Neonatal Herpes Simplex Virus Disease | Infectious Diseases Management Program at UCSF

Patient Population:

Pediatric

Condition	Major Pathogens	First-choice Therapy	Alternative Therapy	Comments
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	Herpes simplex virus	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
Asymptomatic infant born to mother with active HSV lesions		Refer to published guidelines, or consult ID

Condition

Major Pathogens

First-choice Therapy

Alternative Therapy

Comments

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

Herpes simplex virus

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

Asymptomatic infant born to mother with active HSV lesions

Refer to published guidelines, or consult ID

References:

American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021. 

Kimberlin DW, Baley J, Committee on Infectious Diseases, et al. Guidance on management of asymptomatic neonates born to women with active genital herpes lesions. Pediatrics 2013;131:383–6.

Congenital/Perinatal Infections