• A Chantal Caviness, Gail J Demmler, J Michael Swint, and Scott B Cantor.
• Texas Children's Hospital, Section of Pediatric Emergency Medicine, 6621 Fannin St, Houston, TX 77030, USA. accavine@texaschildrenshospital.org
• Arch Pediatr Adolesc Med. 2008 Jul 1;162(7):665-74.

ObjectiveTo determine the clinical effectiveness and cost-effectiveness of testing for and empirically treating herpes simplex virus (HSV) infection in neonates with fever aged from birth to 28 days.DesignCost-effectiveness analysis.SettingDecision model.PatientsNeonates with fever with no other symptoms and neonates with fever with cerebrospinal fluid (CSF) pleocytosis.InterventionsFour clinical strategies: (1) HSV testing and empirical treatment while awaiting test results; (2) HSV testing and treatment if test results were positive for HSV or the patient had symptoms of HSV; (3) treatment alone without testing; or (4) no HSV testing or treatment unless the patient exhibited symptoms. The 2 HSV testing methods used were CSF HSV polymerase chain reaction (PCR) and comprehensive evaluation with blood HSV PCR, CSF HSV PCR, and multiple viral cultures.Main Outcome MeasuresTwelve-month survival and quality-adjusted life expectancy with a cost-effectiveness threshold of $100,000 per quality-adjusted life year (QALY) gained.ResultsClinical strategy 1, when applied in febrile neonates with CSF pleocytosis, saved 17 lives per 10,000 neonates and was cost-effective using CSF HSV PCR testing ($55,652/QALY gained). The cost-effectiveness of applying clinical strategy 1 in all febrile neonates depended on the cost of the CSF HSV PCR, prevalence of disease, and parental preferences for neurodevelopmental outcomes. Clinical strategies using comprehensive HSV testing were not cost-effective in febrile neonates ($368,411/QALY gained) or febrile neonates with CSF pleocytosis ($110,190/QALY gained).ConclusionsTesting with CSF HSV PCR and empirically treating with acyclovir sodium saves lives and is cost-effective in febrile neonates with CSF pleocytosis. It is not a cost-effective use of health care resources in all febrile neonates.

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