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Treatment in the ED should be directed at cardiorespiratory stabilization of the
infants, fluid resuscitation of neonates in septic shock, followed by assessment
for bacterial and viral causes of sepsis. Neonates with suspected HSV should be
admitted to the hospital and started on intravenous acyclovir therapy (60
mg/kg/day in three divided doses). Infants with keratitis or ocular disease should
also be given topical antiviral ophthalmic drops (1% trifluridine, 0.1%
iododeoxyuridine, or 3% vidarabine), in addition to intravenous acyclovir
therapy. Neonates should be placed on contact precautions. Infants receiving
therapy have a mortality rate of 29% in disseminated disease, 4% in CNS disease,
and <1% in SEM.

Neonatal Enteroviral Infection
Enteroviruses can be divided into the nonpolioviruses (coxsackie viruses,
“numbered” enteroviruses, echoviruses, parechoviruses) and polioviruses. The
incidence of infection in the United States is approximately 10% to 12%. These
viruses can be transmitted vertically during the third trimester of pregnancy,
resulting in infection during the immediate postpartum period. They can also be
transmitted horizontally by contact with secretions of infected people (including
the mother or other family members), or through the fecal–oral route. Infants
infected by horizontal transmission may present to the ED within 1 to 2 weeks
after nursery discharge. Infection peaks during the summer and fall months in
temperate areas, although this pattern is not as evident in neonates.
Enterovirus infections are more severe in neonates than in children,
particularly those of coxsackie B4 and echovirus E11. The most common types
reported are coxsackie B1 and echoviruses E11 strains. Absence of passive
maternal antibodies in the neonate’s blood stream (from lack of maternal
exposure or late maternal exposure prior to antibody response), exposure to a
high viral load, and virulent strains all increase the severity of infection. History
of a sick family member with a viral illness can help in making the diagnosis.
Signs and symptoms vary from mild fever to high fever with vomiting, diarrhea,
irritability, poor feeding, respiratory distress, lethargy, hypoperfusion, or shock.

Physical examination may show a diffuse maculopapular rash, hepatomegaly and
jaundice from acute hepatitis, respiratory distress, systemic hypoperfusion,
tachycardia or arrhythmia from myocarditis, coagulopathy in severe cases,
seizures, focal neurologic signs, or altered level of consciousness from
meningoencephalitis. Sepsis workup should be initiated including blood culture,
urine culture, and lumbar puncture. CSF studies reveal typical findings of viral
meningitis, with pleocytosis, elevated protein, and normal glucose levels although