1. Sykes, Stephanie R. DNP, APRN-CNP, NNP-BC
  2. Sharpe, Elizabeth L. DNP, APRN-CNP, NNP-BC, FAANP, FAAN


Background: Neonatal herpes simplex virus (HSV) infections can be challenging to diagnose and often occur without maternal history of infection. Routine initial pharmacologic management when a neonate presents with signs of sepsis in the first weeks of life typically targets antibiotic therapies. This case illustrates the importance of the addition of antiviral coverage, especially when a neonate demonstrates temperature instability and neurologic changes.


Clinical Findings: This case report describes the unique presentation of a 9-day old neonate with clinical findings significant for sepsis. This neonate was diagnosed with methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia with concomitant disseminated HSV-2 infection after presenting with temperature instability, lethargy, and signs of multisystem organ impairment.


Primary Diagnosis: This neonate was diagnosed with disseminated HSV infection, which occurs in 25% of neonatal HSV disease.


Interventions: Treatment was initiated with high-dose intravenous acyclovir at 20 mg/kg/dose every 8 hours along with broad-spectrum antibiotics. Management should include anticipating and monitoring for progressive multisystem organ failure in bacterial or viral infection.


Outcomes: This patient did not survive despite maximal intervention from the neonatal intensive care unit team. Disseminated HSV neonatal infections are associated with high mortality rates when they are present alone, and mortality is higher with concurrent bacteremia.


Practice Recommendations: Providers should have a high index of suspicion for HSV infection in neonates presenting in the first 1 to 3 weeks of life with signs of sepsis. Prophylactic treatment with high-dose acyclovir as an adjunct to broad-spectrum antibiotics while awaiting laboratory confirmation can be lifesaving.