Treating HSV and CMV reactivations in critically ill patients who are not immunocompromised: con

Chanques, Gérald; Jaber, Samir

doi:10.1007/s00134-014-3521-3

Cited by 19 publications

(16 citation statements)

References 19 publications

(21 reference statements)

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“…Previous findings of excess mortality have triggered debate whether antiviral prophylaxis should be used [ 29 , 30 ]. However, a greater understanding of pathophysiology and clinical risk factors is necessary to select the optimal target population for such strategies.…”

Section: Discussionmentioning

confidence: 99%

Cytomegalovirus reactivation and mortality in patients with acute respiratory distress syndrome

et al. 2016

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PurposeCytomegalovirus (CMV) reactivation occurs frequently in patients with the acute respiratory distress syndrome (ARDS) and has been associated with increased mortality. However, it remains unknown whether this association represents an independent risk for poor outcome. We aimed to estimate the attributable effect of CMV reactivation on mortality in immunocompetent ARDS patients.MethodsWe prospectively studied immunocompetent ARDS patients who tested seropositive for CMV and remained mechanically ventilated beyond day 4 in two tertiary intensive care units in the Netherlands from 2011 to 2013. CMV loads were determined in plasma weekly. Competing risks Cox regression was used with CMV reactivation status as a time-dependent exposure variable. Subsequently, in sensitivity analyses we adjusted for the evolution of disease severity until onset of reactivation using marginal structural modeling.ResultsOf 399 ARDS patients, 271 (68 %) were CMV seropositive and reactivation occurred in 74 (27 %) of them. After adjustment for confounding and competing risks, CMV reactivation was associated with overall increased ICU mortality (adjusted subdistribution hazard ratio (SHR) 2.74, 95 % CI 1.51–4.97), which resulted from the joint action of trends toward an increased mortality rate (direct effect; cause specific hazard ratio (HR) 1.58, 95 % CI 0.86–2.90) and a reduced successful weaning rate (indirect effect; cause specific HR 0.83, 95 % CI 0.58–1.18). These associations remained in sensitivity analyses. The population-attributable fraction of ICU mortality was 23 % (95 % CI 6–41) by day 30 (risk difference 4.4, 95 % CI 1.1–7.9).ConclusionCMV reactivation is independently associated with increased case fatality in immunocompetent ARDS patients who are CMV seropositive.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-015-4071-z) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Cytomegalovirus reactivation and mortality in patients with acute respiratory distress syndrome

et al. 2016

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“…Treatment of CMV disease as any other disease should be based on a benefit/risk ratio, taking into consideration all other factors associated with the diagnostic process and treatment such as invasiveness of the diagnostic method, side effects of anti-CMV medications which might be serious especially in critical ill patients, and risk of emergence of CMV resistance to the medications [45]. There is an agreement regarding treatment of established CMV disease and prophylactic treatment for certain populations of immunocompromized patients as is the case in organ transplant recipients, for whom the guidelines are well established [7, 44].…”

Section: Risk Factorsmentioning

confidence: 99%

“…However, the benefit of preemptive treatment of subclinical detected viral replication with no proven direct organ pathology attributed to CMV, and the prophylactic treatment in immunocompetent patients deemed to be at risk of developing CMV disease is much less clear [45]. It is plausible to assume that the best strategy to handle CMV disease in the ICU is to prevent reactivation in seropositive patients as these are at high risk of developing the disease.…”

Section: Risk Factorsmentioning

confidence: 99%

Cytomegalovirus infection in immunocompetent critically ill adults: literature review

Al‐Omari

Aljamaan

Alhazzani

et al. 2016

Ann. Intensive Care

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Cytomegalovirus (CMV) infection is increasingly recognized in critically ill immunocompetent patients. Some studies have demonstrated an association between CMV disease and increased mortality rates, prolonged intensive care unit and hospital length of stay, prolonged mechanical ventilation, and nosocomial infections. However, there is a considerable controversy whether such association represents a causal relationship between CMV disease and unfavorable outcomes or just a marker of the severity of the critical illness. Detection of CMV using polymerase chain reaction and CMV antigenemia is the standard diagnostic approach. CMV may have variety of clinical manifestations reflecting the involvement of different organ systems. Treatment of CMV in critical care is challenging due to diagnostic challenge and drug toxicity, and building predictive model for CMV disease in critical care setting would be promising to identify patients at risk and starting prophylactic therapy. Our objective was to broadly review the current literature on the prevalence and incidence, clinical manifestations, potential limitations of different diagnostic modalities, prognosis, and therapeutic options of CMV disease in critically ill patients.

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“…Nevertheless, whether HSV replication in the lower respiratory tract has clinical consequences remains controversial [5,6]. Linssen et al reported that detection of more than 10 5 HSV-DNA copies/mL in lower respiratory material was associated with a significantly higher mortality (41% vs 20%, p = 0.001) [7].…”

Section: Introductionmentioning

confidence: 99%

Impact of acyclovir use on survival of patients with ventilator-associated pneumonia and high load herpes simplex virus replication

et al. 2020

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Background: Herpes simplex virus (HSV) replication can be detected in the respiratory secretions of a high proportion of ventilated intensive care unit (ICU) patients. However, the clinical significance remains poorly defined. We investigated whether patients with ventilator-associated pneumonia not responding to antibiotics and in whom high levels of HSV could be detected in respiratory secretions benefit from acyclovir treatment. Methods: Respiratory secretions (bronchoalveolar lavage fluid or tracheal aspirates) were tested for HSV replication by quantitative real-time PCR. ICU survival times, clinical parameters, and radiographic findings were retrospectively compared between untreated and acyclovir treated patients with high (> 10 5 HSV copies/mL) and low (10 3 -10 5 HSV copies/mL) viral load.Results: Fifty-seven low and 69 high viral load patients were identified. Fewer patients with high viral load responded to antibiotic treatment (12% compared to 40% of low load patients, p = 0.001). Acyclovir improved median ICU survival (8 vs 22 days, p = 0.014) and was associated with a significantly reduced hazard ratio for ICU death (HR = 0.31, 95% CI 0.11-0.92, p = 0.035) in high load patients only. Moreover, circulatory and pulmonary oxygenation function of high load patients improved significantly over the course of acyclovir treatment: mean norepinephrine doses decreased from 0.05 to 0.02 μg/kg body weight/min between days 0 and 6 of treatment (p = 0.049), and median PaO 2 /FiO 2 ratio increased from 187 to 241 between day 3 and day 7 of treatment (p = 0.02). Chest radiographic findings also improved significantly (p < 0.001). Conclusions: In patients with ventilator-associated pneumonia, antibiotic treatment failure, and high levels of HSV replication, acyclovir treatment was associated with a significantly longer time to death in the ICU and improved circulatory and pulmonary function. This suggests a causative role for HSV in this highly selected group of patients.

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Treating HSV and CMV reactivations in critically ill patients who are not immunocompromised: con

Cited by 19 publications

References 19 publications

Cytomegalovirus reactivation and mortality in patients with acute respiratory distress syndrome

Cytomegalovirus reactivation and mortality in patients with acute respiratory distress syndrome

Cytomegalovirus infection in immunocompetent critically ill adults: literature review

Impact of acyclovir use on survival of patients with ventilator-associated pneumonia and high load herpes simplex virus replication

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