Home / Clinical Guideline Hubs / Chapter 8.3
Section 8 — Infectious Disease & Sepsis Verify against local policy v1.0 · July 2026 Baylor Ed. 33 cross-checked Sept 2026

Chapter 8.3 — Congenital Infections (TORCH)

Toxoplasmosis · Other (syphilis, VZV, parvovirus B19, Zika) · Rubella · CMV · HSV — built on West Midlands Neonatal Guidelines 2025–28, RCOG/UKHSA guidance, AAP Red Book, and CDC congenital-infection guidance

Educational guideline — verify locally. Antiviral/antimicrobial regimens (e.g., valganciclovir for cCMV, aciclovir for neonatal HSV, benzylpenicillin for congenital syphilis) carry significant toxicity and must be verified against the Neonatal Formulary and specialist (ID/virology) advice. Does not replace attending judgment.
BEDSIDE ACTION BOX — Suspected Congenital Infection

1. Overview

Overview

TORCH refers to a group of infections acquired in utero or peripartum that share overlapping presentations: Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19, Zika, HIV, hepatitis), Rubella, Cytomegalovirus, and Herpes simplex virus. Many affected infants are asymptomatic at birth yet at risk of late sequelae (especially hearing loss in CMV), so recognition, timely diagnosis within diagnostic windows, and specialist-guided treatment matter greatly.

Why This Topic Matters

CMV is the commonest congenital infection and a leading non-genetic cause of sensorineural hearing loss — and early antiviral therapy can improve hearing/neurodevelopmental outcomes in symptomatic disease. Neonatal HSV is rapidly fatal without prompt aciclovir, and congenital syphilis is preventable and treatable. Time-critical diagnosis (CMV PCR before day 21) and empirical treatment (HSV) are the highest-yield actions.

2. Who This Guideline Applies To

Scope
  • Neonates with clinical features suggesting congenital infection (IUGR, microcephaly, rash, hepatosplenomegaly, thrombocytopenia, cataracts, chorioretinitis, failed newborn hearing screen).
  • Infants of mothers with known/suspected infection in pregnancy (seroconversion, positive serology, rash illness, genital HSV, inadequately treated syphilis).
  • Cross-references: EOS (8.1), LOS (8.2), neonatal jaundice (10.1), hearing screening, and ophthalmology follow-up.

3. Key Definitions

Core Terminology

Terms used across the congenital-infection pathway.

TermDefinition
Congenital infectionInfection acquired transplacentally (in utero) leading to fetal/neonatal disease.
Perinatal infectionAcquired around birth (e.g., HSV from genital tract, hepatitis, HIV).
cCMVCongenital cytomegalovirus — confirmed by CMV PCR (urine/saliva) within the first 21 days of life.
"Blueberry-muffin" rashPurpuric/petechiae from dermal extramedullary haematopoiesis — classic for CMV/rubella.
SNHLSensorineural hearing loss — key (often progressive) sequela of cCMV.

4. Shared Clinical Clues

Overlapping Features (Prompt a TORCH Screen)
  • Growth restriction (SGA/IUGR), microcephaly, hydrops.
  • Rash — petechiae/purpura, "blueberry-muffin" lesions, vesicles (HSV/VZV).
  • Hepatosplenomegaly, jaundice (conjugated), thrombocytopenia, anaemia.
  • CNS — intracranial calcification, ventriculomegaly, seizures, abnormal tone.
  • Eyes — cataracts, chorioretinitis, microphthalmia; Ears — sensorineural hearing loss.
  • Cardiac defects (rubella: PDA, peripheral pulmonary stenosis); bone changes (syphilis, rubella).
Baseline Work-up

FBC and film, LFTs (conjugated bilirubin), U&E; cranial ultrasound ± MRI; ophthalmology review; audiology (AABR); maternal serology review; then organism-specific PCR/serology guided by the clinical picture. Placental histology can help.

5. Cytomegalovirus (CMV)

Highest-Yield Congenital Infection
  • Features: often asymptomatic; when symptomatic — SGA, microcephaly, petechiae/"blueberry-muffin", hepatosplenomegaly, jaundice, thrombocytopenia, periventricular calcification, chorioretinitis, SNHL.
  • Diagnosis: CMV PCR on urine or saliva within the first 21 days (after 21 days a positive test cannot distinguish congenital from postnatal acquisition — dried blood spot may help retrospectively).
  • Treatment: for symptomatic cCMV (especially CNS involvement), oral valganciclovir (or IV ganciclovir) for ~6 months improves hearing/neurodevelopmental outcomes — specialist-led, with neutrophil/LFT monitoring.
  • Follow-up: long-term audiology (progressive SNHL), ophthalmology, and neurodevelopment. Baylor Ed. 33 puts a schedule on it: serial audiology from 4 months of age and continuing to 10 years, for symptomatic and asymptomatic infants alike — a significant share of CMV-related hearing loss is not detectable in the first month. During antiviral therapy check the absolute neutrophil count weekly for 6 weeks, then at 8 weeks, then monthly, and ALT monthly. Treatment is reserved for moderate-to-severe symptomatic disease started within the first month of life; infants with asymptomatic disease, mild symptomatic disease, or isolated sensorineural hearing loss without other manifestations should not routinely be treated.
  • Scale and testing: congenital CMV is the commonest congenital viral infection in the US and the leading cause of childhood sensorineural hearing loss — 20% of all hearing loss at birth and 25% at 4 years. About 10% of infected infants are symptomatic at birth (mortality 3–10%) and 15% of those asymptomatic at birth develop hearing loss later. In Texas, any newborn who fails a hearing test must be tested for CMV. A bag urine specimen for CMV PCR is sufficient for the initial evaluation; if positive, send a quantitative plasma CMV PCR, which correlates with active infection and tracks progression. Traditional "TORCH titres" have little value and are not recommended; CMV IgM at birth is less specific and yields false positives.
⚠ High-Risk Drug

Valganciclovir/ganciclovir cause neutropenia and hepatotoxicity and are potentially teratogenic/carcinogenic — specialist prescribing only, with defined monitoring. Doses flagged for expert review.

6. Toxoplasmosis

Toxoplasma gondii
  • Classic triad: hydrocephalus, diffuse intracranial calcification, and chorioretinitis (many are subclinical at birth).
  • Diagnosis: serology (IgM/IgG, maternal and infant) and PCR; ophthalmology and neuroimaging.
  • Treatment: prolonged pyrimethamine + sulfadiazine + folinic acid (specialist-led, with blood-count monitoring).

7. Rubella

Congenital Rubella Syndrome
  • Classic triad: cataracts, sensorineural deafness, and cardiac defects (PDA, peripheral pulmonary artery stenosis); also "blueberry-muffin" rash, microcephaly, IUGR.
  • Diagnosis: rubella-specific IgM in the infant, PCR; confirm maternal immunity/history.
  • Management: supportive; the infant is infectious (isolate/consider viral shedding) — no specific antiviral. Prevention is by maternal MMR immunity.

8. Congenital Syphilis

Preventable & Treatable — Act Promptly
  • Features (early): rhinitis ("snuffles"), maculopapular/desquamating rash (palms/soles), hepatosplenomegaly, jaundice, thrombocytopenia, long-bone changes (osteochondritis/periostitis), and pseudoparalysis.
  • Diagnosis: maternal and infant treponemal/non-treponemal serology (compare titres), long-bone X-rays, CSF (VDRL/cell count) for neurosyphilis; dark-field/PCR of lesions.
  • Treatment: parenteral penicillin (benzylpenicillin/procaine penicillin) per national protocol; the regimen depends on maternal treatment adequacy and the infant's evaluation.
The four categories, with the evaluation and regimen for each (Baylor Ed. 33 / Red Book 2024–2027, Table 9-9)

Adequate maternal treatment means all of: penicillin — the only appropriate therapy in pregnancy — documented and completed at least 4 weeks before delivery, appropriate for the stage, with a sustained fourfold or greater fall in titre. Primary, secondary or early latent syphilis: benzathine penicillin G 2.4 million units IM as a single dose (often split into two 1.2 million unit injections, so the patient may report "two doses on one day"). Latent or tertiary: 2.4 million units IM weekly for 3 weeks (reported as six injections in total). Personal recollection of treatment is not documentation — confirm it through the health department or the treating facility.

CategoryDefining findingsEvaluationTreatment
Proven or highly probableAbnormal examination consistent with congenital syphilis, or a serum nontreponemal titre fourfold or more above the birthing parent's at delivery, or a positive darkfield or PCR of lesions or body fluidCSF (VDRL, cell count, protein), CBC with differential and platelets, long-bone radiographs, and as indicated chest radiograph, aminotransferases, neuroimaging, ophthalmological examination, auditory brainstem response, HIV testingAqueous crystalline penicillin G 50,000 units/kg IV every 12 hours in the first week, then every 8 hours, for 10 days (preferred), or procaine penicillin G 50,000 units/kg IM once daily for 10 days
PossibleNormal examination, titre less than fourfold the parent's, but maternal treatment inadequate, undocumented, given within 30 days of delivery, or with evidence of reinfection or relapseSame evaluation as aboveThe same 10-day parenteral course
Less likelyNormal examination, titre less than fourfold the parent's, parent treated appropriately for stage more than 30 days before delivery, no evidence of reinfection or relapseNot recommendedBenzathine penicillin G 50,000 units/kg IM as a single dose (preferred). Alternatively, where the parent's titres fell fourfold after therapy for early syphilis or stayed low and stable, follow every 2–3 months without treatment until the nontreponemal test is nonreactive
UnlikelyNormal examination, titre less than fourfold, parent adequately treated before pregnancy with titres low and stable (serofast) before, during and at deliveryNot recommendedNone, but follow any reactive nontreponemal test serologically to negativity. A single benzathine dose may be considered if follow-up is uncertain. An infant with a negative test at birth whose parent was seroreactive at delivery should be retested at 3 months to exclude incubating infection

Penicillin G is the only effective therapy for congenital syphilis, neurosyphilis and syphilis in pregnancy. Ampicillin given for a sepsis evaluation does not count toward the course, and if 24 hours or more of therapy is missed, the entire course restarts. If CSF is not obtained or is uninterpretable — a bloody tap — give the 10-day course.

Reading the serology, and the follow-up that gets missed
  • Use a neonatal blood sample, not cord blood — Wharton's jelly confounds the result. Keep to the same nontreponemal test on serial samples, since RPR and VDRL titres are not interchangeable. In CSF use VDRL, not RPR, accepting that its sensitivity and specificity are poor in the neonatal period.
  • Positive treponemal testing in the infant must not be used to risk-stratify — maternal IgG crosses the placenta and remains detectable to 15–18 months. TP-PA is preferred over FTA-ABS for confirmation. A positive TP-EIA with a negative RPR and negative TP-PA may mean early infection: repeat it.
  • Serofast means a low stable titre (RPR ≤1:4 or VDRL ≤1:2) a year after successful treatment — it does not apply to treatment during the current pregnancy. Examination is not evaluation: every infant gets an examination, and any abnormality triggers the full evaluation.
  • Follow-up: nontreponemal testing every 2–3 months until nonreactive, alongside the 2-, 4-, 6- and 12-month visits. Titres should be falling by 3 months and nonreactive by 6 months; rising or persistently stable titres at 6–12 months mean re-evaluation with a CSF examination and a 10-day parenteral course even if already treated. In a change from previous CDC advice, an infant with abnormal CSF indices at delivery no longer needs a repeat lumbar puncture at 6 months unless the nontreponemal test stays reactive.
  • Infection control: skin lesions and moist nasal secretions are highly infectious, but organisms are rarely found beyond 24 hours of treatment — standard precautions with gloves until 24 hours of therapy is complete.
  • Scale of the problem: transmission is 60–100% during primary and secondary maternal syphilis, falling with later stages; up to 40% of pregnancies with untreated early syphilis end in miscarriage, stillbirth or perinatal death; and most infected infants look normal at birth. US congenital syphilis has risen nearly 800% in a decade. Syphilis is notifiable within 7 days.

9. Neonatal Herpes Simplex (HSV)

Treat Empirically — Do Not Wait
  • Three patterns: (1) skin-eye-mouth (SEM); (2) CNS (encephalitis — seizures, lethargy, poor feeding, often day 10–21); (3) disseminated (sepsis-like, hepatitis, coagulopathy — highest mortality). Only ~⅓ have vesicles; absence does not exclude it.
  • Diagnosis: HSV PCR (blood, CSF), surface swabs (mouth/eye/nasopharynx/rectum) for PCR/culture, LFTs; LP for CSF HSV PCR.
  • Treatment: start IV aciclovir immediately when suspected — high-dose for 14 days (SEM) or 21 days (CNS/disseminated), with confirmed CSF clearance before stopping CNS disease, followed by oral aciclovir suppression. Monitor renal function/neutrophils.

10. Other Congenital Infections

"Other" Group — Quick Reference

Additional transplacental/perinatal infections to consider.

InfectionKey featuresNote
Varicella (VZV)Congenital varicella syndrome: limb hypoplasia, cicatricial skin scars, eye/CNS defects; severe neonatal varicella if maternal rash near delivery. Timing decides severity: maternal rash 6 or more days before delivery gives mild neonatal disease in the first 4 days of life, protected by transferred antibody; rash within 5 days before to 48 hours after delivery leaves no time for maternal IgG and produces disease at 5–10 days of age with 5–30% mortality — severe pneumonia, hepatitis or meningoencephalitis.VariZIG 125 units per 10 kg, maximum 625 units IM — never intravenously — ideally within 48 hours and at most 96 hours after exposure, and within 10 days per CDC. If VariZIG is unavailable, IVIG 400 mg/kg once. Indicated for: an infant whose parent developed chickenpox within 5 days before or 48 hours after delivery; an exposed preterm infant of 28 weeks or more whose parent lacks a history or evidence of immunity; and any exposed preterm infant below 28 weeks or 1000 g regardless of maternal history. Not indicated for a normal term infant, including one whose parent develops varicella more than 2 days after delivery, nor for intrauterine infection. Airborne and contact isolation to 21 days of age, or 28 days if VariZIG was given; observe for 28 days, since immunoglobulin can prolong incubation. Delay varicella vaccination until 5 months after either product.
Parvovirus B19Fetal anaemia, non-immune hydrops, intrauterine death.Managed antenatally (fetal MCA Dopplers, intrauterine transfusion).
ZikaMicrocephaly, intracranial calcification, ocular abnormalities.Travel/exposure history; supportive care and follow-up.
HIVUsually asymptomatic at birth.Maternal antiretrovirals + infant post-exposure prophylaxis; avoid breastfeeding per local policy.
Hepatitis BPerinatal transmission risk.Birth-dose vaccine ± HBIG per maternal status.

11. Diagnostic & Management Algorithm

1
Recognise the pattern
IUGR, microcephaly, rash, hepatosplenomegaly, thrombocytopenia, cataracts, chorioretinitis, or failed hearing screen → suspect congenital infection.
2
Baseline screen
FBC/film, LFTs, cranial imaging, ophthalmology, audiology; review maternal serology and pregnancy history.
3
Time-critical tests
CMV PCR (urine/saliva) within 21 days; if HSV suspected, HSV PCR (blood/CSF/swabs) — but do not delay treatment for results.
4
Empirical treatment when indicated
Suspected neonatal HSV → start IV aciclovir immediately. Suspected congenital syphilis → parenteral penicillin per protocol. Involve ID/virology.
5
Confirm & target therapy
Symptomatic cCMV → valganciclovir (specialist). Toxoplasmosis → pyrimethamine + sulfadiazine + folinic acid. Rubella → supportive + isolation.
6
⚠ Do-not-miss
Neonatal HSV without vesicles; progressive SNHL in cCMV (needs serial audiology); neurosyphilis (CSF); and disseminated HSV presenting as "culture-negative sepsis" with hepatitis/coagulopathy.

12. Monitoring & Follow-up

Monitoring Table

Surveillance during treatment and long-term follow-up for sequelae.

ParameterWhenWhy
Audiology (serial)Ongoing to childhoodcCMV/rubella SNHL — often progressive; enables early intervention.
OphthalmologyBaseline + follow-upChorioretinitis, cataracts, keratitis.
Neutrophils/LFTsDuring valganciclovir/ganciclovir or aciclovirNeutropenia, hepatotoxicity; renal function with aciclovir.
NeurodevelopmentStructured follow-upAll symptomatic congenital infections.
Syphilis serology titresPost-treatmentConfirm adequate response (falling titres).

13. Contraindications & Precautions

Safety Cautions
  • Do not delay IV aciclovir when neonatal HSV is suspected — absence of vesicles does not exclude it.
  • CMV PCR must be obtained within 21 days to confirm congenital (vs postnatal) infection.
  • Valganciclovir/ganciclovir, pyrimethamine/sulfadiazine — high-toxicity agents requiring specialist prescribing and monitoring.
  • Follow local infection-control (isolation) for rubella and VZV; observe breastfeeding restrictions for HIV per policy.
  • Verify all doses/durations against the Neonatal Formulary and ID advice — flagged for expert review.

14. Escalation & Parent Counselling

Escalate When…
  • Any suspected neonatal HSV, congenital syphilis, or symptomatic cCMV — involve paediatric infectious diseases/virology urgently.
  • Encephalitis, disseminated infection, or coagulopathy — intensive care and multidisciplinary input.
  • Confirmed congenital infection — arrange audiology, ophthalmology, and neurodevelopmental follow-up before discharge.
Parent Counselling Points
  • "Some infections passed from mother to baby during pregnancy can affect hearing, eyes, or the brain — we're running tests to look for these and, where helpful, treat early."
  • "For CMV, we need a urine or saliva test in the first three weeks; some babies benefit from antiviral medicine and long-term hearing checks."
  • "If we're worried about herpes, we start antiviral treatment straight away because it's safest not to wait for the test results."

15. Key Pearls

High-Value Clinical Pearls
  • CMV = commonest congenital infection and top non-genetic cause of SNHL; diagnose by urine/saliva PCR within 21 days; treat symptomatic disease with valganciclovir.
  • Neonatal HSV: treat empirically with IV aciclovir; only ⅓ have vesicles; disseminated disease mimics bacterial sepsis.
  • Toxoplasmosis triad: hydrocephalus + diffuse intracranial calcification + chorioretinitis.
  • Rubella triad: cataracts + deafness + cardiac defects (PDA).
  • Congenital syphilis: snuffles, palm/sole rash, long-bone changes — treatable with penicillin.
  • "Blueberry-muffin" rash → think CMV/rubella (dermal haematopoiesis).

16. Common Mistakes to Avoid

Pitfalls & Better Practice

Recurring errors in congenital-infection diagnosis and management.

MistakeWhy it harmsBetter practice
Sending CMV PCR after day 21.Cannot prove congenital infection.Test urine/saliva within the first 21 days.
Excluding HSV because there are no vesicles.Misses CNS/disseminated disease.Treat empirically with aciclovir when suspected.
Forgetting audiology follow-up in cCMV.Misses progressive SNHL.Serial hearing tests through childhood.
Not reviewing maternal serology.Misses syphilis/rubella/HIV risk.Check booking bloods and pregnancy history.
Prescribing valganciclovir without monitoring.Neutropenia/hepatotoxicity.Specialist-led with blood-count/LFT monitoring.

17. Board-Style High-Yield Summary

Key Takeaways
  • TORCH = Toxoplasma, Other (syphilis, VZV, parvovirus, Zika, HIV, hepatitis), Rubella, CMV, HSV — overlapping features: IUGR, microcephaly, rash, HSM, thrombocytopenia, eye/ear/CNS.
  • CMV: commonest; urine/saliva PCR <21 days; valganciclovir for symptomatic; leading SNHL cause.
  • HSV: empirical IV aciclovir; ⅓ have vesicles; SEM 14 d, CNS/disseminated 21 d.
  • Toxoplasma triad: hydrocephalus + diffuse calcification + chorioretinitis.
  • Rubella triad: cataracts + deafness + cardiac (PDA).
  • Syphilis: snuffles + palm/sole rash + long-bone changes → penicillin.

18. References

Back to Clinical Guideline Hubs