Evaluation of Fluoroquinolones for the Prevention of BK Viremia after Renal Transplantation

Abstract

Background and objectives: Nearly 30% of renal transplant recipients develops BK viremia, a prerequisite for BK nephropathy. Case reports have evaluated treatment options for BK virus, but no controlled studies have assessed prophylactic therapies. Fluoroquinolone antibiotics were studied for prevention of BK viremia after renal transplantation.Design, setting, participants, & measurements: This retrospective analysis evaluated adult renal transplant recipients with at least one BK viral load (blood) between 90 and 400 days after transplantation. Six to 12 months of co-trimoxazole was used for Pneumocystis prophylaxis. In sulfa-allergic/-intolerant patients, 6 to 12 months of atovaquone with 1 month of a fluoroquinolone was used. Fluoroquinolones can inhibit BK DNA topoisomerase. The two groups studied were those that received 30 days of levofloxacin or ciprofloxacin after transplantation and those that did not. The primary endpoint was BK viremia rates at 1 year. Of note, of the 160 patients not receiving fluoroquinolone prophylaxis, 40 received a fluoroquinolone for treatment of a bacterial infection within 3 months after transplantation. Subgroup analysis evaluating these 40 patients against the 120 who had no exposure to fluoroquinolones was completed.Results: A 1-month fluoroquinolone course after transplantation was associated with significantly lower rates of BK viremia at 1 year compared with those with no fluoroquinolone. In the subgroup analysis, exposure to fluoroquinolone for treatment of bacterial infections within 3 months after transplantation was associated with significantly lower 1-year rates of BK viremia.Conclusions: This analysis demonstrates that fluoroquinolones are effective at preventing BK viremia after renal transplantation.

Late-Onset BK Viral Nephropathy in a Kidney Transplant Recipient

“…Quinolones have in vitro as well as in vivo effects on the BK virus. Observational studies have shown a reduction in the incidence of BK nephropathy with 1 month of ciprofloxacin therapy, and the "antiviral" effect seemed to persist even a year after the completion of treatment, suggesting that it can be used for the primary prevention of BK viral infection [27]. The clinical use of intravenous immunoglobulin has been limited owing to lack of clear benefit [28].…”

Efficacy of Levofloxacin in the Treatment of BK Viremia

“…In kidney transplant recipients, a 10-day course of gatifloxacin was shown to decrease BK viremia in 7 of 10 patients after 2 months of follow-up. The effective use of fluoroquinolones as prophylaxis against the development of BK viremia has also been studied in both the hematopoietic stem cell transplant and kidney transplant populations (14,16,17). Gabardi et al showed that a 1-month course of fluoroquinolones after kidney transplantation was associated with significantly lower rates of BK viremia at 1 year (14).…”

“…Duration of therapy was based on our previous study on the use of levofloxacin in the prevention of BK viremia (14).…”

“…Definitive evidence for the use of antiviral agents, such as cidofovir, leflunomide, or intravenous immunoglobulin, to treat BK infection is lacking (11,12). Fluoroquinolone antibiotics have also been shown to have antiviral properties, and their efficacy against BKV has been suggested by in vitro studies and small, single-center in vivo analyses (13)(14)(15)(16)(17). No randomized, controlled trials have validated the use of any treatments for BK viremia.…”

Intravenous Immunoglobulin in BK Virus Nephropathy

“…The use of leflunomide, cidofovir, IVIg and fluoquinolones as adjunct therapy in addition to immunosuppression reduction in the management of BK virus nephropathy has been evaluated in several small clinical studies [3][4][5][6]. There have however been no prospective randomized studies to compare the various agents and provide much needed information on long-term benefits.…”