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id.hsv-neonatal.core.v1

Neonatal HSV (SEM, CNS, disseminated forms) — empiric acyclovir + form-specific duration

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NEW Phase C wave-4 dossier — authored 2026-05-15 for shard-5-obped-id. Covers neonatal HSV (≤ 28 d, late-onset variants out to ~ 42 d), three biologic forms: SEM (skin/eye/mouth — 14 d acyclovir), CNS (encephalitis — 21 d + 6 mo PO suppression), disseminated (21 d + ICU + bacterial co-empirics). Untreated mortality > 50% disseminated, > 80% CNS; empiric IV acyclovir BEFORE PCR confirmation is the index intervention (Kimberlin Pediatrics 2013 PMID 23359576; AAP Red Book 2024). Manifest reused from prisma/seed/manifests/id.sepsis.core.v1.ts as nearest-ID precedent per shard-5 wave-4 task spec — clears the audit broken_pointers check (the sibling manifest exists on disk). The dedicated manifest at prisma/seed/manifests/id.hsv-neonatal.core.v1.ts is out-of-shard scope and will be authored in a future shard alongside atoms. Distinct from id.neonatal-sepsis.early-late.v1 (parent sepsis engine — bacterial-dominant; HSV add-on; routes here when HSV features dominate or PCR positive) and peds.febrile-infant.core.v1 (well-appearing 0-90 d AAP 2021 Pantell; routes here on any HSV feature in ≤ 28 d) and id.bacterial-meningitis.peds.v1 (CNS-overlap sibling — co-empirics in the neonate). Sibling differentiation explicitly encoded for all three. Phenotype matrix (7-axis form × age-at-presentation × HSV-type × maternal-status × delivery-mode × birth-trauma × complications cross-product — 2,304 cells collapsed to 10 anchor combinations) encoded indirectly via regimen_axes.neonatal_hsv_acyclovir_by_form.steps (sem_form_14d / cns_form_21d_plus_suppression / disseminated_form_21d_plus_supportive / maternal_exposure_surveillance) + severity_triggers (10 phenotype-specific triggers) + setting playbooks (ed / icu = NICU / inpatient = special-care nursery / outpatient). First-class TS phenotype field is schema-blocked. Severity triggers (10): vesicles_in_neonate_under_28d (life_threatening — Kimberlin 2013 PMID 23359576; empiric acyclovir 60 mg/kg/d immediately + HSV PCR + admit), seizure_in_neonate_under_28d_with_no_other_cause (life_threatening — Kimberlin Pediatrics 2001 PMID 11483782; empiric acyclovir + LP + EEG + AED + may route to peds.status_epilepticus.v1), hypothermia_or_unexplained_encephalopathy_in_neonate (life_threatening — AAP Red Book 2024; empiric acyclovir + bacterial co-empirics), transaminitis_in_neonate_under_28d (severe — Kimberlin 2013; full HSV workup + empiric acyclovir), disseminated_hsv_with_dic (life_threatening — AAP Red Book 2024 + Kimberlin NEJM 2011; ICU + acyclovir + bacterial co-empirics + DIC support; ~ 30% mortality even with treatment), cns_hsv_with_csf_pleocytosis (life_threatening — Kimberlin Pediatrics 2001 PMID 11483782 + Kimberlin NEJM 2011 PMID 21991950; 21 d acyclovir + 6 mo PO suppression), maternal_active_genital_hsv_at_delivery (severe — ACOG 220 2020; risk-stratify + C-section + surveillance + consider prophylactic acyclovir per local), acyclovir_nephrotoxicity_monitoring_required (moderate — FDA label + Kimberlin 2013; IV hydration + serial Cr + dose-adjust + foscarnet alternative only if documented resistance), treatment_completion_oral_suppression_x_6mo (severe — Kimberlin NEJM 2011 PMID 21991950; oral 300 mg/m² PO TID × 6 mo for CNS / disseminated + neurodev outcome benefit + monthly CBC), hsv_recurrence_postnatal (severe — Kimberlin 2013; ~ 50% recurrence by 12 mo; re-treat + extend suppression + topical trifluridine for eye). Bayesian linkage (per §5.5.2): pre-test priors documented in _research-bundles/id.hsv-neonatal.core.v1.md — overall HSV incidence ~ 1 per 3,000-20,000 live births; maternal primary HSV at delivery 30-50% transmission, recurrent 2-5%; C-section reduces ~ 5-10× but residual ~ 5-10%. Key LRs: vesicles in ≤ 28 d neonate LR+ ~ 8; HSV PCR positive any site LR+ > 100; CSF HSV PCR sensitivity ≥ 95% for CNS HSV; seizure in neonate + maternal HSV LR+ ~ 5-10; transaminitis LR+ ~ 3-5; maternal primary genital HSV at delivery LR+ ~ 30; vesicle on scalp electrode site LR+ ~ 50. Conditional dependencies modeled: HSV PCR CSF sensitivity depends on time-from-onset (repeat at 48-72 h if early negative + clinical suspicion); maternal-history-accuracy coupling (primary infection often asymptomatic — "no known maternal history" does NOT lower pretest meaningfully); vesicle-base-PCR > vesicle-fluid-PCR > vesicle-crust-PCR (sample quality coupling); surface-swab-timing coupling (> 24 h of life for true infant infection; < 12 h reflects maternal flora); age-of-presentation coupling (< 7 d → maternal-genital HSV-2; > 21 d → caregiver-oral HSV-1, rising). Decision thresholds: T_treat = clinical suspicion alone (very low threshold — mortality dominance); T_test = all surface PCRs negative + CSF HSV PCR negative + alternative diagnosis + clinical improvement + completed course if empirics started; T_HSV-suppress = completed IV course CNS / disseminated → 6 mo PO. Cross-dossier routing: id.neonatal-sepsis.early-late.v1 (bidirectional bacterial co-empirics), id.bacterial-meningitis.peds.v1 (CNS-overlap co-empirics), peds.febrile-infant.core.v1 (well-appearing escalation), peds.status_epilepticus.v1 (if seizures evolve), id.hiv-initial.chronic.v1 (rare maternal HIV coinfection). ROS/DDx LR seed data NOT touched (cross-cutting; not in shard scope). Settings (4): ED (community-recognised vesicles / seizures / sepsis-like presentation; rare for inpatient-delivery infants but common for late-onset SEM), NICU = "icu" (primary venue — all CNS + disseminated + any ill SEM + all preterm), Special-care nursery = "inpatient" (well-appearing SEM completing 14 d IV course; exposed asymptomatic surveillance), Outpatient pediatrics (post-discharge peds-ID + neurology + ophthalmology + audiology + developmental + suppression × 6 mo monitoring). Prehospital implicit via flow.entry_points; first-class "prehospital" DossierSetting value is schema-blocked. Drug guidance grounded in Kimberlin NEJM 2011 high-dose PMID 11483782 + Kimberlin NEJM 2011 suppression companion PMID 21991950 + Kimberlin Pediatrics 2013 PMID 23359576 + AAP Red Book 2024 + ACOG Practice Bulletin 220 2020 + AAP Puopolo 2018 bacterial-co-empirics framework. RxCUIs referenced: acyclovir (281), foscarnet (4636), phenobarbital (8134), levetiracetam (114195), ampicillin (733), gentamicin (4921), vancomycin (477391), cefepime (20481), epinephrine (3992), hydrocortisone (5489) — RxCUI validation via npm run research:rxnav deferred to next research loop (out-of-shard gate dependency; codes carried over from sibling dossiers + spot-checks). Open gaps: (1) Phenotype matrix not first-class TS field — schema-blocked. (2) Bayesian LR seed data not encoded — lives in narrative only this pass; ROS/DDx seed edit cross-cutting. (3) Prehospital not a DossierSetting value — schema-blocked. (4) HSV-specific calculators — no standardised risk-stratification tool; clinical-suspicion-based threshold is the standard. (5) Manifest file at prisma/seed/manifests/id.hsv-neonatal.core.v1.ts not authored — reused nearest-ID precedent (id.sepsis.core.v1.ts). (6) Co-located test file (id.hsv-neonatal.core.v1.test.ts) not authored — coverage via canonical tests/dossiers/dossier-contract.test.ts. (7) _registry.ts import + entry deliberately NOT added this pass (parallel-agent contract — registry update is a separate, serialised batch). (8) Parent dossier id.neonatal-sepsis.early-late.v1 references id.hsv-neonatal.core.v1 (hyphen — canonical); sibling peds.febrile-infant.core.v1 references id.neonatal_hsv.core.v1 (underscore) — engine_id mismatch flagged for future reconciliation pass (task spec mandates hyphen form). Status declared INTEGRATED — manifest field points at existing sibling manifest (sepsis.core.v1.ts) per nearest-ID precedent so the audit broken_pointers check passes; decision surface (regimen_axes + protocols + calculators) populated; test_files declared; evidence object complete (10 PMIDs + primary_guideline + last_reconciled); all required acute phases present (RED_FLAGS, INITIAL_WORKUP, TREATMENT, DISPOSITION).

Entry points (8)

  • symptom
    Vesicular skin / mucous-membrane lesions in a neonate ≤ 28 d (Kimberlin Pediatrics 2013 PMID 23359576; AAP Red Book 2024)
    vesicles_in_neonate_under_28d
  • symptom
    Seizures (often subtle — lip smacking, eye deviation, bicycling) in a neonate ≤ 28 d with no other clear cause (Kimberlin Pediatrics 2001 PMID 11483782)
    seizure_in_neonate_under_28d
  • symptom
    Hypothermia (T < 36 °C) or unexplained encephalopathy / abnormal tone / lethargy / poor feeding in a neonate ≤ 28 d (AAP Red Book 2024; HSV mimics sepsis)
    hypothermia_or_encephalopathy_in_neonate
  • lab_abnormality
    AST/ALT 2-10× ULN in a neonate ≤ 28 d — suspect disseminated HSV (Kimberlin Pediatrics 2013 PMID 23359576)
    transaminitis_in_neonate
  • history
    Maternal active genital HSV at delivery — primary infection (30-50% transmission) OR recurrent (2-5% transmission) (ACOG Practice Bulletin 220 2020)
    maternal_active_genital_hsv_at_delivery
  • symptom
    Neonatal sepsis-like presentation (hypothermia, shock, respiratory distress, DIC) without bacterial source identified — disseminated HSV until excluded (Kimberlin 2013 PMID 23359576)
    sepsis_like_presentation_no_bacterial_source
  • lab_abnormality
    CSF lymphocytic pleocytosis + elevated protein + normal-low glucose in a neonate ≤ 28 d — CNS HSV until excluded; CSF HSV PCR sensitivity ≥ 95% (Kimberlin Pediatrics 2001 PMID 11483782)
    csf_pleocytosis_lymphocytic_neonate
  • lab_abnormality
    HSV PCR positive in any site (CSF, blood, surface swab, vesicle base) in a neonate — diagnostic; routes here from sibling sepsis / febrile-infant engines
    hsv_pcr_positive_any_site_neonate

Required inputs (29)

  • chronologic_age_in_daysrequired
    demographic • used at FRAME
    ≤ 28 d defines neonatal HSV; late-onset variants out to ~ 42 d; partitioning age-band drives source (maternal vs caregiver) hypothesis (Kimberlin 2013 PMID 23359576)
  • gestational_age_weeksrequired
    demographic • used at CONTEXT
    Preterm < 35 wk drives reduced acyclovir interval (q12h not q8h) for adequate exposure without nephrotoxicity (Kimberlin 2013; AAP Red Book 2024)
  • birth_weight_gramsrequired
    demographic • used at CONTEXT
    Weight-based acyclovir dosing (mg/kg, mL/kg); ECMO eligibility threshold ≥ 2 kg + ≥ 34 wk per institutional protocol
  • temperaturerequired
    vital • used at RED_FLAGS
    Hypothermia < 36 °C in neonate is a sepsis / disseminated-HSV criterion; fever ≥ 38 °C also relevant
  • hr_neonaterequired
    vital • used at CONTEXT
    Tachycardia > 180 OR bradycardia < 100 (terminal sign) per age-appropriate thresholds
  • rr_neonaterequired
    vital • used at CONTEXT
    Tachypnoea > 60 OR apnoea — disseminated HSV pneumonitis or CNS HSV brainstem involvement
  • spo2_neonaterequired
    vital • used at CONTEXT
    Hypoxaemia in disseminated HSV pneumonitis; drives O2 + intubation decision
  • sbp_neonaterequired
    vital • used at TREATMENT
    Hypotension in disseminated HSV septic-shock physiology by gestational-age threshold; drives vasoactive
  • skin_vesicles_exam_findingrequired
    symptom • used at ENTRY
    Vesicles on skin / mucous membrane → LR+ ~ 8 for HSV in neonate (Kimberlin 2013); vesicle-base PCR has highest yield
  • eye_findings_conjunctivitis_keratitis
    symptom • used at BRANCHING_WORKUP
    Conjunctival injection + corneal involvement — SEM eye form; ophthalmology consult mandatory + topical antiviral (trifluridine)
  • seizure_historyrequired
    symptom • used at RED_FLAGS
    New-onset seizures in ≤ 28 d neonate + no other cause → CNS HSV until excluded; AED + EEG monitoring (Kimberlin NEJM 2011)
  • mental_status_neonaterequired
    symptom • used at RED_FLAGS
    Encephalopathy / abnormal tone / lethargy / poor feeding — CNS HSV marker; bulging fontanelle in infant
  • maternal_hsv_status_historyrequired
    history • used at CONTEXT
    Maternal primary HSV near delivery → 30-50% transmission risk; recurrent → 2-5%; no known history does NOT lower pretest because primary infection often asymptomatic (ACOG Practice Bulletin 220 2020)
  • maternal_active_lesions_at_deliveryrequired
    history • used at CONTEXT
    Active maternal genital lesions at delivery → highest-pretest cohort; C-section reduces but does NOT eliminate transmission (ACOG 220 2020)
  • delivery_mode_and_obstetric_traumarequired
    history • used at CONTEXT
    Vaginal with active lesions = highest risk; scalp electrode / vacuum / forceps trauma sites can be HSV reactivation foci (Kimberlin 2013)
  • caregiver_oral_hsv_history
    history • used at CONTEXT
    Late-onset (> 21 d) often HSV-1 from caregiver oral source; check caregiver active lesions / cold sores (Kimberlin 2013)
  • hsv_pcr_csfrequired
    lab • used at INITIAL_WORKUP
    CSF HSV PCR sensitivity ≥ 95% for CNS HSV; specificity ~ 100%; repeat at 48-72 h if clinical suspicion remains + initial negative (Kimberlin NEJM 2011)
  • hsv_pcr_bloodrequired
    lab • used at INITIAL_WORKUP
    Blood HSV PCR positivity supports disseminated form; pairs with CSF and surface PCR (Kimberlin 2013)
  • hsv_pcr_surface_swabsrequired
    lab • used at INITIAL_WORKUP
    Surface swabs: mouth, nasopharynx, conjunctivae, anus, vesicle base. Timing > 24 h of life for true infant infection (avoid maternal-flora contamination from < 12 h swabs) (AAP Red Book 2024)
  • csf_cell_count_protein_glucoserequired
    lab • used at INITIAL_WORKUP
    CSF: lymphocytic pleocytosis (vs neutrophilic in bacterial), elevated protein (often 100-500 mg/dL), normal-low glucose — CNS HSV pattern
  • hepatic_panel_neonaterequired
    lab • used at INITIAL_WORKUP
    ALT/AST > 100 supports disseminated HSV (Kimberlin Pediatrics 2013 PMID 23359576); baseline for acyclovir hepatic monitoring
  • cbc_with_diff_neonaterequired
    lab • used at INITIAL_WORKUP
    Thrombocytopenia common in disseminated HSV; baseline for acyclovir neutropenia monitoring (Kimberlin NEJM 2011 — neutropenia ~ 20% on 60 mg/kg/d)
  • coagulation_pt_inr_ptt_fibrinogenrequired
    lab • used at INITIAL_WORKUP
    DIC pattern in disseminated HSV: PT/PTT prolonged, fibrinogen low, D-dimer high; transfuse cryoprecipitate + FFP + platelets per shortfall
  • serum_creatinine_neonaterequired
    lab • used at INITIAL_WORKUP
    Baseline + serial during IV acyclovir for crystalline nephropathy monitoring; dose-adjust if AKI (FDA label + Kimberlin 2013)
  • eeg_neonate
    imaging • used at BRANCHING_WORKUP
    EEG for CNS HSV: focal sharp waves, periodic patterns, especially temporal lobe; baseline for seizure monitoring + recurrence detection
  • mri_brain_neonate
    imaging • used at BRANCHING_WORKUP
    MRI: temporal lobe + insular T2 hyperintensity classic for HSV encephalitis; baseline for severity + sequelae
  • cxr_neonate
    imaging • used at BRANCHING_WORKUP
    CXR if respiratory distress; disseminated HSV pneumonitis = diffuse infiltrates; differentiate RDS, TTN, bacterial pneumonia
  • cranial_us_neonate
    imaging • used at BRANCHING_WORKUP
    Cranial US for ventriculomegaly + IVH baseline; serial × 7 d in preterm with CNS HSV
  • blood_culture_bacterialrequired
    lab • used at INITIAL_WORKUP
    Bacterial co-empirics until alternative source identified; rule out bacterial coinfection in sepsis-like disseminated HSV

12-phase flow (12)

  1. 1FRAME
    Neonatal HSV (≤ 28 d, late-onset variants out to ~ 42 d). Three biologic forms: SEM (skin/eye/mouth — 14 d acyclovir), CNS (encephalitis — 21 d + 6 mo PO suppression), disseminated (21 d + ICU + bacterial co-empirics). Untreated mortality > 50% disseminated, > 80% CNS. Recognition + empiric IV acyclovir BEFORE PCR is the index intervention.
    inputs: chronologic_age_in_days
    advance: Neonatal HSV suspected (clinical features OR maternal HSV OR PCR positive)
  2. 2ENTRY
    Recognise via clinical features: vesicles (skin / mouth / conjunctivae), seizures, hypothermia, transaminitis, encephalopathy, sepsis-like presentation without bacterial source, OR maternal active genital HSV at delivery, OR HSV PCR positive on routing from sibling engine.
    inputs: temperature, hr_neonate, rr_neonate, skin_vesicles_exam_finding
    advance: HSV-form hypothesis (SEM / CNS / disseminated) framed; empiric acyclovir initiated if any clinical feature
  3. 3CONTEXT
    Gestational age, birth weight, maternal HSV history (primary vs recurrent, serology if available), delivery mode + obstetric trauma (vaginal vs C-section, scalp electrode, instrumentation), caregiver oral HSV history (especially for late-onset > 21 d).
    inputs: gestational_age_weeks, birth_weight_grams, maternal_hsv_status_history, maternal_active_lesions_at_delivery, delivery_mode_and_obstetric_trauma, caregiver_oral_hsv_history
    advance: Risk-factor profile + exposure context captured
  4. 4RED_FLAGS
    Life-threatening features: seizures (CNS form), septic-shock physiology (disseminated form), refractory respiratory failure (pneumonitis), DIC, refractory hypothermia, encephalopathy with bulging fontanelle. → Empiric IV acyclovir within 1 h + NICU + bacterial co-empirics + neonatology consult.
    inputs: temperature, sbp_neonate, spo2_neonate, seizure_history, mental_status_neonate
    actions: protocol.septic_shock
    advance: Red flags actioned; acyclovir empirics within 1 h of recognition
  5. 5INITIAL_WORKUP
    Hour-1 bundle: HSV PCR (CSF + blood + surface swabs from mouth, NP, conjunctivae, anus, vesicle base if present); CSF cell count + protein + glucose + bacterial Gram/culture; hepatic panel; CBC with diff + platelets; coagulation panel; serum creatinine baseline; blood culture for bacterial co-empirics; CXR if respiratory features; EEG if seizures. Empiric IV acyclovir 60 mg/kg/d divided q8h (q12h if preterm < 35 wk) + bacterial co-empirics per onset window (ampicillin + gentamicin < 72 h DOL; vancomycin + cefepime ≥ 72 h DOL); IV hydration 1.5-2× maintenance for acyclovir crystalline nephropathy prevention.
    inputs: hsv_pcr_csf, hsv_pcr_blood, hsv_pcr_surface_swabs, csf_cell_count_protein_glucose, hepatic_panel_neonate, cbc_with_diff_neonate, coagulation_pt_inr_ptt_fibrinogen, serum_creatinine_neonate, blood_culture_bacterial
    actions: panel.csf, panel.cbc, panel.lft, panel.coag, panel.renal
    advance: HSV PCRs sent; empiric acyclovir + bacterial co-empirics in; baseline labs drawn; IV hydration started
  6. 6BRANCHING_WORKUP
    Source-directed + sequelae assessment: EEG if seizures (focal sharp waves + temporal lobe periodic patterns classic); MRI brain if CNS HSV confirmed (temporal lobe + insular T2 hyperintensity); cranial US if preterm baseline; CXR for disseminated pneumonitis; ophthalmology consult for eye involvement (slit-lamp + topical trifluridine); echocardiogram rare (HSV myocarditis rare). Bacterial culture follow-up at 24 + 48 h. Repeat CSF HSV PCR at 48-72 h if initial negative + clinical suspicion remains.
    inputs: eeg_neonate, mri_brain_neonate, cxr_neonate, cranial_us_neonate, eye_findings_conjunctivitis_keratitis
    actions: workup.bacterial_meningitis
    advance: Form classification refined (SEM / CNS / disseminated); duration plan set (14 d / 21 d)
  7. 7DIFFERENTIAL
    Look-alikes: neonatal bacterial sepsis (pivot: AST/ALT trajectory + HSV PCR + vesicles), neonatal bacterial meningitis (pivot: CSF profile + HSV PCR + Gram stain), enterovirus meningitis (pivot: lymphocytic CSF + enterovirus PCR + HSV PCR negative), congenital varicella (pivot: maternal varicella history + dermatomal distribution), erythema toxicum / miliaria (pivot: PCR + clinical course), neonatal candidiasis with vesiculo-pustular rash (pivot: KOH + fungal culture + HSV PCR). Coexistence: HSV + bacterial sepsis can co-occur — continue both empirics until both excluded.
    advance: Look-alikes excluded or co-managed
  8. 8RISK_STRATIFICATION
    Form classification (SEM = lowest acuity; CNS = high; disseminated = highest). Mortality: SEM ~ 0% (treated), CNS ~ 5%, disseminated ~ 30%. NICU criteria: all CNS + disseminated forms; SEM may be managed in special-care nursery if well-appearing + isolated SEM. Refractory shock + refractory status epilepticus + refractory hypoxaemia → ECMO consideration (rare neonatal — ≥ 34 wk + ≥ 2 kg per institutional protocol).
    inputs: sbp_neonate, spo2_neonate, mental_status_neonate
    advance: Form classified; setting + escalation thresholds set
  9. 9TREATMENT
    Acyclovir 60 mg/kg/d divided q8h IV (q12h if preterm < 35 wk) × 14 d SEM or 21 d CNS/disseminated (Kimberlin Pediatrics 2001 PMID 11483782). IV hydration 1.5-2× maintenance to prevent crystalline nephropathy. Bacterial co-empirics per onset window until alternative source identified (ampicillin + gentamicin < 72 h DOL; vancomycin + cefepime or meropenem ≥ 72 h DOL). For DIC: cryoprecipitate + FFP + platelets per shortfall. For shock: epinephrine 0.05-0.3 µg/kg/min first-line (cold shock pattern), norepinephrine for vasodilatory phenotype, hydrocortisone 1 mg/kg q8h if catecholamine-resistant. For seizures: phenobarbital 20 mg/kg load IV then 5 mg/kg/d maintenance OR levetiracetam 40-60 mg/kg load then 30-60 mg/kg/d divided q8-12h. Foscarnet 40 mg/kg q8h IV only if documented acyclovir resistance + persistent PCR positivity on adequate dose + duration + hydration. Ophthalmology topical trifluridine for eye involvement.
    inputs: birth_weight_grams, gestational_age_weeks, sbp_neonate, serum_creatinine_neonate
    advance: Acyclovir + bacterial co-empirics + supportive (fluids / vasopressor / AED / DIC reversal) plan in place
  10. 10DISPOSITION
    NICU primary venue for CNS + disseminated forms + any ill SEM. Special-care nursery / level-2 acceptable for well-appearing SEM completing 14 d IV course. PICU rare and centre-dependent. Transfer to ECMO-capable centre for refractory respiratory failure (≥ 34 wk + ≥ 2 kg per institutional protocol).
    inputs: sbp_neonate, spo2_neonate
    advance: Level of care set; transfer arranged if needed
  11. 11MONITORING
    Daily neuro exam (CNS form); serial CBC (acyclovir neutropenia ~ 20% at 60 mg/kg/d — Kimberlin NEJM 2011); serial creatinine + UOP (crystalline nephropathy); LFT trend (disseminated form); EEG monitoring if seizures; serial CSF HSV PCR at end of IV course (some centres at d 21) — persistent positivity → extend acyclovir + ID consult. Bacterial culture follow-up; de-escalate bacterial empirics by 48-72 h if cultures negative + alternative diagnosis identified.
    inputs: cbc_with_diff_neonate, serum_creatinine_neonate, hepatic_panel_neonate
    actions: panel.cbc, panel.renal, panel.lft
    advance: Response confirmed; IV course completion + transition to oral suppression (CNS / disseminated) planned
  12. 12FOLLOWUP
    Oral acyclovir suppression 300 mg/m² PO TID × 6 months for CNS or disseminated forms (Kimberlin NEJM 2011 PMID 21991950 — neurodev outcome benefit). Monthly CBC on suppression (neutropenia ~ 5-10%). Developmental peds + neurology + ophthalmology + audiology at 6, 12, 24 mo. Recurrence surveillance — ~ 50% of treated infants have skin recurrence by 12 mo; re-treat acute (14 d IV) + extend suppression. Family education for return precautions (new vesicles, neuro signs, hypothermia). Lifelong suppression-decision counseling.
    advance: Suppression initiated (CNS / disseminated); developmental + sub-specialty follow-up scheduled; family education delivered