Algorithm for the evaluation and management of asymptomatic neonates after vaginal or cesarean delivery to women with active genital herpes lesions

HSV: herpes simplex virus; PCR: polymerase chain reaction; CSF: cerebrospinal fluid; ALT: alanine aminotransferase; IV: intravenous; SEM: skin, eye, and mouth; CNS: central nervous system.
* Evaluation and treatment is indicated prior to 24 hours of age if the infant develops signs and symptoms of neonatal HSV disease (eg, mucocutaneous vesicles, seizures, lethargy, respiratory distress, thrombocytopenia, coagulopathy, hypothermia, sepsis-like illness, hepatomegaly, ascites, or markedly elevated transaminases). In addition, immediate evaluation and treatment may be considered if there is prolonged rupture of membranes (>4 to 6 hours) or if the infant is preterm (≤37 weeks gestation).
¶ Surface cultures should be obtained from ALL of the following sites: conjunctivae, mouth, nasopharynx, and rectum. In addition, if the neonate had a scalp electrode placed, its site should be cultured.
Δ For details regarding determining maternal HSV infection classification, refer to UpToDate's content on genital HSV infection in pregnancy.
◊ Discharge after 48 hours of negative HSV cultures (and negative PCRs) is acceptable if other discharge criteria have been met, there is ready access to medical care, and a person who is able to comply fully with instructions for home observation will be present. If any of these conditions are not met, the infant should be observed in the hospital until HSV cultures are finalized as negative or are negative for 96 hours after being set up in cell culture, whichever is shorter.
§ The dose of acyclovir must be adjusted for neonates with renal impairment and/or weight <1 kg. Refer to Lexicomp for additional dosing information. If IV acyclovir is not available, ganciclovir is an alternative. Refer to UpToDate's content on management of neonatal HSV infection for additional information.
¥ Serum ALT values in neonates may be elevated due to noninfectious causes (eg, delivery-related perfusion). For this algorithm, ALT values >2 times the upper limit of normal may be considered suggestive of neonatal disseminated HSV disease for HSV-exposed neonates.
‡ Refer to UpToDate's content on clinical features and diagnosis of neonatal HSV infection for more details.
† Refer to UpToDate's content on diagnosis of neonatal HSV infection for details of distinguishing between the three disease categories (SEM, CNS, and disseminated disease).
** Consultation with a pediatric infectious disease specialist is warranted in cases of persistently positive CSF HSV PCR.