A risk‐adapted approach to treating respiratory syncytial virus and human parainfluenza virus in allogeneic stem cell transplantation recipients with oral ribavirin therapy: A pilot study

Abstract

Here we report the applicability of a protocol based on clinical conditions and risk factors (RFs) for managing 35 allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients who developed a total of 52 episodes of respiratory viral infections (RVIs) caused by respiratory syncytial virus (RSV; n=19), human parainfluenza virus (HPIV; n=29), or both (n=4) over a 2-year study period. Risk categories were classified as high risk (cat-1) when the immunodeficiency scoring index was ≥3 and/or ≥3 RFs and/or ≥1 co-infective virus(es) were present; the remaining cases were classified as low risk (cat-0). The presence of two or more signs or symptoms including fever (T>38 °C), sinusitis, otitis, sore throat, tonsillitis, or baseline C-reactive protein increased by >2-fold at the time of the RVI, was considered a clinically-intense episode (CIE). Overall, 34 out of 52 episodes (65%) were limited to upper respiratory tract infections (URTIs). Overall, 26 (50%) received oral ribavirin. Twenty-four of 40 (60%) cat-1 episodes were treated, compared to 2 of 12 (17%) cat-0 RVIs (P=.01), while 17 of the 25 (68%) CIEs were treated compared to 9 of the remaining 27 (33%) episodes (P=.02). Regardless of antiviral therapy, the overall resolution rate was 100% for URTI and 95% for lower respiratory tract infection; the virus-related mortality was low (4%). In conclusion, the use of a risk-adapted protocol to guide therapeutic decisions for allo-HSCT recipients with RSV or HPIV RVIs is feasible and may limit unnecessary antiviral therapy.

The clinical benefit of instituting a prospective clinical community-acquired respiratory virus surveillance program in allogeneic hematopoietic stem cell transplantation

“…This assumption is supported by prior experience in another institution running the same ProClinCarvSur-P in allo-HCT recipients achieving low mortality rates ( < 5%) in recipients with RSV and/or HPiV LRTD. 26 Although we suppose that several elements of the ProClinCarvSur-P have significantly contributed to these encouraging results, in our opinion the improvement has three major key points. First, the decision to using syndromic multiplex RT-PCR panels as the primary CARV test, a factor that undoubtedly increased sensitivity and specificity compared to rapid detection technics 42 increasing CARV type detections.…”

“…We treated RSV and HPiV with oral ribavirin at early stage of the disease in the outpatient clinic according to our prior interventional protocol. 26 Influenza infections were treated with oseltamivir at dose of 75 mg/12 h or 150 mg/12 h in severe cases or cases with long lasting symptoms ( > 3 weeks). In RSV and HPiV, oral ribavirin was given at a loading dose (maximum daily dose of 30 mg/kg) in the outpatient clinic whereas aerolized ribavirin at 2 g/8 h each course lasting 2 h was used in cases with LRTD.…”

Practical Guidance for Clinical Microbiology Laboratories: Viruses Causing Acute Respiratory Tract Infections

“…Researchfocused approaches regarding RSV mutations is not described further here; however, potential mutations driving resistance against palivizumab and issues with ribavirin are described in a recent review (215). A comprehensive review of the effectiveness of antivirals for these viruses is beyond the scope of this guidance document, but there are emerging data supporting the use of oral ribavirin in treatment of URTI and LRTI in stem cell transplant patients (102,103,(316)(317)(318). As new antiviral agents for RSV (and other viruses) become approved, laboratorians may need to develop processes for systematic antiviral resistance testing and surveillance.…”

Epidemiologic and Clinical Characteristics of Coronavirus and Bocavirus Respiratory Infections after Allogeneic Stem Cell Transplantation: A Prospective Single-Center Study

“…All recipients with respiratory symptoms between December 23, 2013 and June 26, 2016 were prospectively screened for CARVs by real-time PCR. Clinical and biologic characteristics were prospectively recorded as reported in detail elsewhere [21]. Immunodeficiency scoring index (ISI) variables were recorded at the first clinical evaluation as previously described [22].…”