Efficacy of Oral Ribavirin in Lung Transplant Patients With Respiratory Syncytial Virus Lower Respiratory Tract Infection

Abstract

Background Respiratory syncytial virus (RSV) can cause severe lower respiratory tract infection (LRI) and is a risk factor for the development of bronchiolitis obliterans syndrome (BOS) after lung transplantation (LTx). Currently, the most widely used therapy for RSV is inhaled ribavirin. However, this therapy is costly and cumbersome. We investigated the utility of using oral ribavirin for the treatment of RSV infection after LTx. Methods RSV was identified in nasopharyngeal swabs (NPS) or bronchoalveolar lavage (BAL) using direct fluorescent antibody (DFA) in 5 symptomatic LTx patients diagnosed with LRI. Data were collected from December 2005 and August 2007 and included: age; gender; type of LTx; underlying disease; date of RSV; pulmonary function prior to, during and up to 565 days post-RSV infection; need for mechanical ventilation; concurrent infections; and radiographic features. Patients received oral ribavirin for 10 days with solumedrol (10 to 15 mg/kg/day intravenously) for 3 days, until repeat NPS were negative. Results Five patients had their RSV–LRI diagnosis made at a median of 300 days post-LTx. Mean forced expiratory volume in 1 second (FEV1) fell 21% (p < 0.012) during infection. After treatment, FEV1 returned to baseline and was maintained at follow-up of 565 days. There were no complications and no deaths with oral therapy. A 10-day course of oral ribavirin cost $700 compared with $14,000 for nebulized ribavirin at 6 g/day. Conclusions Treatment of RSV after LTx with oral ribavirin and corticosteroids is well tolerated, effective and less costly than inhaled ribavirin. Further studies are needed to directly compare the long-term efficacy of oral vs nebulized therapy for RSV.

Respiratory Syncytial Virus: Infection, Detection, and New Options for Prevention and Treatment

“…Some recent studies have identified a 30 to 100% mortality rate due to RSV infection in solid organ and bone marrow transplant recipients, particularly when infection has occurred within a few days after transplant surgery (20)(21)(22). In lung transplant patients, lower respiratory tract infections (LRTIs) with RSV can be a risk factor for bronchiolitis obliterans (23,24) and death in up to 20% of cases (20). RSV infection in allogeneic stem cell transplant patients leads to LRTI that is associated with an increased risk of death in up to 70% of those infected (21,25).…”

Monitoring and managing viral infections in pediatric renal transplant recipients

“…Ribavirin has been employed in the treatment of RSV, PIV, and AdV infections [91][92][93], although its use is proven only in RSV-related disease, whereas neuraminidase inhibitors were effective in controlled trials in adults and children with IVs [94]. Although no randomized controlled trials of therapy for AdV infection have been published, cidofovir given i.v.…”

Respiratory Syncytial Virus Disease: Prevention and Treatment

“…There is concern about its penetration in the setting of graft versus host disease in HSCT recipients, and studies have shown poorer outcomes with oral versus inhaled ribavirin in HSCT patients. In one study of lung transplant recipients with RSV LRTI, use of oral ribavirin in combination with corticosteroids was associated with no complications or deaths, and cost $700 as compared to $14,000 for aerosolized ribavirin therapy (Pelaez et al 2009). …”