Treatment for Viral Meningitis in a 2-Day-Old Infant
For viral meningitis in a 2-day-old infant, supportive care is the mainstay of treatment, but empiric intravenous aciclovir (60 mg/kg/day divided in three doses) should be started immediately while awaiting confirmation of the specific viral etiology.
Initial Management Approach
Immediate Interventions
- Start empiric intravenous aciclovir at 60 mg/kg/day divided in three doses 1
- Obtain diagnostic samples before initiating treatment:
- Cerebrospinal fluid (CSF) for PCR testing for herpes viruses and enteroviruses
- Blood cultures
- Surface swabs of any skin lesions if present
Antibiotic Coverage
- Administer empiric antibiotics alongside aciclovir:
- Cefotaxime plus ampicillin (to cover bacterial pathogens including Listeria) 2
- Continue until bacterial infection is ruled out by cultures (typically 48-72 hours)
Treatment Based on Viral Etiology
Herpes Simplex Virus (HSV)
- Continue intravenous aciclovir for a full 21-day course if HSV is confirmed
- Dosing: 60 mg/kg/day divided in three doses 1
- Monitor renal function during treatment
- Consider suppressive therapy after completion of acute treatment if recurrent episodes
Enterovirus
- No specific antiviral treatment is currently recommended for enterovirus meningitis 2, 3
- Discontinue aciclovir once enterovirus is confirmed and HSV is ruled out
- Provide supportive care only
Human Herpesvirus-6 (HHV-6)
- Consider continuing aciclovir if HHV-6 is detected, particularly in premature or immunocompromised infants 4
- Duration of therapy should be guided by clinical response
Supportive Care Measures
- Maintain adequate hydration
- Fever management with appropriate antipyretics
- Monitor for:
- Signs of increased intracranial pressure
- Seizures
- Respiratory distress
- Feeding difficulties
Special Considerations in Neonates
Immunocompromised Status
- All neonates should be considered relatively immunocompromised due to immature immune systems
- More aggressive antiviral therapy is warranted compared to older children 5
- Lower threshold for prolonged treatment courses
Monitoring for Complications
- Serial neurological examinations
- Consider repeat lumbar puncture if clinical deterioration occurs
- Monitor for development of virus-associated hemophagocytic syndrome, which may require additional anti-inflammatory treatment 1
Follow-up Care
- Audiological assessment before discharge
- Neurodevelopmental follow-up
- Monitor for potential sequelae:
- Hearing loss
- Neurological complications
- Developmental delays
Common Pitfalls to Avoid
- Delaying aciclovir administration while awaiting diagnostic confirmation - this can significantly worsen outcomes in HSV meningitis
- Premature discontinuation of empiric therapy before HSV is ruled out
- Failure to consider co-infection with bacterial pathogens
- Inadequate monitoring for complications during and after treatment
The management of viral meningitis in neonates requires aggressive empiric treatment initially, with therapy adjustments based on diagnostic results and clinical response. The stakes are particularly high in this age group due to their immature immune systems and the potential for devastating neurological sequelae.