baby was ill or a "true" bloody tap.  I think that any CSF abnormality at this age should be covered with meningitic doses because you may not get significant pleocytosis early on.  Most recent meningitis studies exclude 3mo and under patients for this reason.  Another reason, and perhaps this is regional, is that we have seen an increase in the number of cases of strep sepsis and meningitis.  The ID people are telling me that there are emerging strains of strep that are not covered by the vaccine that are doing this, so herd immunity is not really helping the infants that much.  Then again, AMP is not the greatest drug for strep anyway...  I guess this was the dogma when I was a resident and I do not have any good reason to change my practice.

The interesting question to me would for anyone who has a rapid turnaround time for CSF PCR and if, as in this case, it was positive, would you be sending the baby home?

Michael Gorn
St. Joseph's Regional Medical Center
Paterson, NJ

--- On Fri, 8/7/09, scott barron <[log in to unmask]> wrote:

From: scott barron <[log in to unmask]>
Subject: Re: question
To: [log in to unmask]
Date: Friday, August 7, 2009, 7:04 PM

     Not in a clinically well child with those CSF values.  As far as acyclovir, again, these children are not well appearing and the CSF can be rather bloody.  LFTs are usually elevated in young infants with systemic herpes as well.

     Some may not start antibiotics or even admit a child greater than 28-days with this scenario and reliable parents.  SB 

Scott A. Barron, MD, FAAP

Children's Emergency Center

Mercy Medical Center

Des Moines, IA  50314



> Date: Fri, 7 Aug 2009 11:21:18 -0400
> From: [log in to unmask]
> Subject: question
> To: [log in to unmask]
> Ok...I am trying to summarize this as briefly as possible...
> I had a 5 week old, nl birth hx, no maternal herpes/lesions, feeding well, 
> temp at home 101.6 Axillary, no fever in ER.
> Pt. looked well, NL exam except classic viral exanthem.
> I did a "complete sepsis w/u":
> WBC 18 nl diff, lytes nl, UA nl, serum glucose from lytes 75
> CSF 64 WBC's, 2 RBC's, CSF Glucose 38, CSF protein 78, CSF gram stain - 
> CXR -
> I ordered 50mg/kg of ampicillin and 50 mg kg of cefotaxime and called for 
> admission. The peds hospitalist, a great guy, asked if I would mind to 
> increase my amp dose to 100mg/kg and to add on acyclovir. 
> I complied, not the biggest deal in the world.
> To me, this was 64 WBC's, NL gram stain, with obvious viral exanthem,, 
> clinically I was thinking this was most likely a viral meningitis.
> Turns out the CSF Enteroviral PCR was +.
> The PICU attending, kindly asked me why I did not give 100mg/kg of Amp 
> right away, rather than 50mg/kg that I originally ordered. And this was asked 
> in a very non confrontational manner.
> My answer was, as above, classic viral exanthem, 64 WBC's, nl CSF gram 
> stain, and this appeared to be a viral meningitis. PICU attending's response 
> was, basically, that he felt that if there is ANY abnormality on the tap we 
> should start with the higher amp dose in the ER. 
> I am a believer of making errors in the side of caution (to a degree, of 
> course), and I have been thinking about this for the past 2 hours now....
> To my Peds ER you give 100mg/kg of amp with any, and I 
> mean ANY abnormality to the CSF, whatsoever.....
> Thanks for considering this....
> -Todd Z
> Dr. Todd Zimmerman
> Medical Director, Pediatric Emergency Medicine
> St. Alexius Medical Center/Alexian Brothers Medical Center
> Midwest Emergency Associates 
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:

Get back to school stuff for them and cashback for you.
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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The URL for the PED-EM-L Web Page is: