Congenital/Perinatal Infections

Ophthalmia neonatorum (eye infection at <30 days of age) 

Gonococcal ophthalmia usually manifests 2-5 days after birth with acute, severe conjunctivitis 

C. trachomatis ophthalmia usually manifests 5-12 days after birth with less severe conjunctivitis 

Either can present with discharge +/- conjunctival injection. If clinical concern in infant <30 days, at BCH the following tests should be obtained by swabbing everted eyelid: 

1. Chlamydia/Gonorrhea RNA NAAT (independently validated both BCH OAK and SF labs but not FDA-approved)

AND  

2. “Eye culture” (respiratory bacterial culture with Gram stain,  with comment to “look for N. gonorrhoeae”)  

Presumptive treatment (without a confirmed diagnosis) for N. gonorrhoeae is indicated for intracellular gram-negative diplococci on Gram stain, or high index of clinical suspicion pending cultures 

See guidance on HSV evaluation & management in neonates  

Chlamydia trachomatis 

Neisseria gonorrhoeae 

Consider HSV, other bacterial pathogens (per culture results), or noninfectious causes 

Proven or presumptive N. gonorrhoeae: 

Ceftriaxone 50 mg/kg/dose (max 125 mg/dose) IM/IV x 1 dose 

Refer to guidance addressing use of Ceftriaxone in neonates. Intravenous calcium-containing solutions should not be administered within 48 hours before or after Ceftriaxone administration 

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Proven C trachomatis: 

Azithromycin  
20 mg/kg/dose enterally daily x 3 days* 

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Other:  

Management based on clinical characteristics, culture results as indicated 

Topical therapy is not indicated for C. trachomatis or N. gonorrhoeae treatment - both require systemic therapy  

Infants with N. gonorrhoeae ophthalmia neonatorum require Ophthalmology consultation, admission for eye irrigation, and should be evaluated clinically for signs of disseminated infection (e.g., sepsis, arthritis, and/or meningitis) 

*Enteral Azithromycin recommended over Erythromycin given equivalent spectrum of activity with more convenient dosing and better side effect profile (decreased potential risk of QT prolongation and pyloric stenosis; fewer medication interactions) 

C. trachomatis ophthalmia neonatorum is generally self-limited, treatment is indicated to reduce risk of subsequent pneumonia or invasive disease 

Refer birth parent for evaluation as clinically indicated 

Syphilis (congenital) 

Refer to CDPH algorithm for guidance on interpretation of infant risk and recommended evaluation 

Full treatment course (as indicated per algorithm): 

Preterm infant (<=36 weeks GA): Refer to neonatal dosing guidelines for penicillin interval adjustments 

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Age <=7d:
Penicillin G 50,000 units/kg/dose IV q12h 

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Age 8 days to <1 month:
Penicillin G 50,000  units/kg/dose IV q8h 

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Age >=1 month:
Penicillin G 50,000 units/kg/dose IV q4-6 hours  

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Single dose - only use in selected infants as indicated per algorithm: Benzathine penicillin 50,000 units/kg IM x 1 dose 

Consider ID consult 

Duration (IV): 10 days 

Penicillin treatment should be continued without interruption; if > 1 day of treatment is missed, the entire course should be resumed and continued for the full duration from time of re-initiation  

Neonatal herpes simplex disease - disseminated, CNS/encephalitis, or mucocutaneous (skin/eye/mouth) (including young infants < 3 months old) 

Consider diagnosis in infants with cutaneous vesicles, seizure, focal neurologic signs, CSF pleocytosis, unexplained thrombocytopenia or hepatitis 

See guidance on HSV disease in older pediatric patients 

Acyclovir 20 mg/kg/dose IV q8h 

All infants with neonatal HSV disease should receive suppressive therapy following completion of above treatment course, for a minimum 6 months: 

Acyclovir 300 mg/m2/dose enterally tid  

ID consult recommended 

All infants with suspected or proven neonatal HSV disease should have a full evaluation with LP, CSF HSV PCR, plasma HSV PCR, cultures or PCR of conjunctivae, mouth, nasopharynx, and rectum  

Consider  ophthalmologic examination and neuroimaging for infants diagnosed with neonatal HSV disease  

Ocular HSV requires addition of topical antivirals  (trifluridine or ganciclovir gel) and ophthalmology co-management 

Duration:  
Skin/eye/mouth disease: 14 days 

CNS disease: Minimum of 21 days (repeat LP near end of therapy, duration extended if HSV still detected in CSF) 

Disseminated disease: 21 days 

Symptomatic congenital CMV disease  

Diagnosed based on detection of CMV in the urine or saliva within the first 3 weeks of life 
 
WITH  

Symptoms:  

Moderately to severely symptomatic: 

Multiple manifestations attributable to CMV infection: thrombocytopenia, petechiae, hepatomegaly, splenomegaly, intrauterine growth restriction, hepatitis 
 
OR  

CNS involvement such as microcephaly, radiographic abnormalities consistent with CMV-related CNS disease (ventriculomegaly, calcifications, periventricular echogenicity, cortical or cerebellar malformations), abnormal CSF indices for age, chorioretinitis, or detection of CMV DNA in CSF  

See 2nd column for continued categories 

Cytomegalovirus 

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Symptom classification continued from 1st column:  

Mildly symptomatic: 

1-2 isolated manifestations that are mild and transient, occurring in isolation (e.g. single measurement of low platelet count) 

Asymptomatic congenital CMV infection with isolated sensorineural hearing loss (SNHL):  

Sensorineural hearing loss, with no other apparent abnormalities 

Asymptomatic congenital CMV infection: 

No apparent abnormalities to suggest congenital CMV disease, and normal hearing 

Asymptomatic with normal hearing:  
Treatment not recommended  

Mildly symptomatic, or asymptomatic with isolated SNHL, or diagnosed after first month of life: 
Current guidelines do not recommend  treatment routinely. Consult ID for individualized assessment.  

Moderate to severely  symptomatic, within first month of life, gestational age >= 32 weeks:  

Valganciclovir  
16 mg/kg/dose enterally bid 

Adjust dose monthly to account for weight gain 

Moderate to severely  symptomatic, within first month of life, gestational age <32 weeks: 
Consult ID for individualized management & medication dosing 

Unable to take enteral medication: 

Ganciclovir  

6 mg/kg/dose IV q12h  

ID consult recommended. Multiple follow-up evaluations are recommended, recommendations here focused on treatment with antivirals only 

Monitoring During Therapy:  
Absolute neutrophil count weekly x 6 weeks, at 8 weeks, then monthly for duration of therapy 

AND 

AST, ALT monthly 

Duration: 6 months