Neonatal Herpes Simplex Viral Infections and Acyclovir: An Update

Abstract

Neonatal herpes simplex virus (HSV) infections have high morbidity and mortality rates. Optimization of treatment and prevention strategies are imperative to improve the care and outcomes of neonates infected with HSV. Management of HSV includes reducing neonatal transmission, treating acute infections, and limiting adverse neurodevelopmental outcomes and future cutaneous outbreaks after acute infections. Transmission risk may be affected by route of delivery and maternal suppressive therapy. Neonatal HSV infections are divided into 3 categories: localized skin, eyes, or mouth; localized central nervous system; or disseminated infections. Parenteral acyclovir, the pharmacologic agent of choice, is used when treating each type of infection. However, dosage strategies and durations of therapy may vary based on disease state severity, presentation, and patient characteristics. Oral acyclovir may be used as suppressive therapy after acute treatment completion in specific neonatal populations, reducing long-term adverse neurodevelopmental outcomes and future skin eruptions. The mortality rate remains high even with treatment.

Neonatal Sepsis

“…Guidelines for prevention of perinatal transmission of HSV recommend cesarean delivery for women with active genital lesions or prodromal symptoms. It is also recommended that pregnant women with a history of genital herpes infection begin taking oral suppressive therapy at 36 weeks of gestation [62].…”

The Impact of Maternal Infection on the Neonate

“…The remaining 25% of infants with HSV will have disseminated disease which can involve multiple organs, most commonly the liver and lungs [18]. The onset of disease varies between the different manifestations, with SEM disease presenting at 5-11 days of life, CNS disease presenting between 8 and 17 days of life, and disseminated disease presenting between 10 and 12 days of life [61]. Initial symptoms may be non-specific and include feeding difficulties, lethargy, seizures, suspected sepsis, vesicular rash or severe liver dysfunction, with as many as 30% of infected neonates not having skin lesions [52,60].…”

“…Only 10% of infants survive in untreated HSV disseminated disease with 50% of infants surviving in untreated HSV CNS disease [61]. Inadequately treated or untreated HSV SEM disease can progress to either disseminated or CNS disease; those that survive have a significant proportion that show some neurologic sequelae, namely in the form of motor, speech, and developmental delay [61]. Outcomes, especially mortality, improve the earlier that treatment is initiated, making it imperative to evaluate and begin empiric treatment whenever HSV infection is suspected [61].…”

Liver Diseases in the Perinatal Period: Interactions Between Mother and Infant

“…Additional risk factors include a prolonged rupture of membranes or disruption of the mucocutaneous barrier, whereas delivery by C‐section may be protective . Only 10% of neonates with disseminated disease, including hepatic involvement, survive without treatment . Given the significant potential mortality, initiation of acyclovir treatment in all potential cases of neonatal HSV may be life‐saving while awaiting definitive diagnostic testing .…”

“…(4) Only 10% of neonates with disseminated disease, including hepatic involvement, survive without treatment. (5) Given the significant potential mortality, initiation of acyclovir treatment in all potential cases of neonatal HSV may be life-saving while awaiting definitive diagnostic testing. (4) HSV diagnosis requires isolation of HSV in tissue culture or polymerase chain reaction testing.…”