RSV prevention and treatment in pediatric lung transplant patients: a survey of current practices among the International Pediatric Lung Transplant Collaborative.
ABSTRACT RSV infection can be severe after pediatric lung transplantation. Strategies to prevent and treat RSV in this population are underreported. To assess the current practices, we surveyed the members of the IPLTC regarding RSV prevention and treatment strategies. Twenty-eight programs were surveyed; 18 (64.3%) responded at least partially. A median of 53 transplants (range, 8-355) occurred since inception. RSV testing occurs in asymptomatic (6/17) and symptomatic (17/17) patients. Diagnostic method is polymerase chain reaction at 13 sites and DFA at 8. Transplant candidates were received prophylaxis at 10 sites, with nine following national (5) or local (4) guidelines. All use palivizumab IM and/or IV. Recipients were received prophylaxis with palivizumab at eight centers (eight IM, one IV). Fourteen were treated for RSV (seven all patients; seven age-related). Medications include inhaled (6), oral (4), or IV (4) ribavirin, plus IVIG (9), steroids (8), and IV (2) or IM (3) palivizumab. Prevention and treatment barriers include insurance/hospital concerns, such as institutional reluctance to use inhaled ribavirin. RSV prevention and treatment strategies are diverse at pediatric lung transplant programs. Many centers offer prophylaxis (9/17) and treatments (14/17), but strategies are not uniform.
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ABSTRACT: Paramyxoviral infections are reported in 6% to 21% of lung transplant recipients. Aerosolized ribavirin is used to treat paramyoxviral infections, but data on outcomes of this treatment in lung transplant patients are limited. Lung recipients treated with aerosolized ribavirin from 1992 through 2000 for pulmonary respiratory syncytial virus (RSV) or parainfluenza virus (PIV) infection were assessed for the following variables: age; gender; underlying diagnosis; time from transplantation; duration of illness; clinical symptoms; and change from baseline FEV(1) (forced expiratory volume in 1 second). Outcomes included FEV(1) values at 30 and 90 days, need for intubation, development of acute rejection or obliterative bronchiolitis (OB) in the year after treatment; and 90-day and overall mortality. Fifteen patients received ribavirin for a median of 5 days (range 3 to 7) for 17 episodes of RSV (n = 12) or PIV (n = 5) infection. The clinical presentations of RSV and PIV infection were similar. Infection occurred a median of 520 days (range 7 to 1700) after transplantation. Three episodes required intubation; 2 episodes were fatal accounting for a 90-day mortality per episode of 12%. The FEV(1) at presentation declined by 25% (range 4% to 44%) from baseline. In 3 patients the FEV(1) did not return to baseline by 90 days or thereafter. All 3 patients had underlying pulmonary fibrosis (IPF) vs no IPF in 0 of 9 evaluable patients who recovered (p = 0.009). There was no correlation between response to ribavirin and subsequent development of OB. About 33% of lung transplant patients with lower respiratory tract paramyxoviral infections who were treated with inhaled ribavirin died or did not return to baseline FEV(1). This effect was acute and not associated with later complications, including OB. Underlying IPF may be a risk factor for failure to return to baseline. Larger, prospective, multicenter studies are required to confirm these findings.The Journal of Heart and Lung Transplantation 08/2003; 22(7):745-53. · 5.11 Impact Factor
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ABSTRACT: Community respiratory viruses, such as respiratory syncytial virus (RSV), influenza viruses, parainfluenza viruses, adenoviruses, and picornaviruses, are an important cause of respiratory disease in the immunocompromised adult with cancer. Recent studies have demonstrated that a minimum of 31% of adult bone marrow transplant (BMT) recipients and 18% of adults with leukemia who are hospitalized with an acute respiratory illness have a community respiratory virus infection. The temporal occurrence of these infections in immunocompromised patients tends to mirror their occurrence in the community. The clinical illnesses range from self-limited upper respiratory illnesses to fatal pneumonias, depending on the type of virus and the type and degree of immunosuppression. The pneumonias may be viral, bacterial/fungal, or mixed. The highest frequency of progression to fatal viral pneumonia has been reported for RSV infections in recently transplanted BMT recipients and myelosuppressed patients with leukemia. Studies have suggested that early therapy for RSV pneumonia with a combination of aerosolized ribavirin and intravenous immunoglobulin may be of benefit. Defining effective prophylactic and therapeutic strategies will be a challenge, given the diversity of viruses, the wide spectrum of immunocompromised patients with varying vulnerability to serious community respiratory virus disease, and the frequent presence of other opportunistic infections and medical problems. A combination of antiviral drugs and immunotherapy may need to be considered for their potential additive effect as well as to prevent the emergence of resistant virus, as occurs during monotherapy for influenza with amantadine or rimantadine. The optimal therapies need to be defined in controlled trials; however, it appears that a favorable response will hinge on the initiation of therapy at an early stage of the respiratory illness.The American Journal of Medicine 04/1997; 102(3A):10-8; discussion 25-6. · 4.77 Impact Factor
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ABSTRACT: Respiratory infections are common after solid organ transplantation, but the significance of community respiratory viral infections in this patient population has not been determined. Review of the literature indicates that infection of organ transplant recipients by community respiratory viruses can result in significant morbidity with some associated mortality. These viruses include respiratory syncytial virus (RSV), parainfluenza virus (PIV), influenza virus, and adenovirus. As in normal hosts, infection of organ transplant recipients by these viruses can result in limited upper respiratory tract symptoms, such as rhinorrhea, cough, and fever. Immunocompromised patients can also have lower respiratory tract infection, resulting in bronchiolitis, pneumonitis, respiratory failure, and death. The highest incidence of infection with these viruses is reported in lung transplant recipients, with an incidence up to 21%. In addition to the effects of the usual immunosuppressant regimen, lung transplant recipients have altered lung immunity due to impaired ciliary clearance, poor cough reflex, and abnormal lymphatic drainage, predisposing these patients to lower respiratory tract infections. Of additional importance to organ transplant recipients is the correlation of organ rejection to recent viral infections with these agents. Influenza A and B, PIV, and adenovirus have been reported to be associated with acute rejection in renal transplant recipients. Diagnosis of these infections is often made by positive respiratory cultures, often with a delay between symptom onset and diagnosis. Clinical trials of antiviral agents in this patient population have not been carried out, and treatment has often been limited to severe, life-threatening cases.The American Journal of Medicine 04/1997; 102(3A):31-6; discussion 42-3. · 4.77 Impact Factor