Management of Respiratory Viral Infections in Hematopoietic Cell Transplant Recipients and Patients With Hematologic Malignancies

Abstract

Despite preventive strategies and increased awareness, a high incidence of respiratory viral infections still occur in patients with hematologic malignancies (HMs) and in recipients of hematopoietic cell transplant (HCT). Progression of these viral infections to lower respiratory tract may prove fatal, especially in HCT recipients. Increasing evidence on the successful use of ribavirin (alone or in combination with immunomodulators) for the treatment of respiratory syncytial virus infections in HM patients and HCT recipients is available from retrospective studies; however, prospective clinical trials are necessary to establish its efficacy with confidence. The impact on progression to pneumonitis and/or mortality of treating parainfluenza virus infections with available (ribavirin) or investigational (DAS181) antiviral agents still needs to be determined. Influenza infections have been successfully treated with neuraminidase inhibitors (oseltamivir or zanamivir); however, the efficacy of these agents for influenza pneumonia has not been established, and immunocompromised patients are highly susceptible to emergence of antiviral drug resistance, most probably due to prolonged viral shedding. Infection control measures and an appreciation of the complications following respiratory viral infections in immunocompromised patients remain crucial for reducing transmission. Future studies should focus on strategies to identify patients at high risk for increased morbidity and mortality from these infections and to determine the efficacy of novel or available antiviral drugs.

Compassionate use experience with high‐titer respiratory syncytical virus (RSV) immunoglobulin in RSV‐infected immunocompromised persons

“…However, several retrospective studies and a recent pooled analysis suggest that ribavirin in any form is associated with decreased progression of upper respiratory tract infection (URTI) to LRTI (45% down to 16%) and decreased mortality (70% down to 13%). 8,9 Although observational data suggest benefit of early treatment with ribavirin, multiple issues remain, including high cost ($29 953/day) toxicity, and administration difficulties with the inhaled preparation and of IV ribavirin. have not demonstrated clinical advantage, it is possible that immunodeficient patients might derive benefit.…”

“…[5][6][7][8][9] Optimal therapy for immunocompromised patients with RSV infection has not been defined and data on treatment are limited. Inhaled ribavirin (Virazole ® ) is US Food and Drug Administration (FDA) approved only for use in RSV-infected hospitalized infants and young children.…”

“…10,11 A second option for treatment of RSV infection is immunoglobulin, generally combined with ribavirin. 8,12,13 Presently, two immunoglobulin products are available, including the monoclonal antibody palivizumab (Synagis ® , MedImmune, Gaithersburg, MD, USA), approved for prophylaxis in high-risk infants, and pooled human intravenous immunoglobulin (IVIG). Because palivizumab is dosed based on weight and is costly, IVIG is generally used in adults when an immunoglobulin product is used.…”

Time course of immune recovery and viral reactivation following hematopoietic stem cell transplantation

“…Therefore, HSCT patients are at high risk for bacterial and viral infections, at least, at early terms (<100 days) post-transplant (Fig.1). The organ-specific bacterial and virus-associated complications following intensive chemoand/or radiotherapy are treated with antimicrobial and antiviral drugs, either in pre-emptive mode, or upon detection of the pathogens [6].…”

A New Era for Ribavirin Aerosols to Treat Respiratory Syncitial Virus Infections in Immunocompromised Patients?

“…During the last few years, this treatment has been revisited. New clinical data support the efficiency of aerosolized ribavirin to treat respiratory syncitial virus infections in immunocompromised hematopoietic cell transplant recipients [3][4][5] and in patients with cancer. 6 In 2012, Chemaly et al 6 introduced the possibility of administering aerosolized ribavirin, still with the smallparticle aerosol generator-2 but intermittently, in the form of 2 g over 3 h every 8 h daily, rather than continuously (ie, 6 g over 18 h daily).…”