Neonatal HSV Infection

Presentation (3 Classifications)

• SEM (Skin, Eye, Mouth): Vesicular rash, conjunctivitis, mouth ulcers (presents 1-2 weeks of life)
• CNS (Central Nervous System): Seizures, lethargy, irritability, poor feeding, bulging fontanelle (presents 2-3 weeks of life)
• Disseminated disease: Severe viral sepsis, DIC, liver failure, severe pneumonitis (presents 1st week of life)

Diagnostic Workup

• HSV Surface Swabs: Swab conjunctiva, mouth, nasopharynx, and rectum for HSV PCR/culture (Wait 24h of life before swabbing asymptomatic exposed infants)
• Vesicle swab (if lesions present)
• CSF HSV PCR, cell count, and protein
• Blood HSV PCR
• Liver Function Tests (ALT/AST) to assess for disseminated disease

Management

• Do NOT delay therapy if symptomatic: Start High-dose IV Acyclovir (60 mg/kg/day divided q8h)
• Duration: 14 days for SEM, 21 days for CNS or Disseminated disease
• Repeat CSF HSV PCR near end of 21-day course for CNS disease; must be negative to stop therapy
• Oral Acyclovir suppression therapy for 6 months after IV course completion

Infection Control & Pharmacokinetics

• Ampicillin dosing (<7 days, >2kg): 100 mg/kg/dose IV q8h for meningitis coverage; 50mg/kg/dose q12h for bacteremia.
• Gentamicin dosing: 4-5 mg/kg/dose IV q24h; MUST check trough levels prior to 3rd dose (Target trough < 1.0 mcg/mL).
• Strict contact and droplet precautions until specific viral/bacterial pathogen is ruled out.
• Assess for osteomyelitis/septic arthritis with thorough physical exam including joint mobility and symmetry.
• LP execution: Defer lumbar puncture ONLY if infant is hemodynamically unstable or profoundly thrombocytopenic.

Standardized Discharge & Follow-Up Criteria

• Adequate weight gain explicitly > 15-30g/day over a continuous 3-5 day period.
• Maintenance of temperature in an open crib with standard clothing for 48 hours.
• Successful completion of the 90-120 minute Infant Car Seat Challenge.
• Caregiver successfully completed CPR training, rooming-in, and independent medication administration.
• Referrals placed for High-Risk Infant Follow-Up Clinic, Early Intervention (PT/OT), and appropriate sub-specialists.

Diagnostic & Management Algorithm

• Neonatal HSV Algorithm: [START] Vesicles OR Seizures OR Maternal History -> [ACTION] Swab infant / stat CSF PCR -> [PHARMACOLOGY] IV Acyclovir 60mg/kg/day -> [GOAL] Treat 14 days (SEM) or 21 days (CNS/Disseminated)

References

1. Kimberlin DW, Baley J. Guidance on management of asymptomatic neonates born to women with active genital herpes lesions. Pediatrics.
2. Pinninti SG, Kimberlin DW. Preventing herpes simplex virus in the newborn. Clin Perinatol.