Asymptomatic neonate following vaginal or cesarean delivery to a person with visible genital lesions that are characteristic of HSV

Obstetric provider obtains swab of lesion for HSV NAAT and, if available, culture Type all positives

Maternal history of genital HSV preceding pregnancy?

Send type specific serology for HSV-1 and HSV-2 antibodies in birthing person, if test assays are available at the delivery hospital

At ~ 24 hours of age^a obtain from the neonate:

HSV surface^b cultures, if available, and NAATs
HSV blood NAAT^c

If infant remains asymptomatic, do not start acyclovir

At ~ 24 hours of age^a obtain from the neonate:

HSV surface^b cultures, if available, and NAATs
HSV blood NAAT^c
CSF cell count, chemistries, and HSV NAAT
Serum ALT
Start IV acyclovir at 60 mg/kg/DAY in three divided doses

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Stop acyclovir. Educate family for signs and symptoms of neonatal HSV disease and follow closely.^d

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Obtain CSF for cell count, chemistries, and HSV NAAT. Send serum ALT. Start IV acyclovir at 60 mg/kg/DAY in three divided doses.

Educate family on signs and symptoms of neonatal HSV disease and follow closely.^d

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^a Evaluation and treatment is indicated prior to 24 hours of age if the infant develops signs and symptoms of neonatal HSV disease. In addition, immediate evaluation and treatment may be considered if:

There is prolonged rupture of membranes (>4–6 hours)
The infant is premature (≤37 weeks gestation)

^b Conjunctivae, mouth, nasopharynx, and rectum, and scalp electrode site, if present.

^c HSV blood PCR is not utilized for assignment of disease classification.

^d Discharge following 48 hours of negative HSV cultures (if sent) 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. Discharge does not need to be delayed awaiting NAAT results if all other above criteria have been met and a clear plan to follow-up on all virology results is in place. If any of these conditions is not met, the infant should be observed in the hospital until all HSV testing is finalized as negative or HSV cultures are negative for 96 hours after being set up in cell culture, whichever is shorter.