1
|
Guiouillier F, Derely J, Salvadori A, Pochard J, Le Goff J, Martinez T, Raffin F, Laitselart P, Beaucreux C, Priou S, Conan PL, Foissaud V, Servonnet A, Vest P, Boutonnet M, de Rudnicki S, Bigaillon C, Libert N. Reactivation of Epstein-Barr virus among intensive care patients: a prospective observational study. Intensive Care Med 2024; 50:418-426. [PMID: 38436725 DOI: 10.1007/s00134-024-07345-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE Herpesvirus reactivation has been documented among patients in the intensive care unit (ICU) and is associated with increased morbidity and mortality, particularly for cytomegalovirus (CMV). Epstein-Barr virus (EBV) has been poorly studied despite >95% of the population being seropositive. Our preliminary study suggested an association between EBV reactivation and increased morbidity and mortality. This study aimed to investigate this association among patients admitted to the ICU. METHODS In this multicenter prospective study, polymerase chain reaction was performed to quantify EBV in patients upon ICU admission and then twice a week during their stay. Follow-up was 90 days. RESULTS The study included 129 patients; 70 (54.3%) had EBV reactivation. On day 90, there was no difference in mortality rates between patients with and without reactivation (25.7% vs 15.3%, p = 0.22). Patients with EBV reactivation at admission had increased mortality compared with those without reactivation and those with later reactivation. EBV reactivation was associated with increased morbidity. Patients with EBV reactivation had fewer ventilator-free days at day 28 than those without reactivation (18 [1-22] vs. 21 days [5-26], p = 0.037) and a higher incidence of acute respiratory distress syndrome (34.3% vs. 17%, p = 0.04), infections (92.9% vs. 78%, p = 0.03), and septic shock (58.6% vs. 32.2%, p = 0.004). More patients with EBV reactivation required renal replacement therapy (30% vs. 11.9%, p = 0.02). EBV reactivation was also associated with a more inflammatory immune profile. CONCLUSION While EBV reactivation was not associated with increased 90-day mortality, it was associated with significantly increased morbidity.
Collapse
Affiliation(s)
- François Guiouillier
- Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Jean Derely
- Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Alexandre Salvadori
- Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Bégin, Saint Mandé, France
| | - Jonas Pochard
- Service d'Anesthésie-réanimation Chirurgicale, Hôpital de Bicêtre, Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Jérôme Le Goff
- Département des Agents Infectieux, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Thibault Martinez
- Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Florent Raffin
- Institut de Recherche Biomédicale des Armées, Unité d'Analyses Biologiques, Brétigny sur Orge, France
| | - Philippe Laitselart
- Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Charlotte Beaucreux
- Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Bégin, Saint Mandé, France
| | - Sonia Priou
- CentraleSupelec, Université Paris Saclay, Laboratoire Génie Industriel, Gif-Sur-Yvette, France
| | - Pierre-Louis Conan
- Service de maladie infectieuse, Hôpital d'Instruction des Armées Bégin, Saint Mandé, France
| | - Vincent Foissaud
- Service de biologie médicale, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Aurélie Servonnet
- Institut de Recherche Biomédicale des Armées, Unité d'Analyses Biologiques, Brétigny sur Orge, France
| | - Philippe Vest
- Service de biologie médicale, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Mathieu Boutonnet
- Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Stéphane de Rudnicki
- Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Christine Bigaillon
- Service de biologie médicale, Hôpital d'Instruction des Armées Bégin, Saint Mandé, France
| | - Nicolas Libert
- Service d'Anesthésie-Réanimation, Hôpital d'Instruction des Armées Percy, Clamart, France.
| |
Collapse
|
2
|
O'Grady NP, Alexander E, Alhazzani W, Alshamsi F, Cuellar-Rodriguez J, Jefferson BK, Kalil AC, Pastores SM, Patel R, van Duin D, Weber DJ, Deresinski S. Society of Critical Care Medicine and the Infectious Diseases Society of America Guidelines for Evaluating New Fever in Adult Patients in the ICU. Crit Care Med 2023; 51:1570-1586. [PMID: 37902340 DOI: 10.1097/ccm.0000000000006022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
RATIONALE Fever is frequently an early indicator of infection and often requires rigorous diagnostic evaluation. OBJECTIVES This is an update of the 2008 Infectious Diseases Society of America and Society (IDSA) and Society of Critical Care Medicine (SCCM) guideline for the evaluation of new-onset fever in adult ICU patients without severe immunocompromise, now using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. PANEL DESIGN The SCCM and IDSA convened a taskforce to update the 2008 version of the guideline for the evaluation of new fever in critically ill adult patients, which included expert clinicians as well as methodologists from the Guidelines in Intensive Care, Development and Evaluation Group. The guidelines committee consisted of 12 experts in critical care, infectious diseases, clinical microbiology, organ transplantation, public health, clinical research, and health policy and administration. All task force members followed all conflict-of-interest procedures as documented in the American College of Critical Care Medicine/SCCM Standard Operating Procedures Manual and the IDSA. There was no industry input or funding to produce this guideline. METHODS We conducted a systematic review for each population, intervention, comparison, and outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as best-practice statements. RESULTS The panel issued 12 recommendations and 9 best practice statements. The panel recommended using central temperature monitoring methods, including thermistors for pulmonary artery catheters, bladder catheters, or esophageal balloon thermistors when these devices are in place or accurate temperature measurements are critical for diagnosis and management. For patients without these devices in place, oral or rectal temperatures over other temperature measurement methods that are less reliable such as axillary or tympanic membrane temperatures, noninvasive temporal artery thermometers, or chemical dot thermometers were recommended. Imaging studies including ultrasonography were recommended in addition to microbiological evaluation using rapid diagnostic testing strategies. Biomarkers were recommended to assist in guiding the discontinuation of antimicrobial therapy. All recommendations issued were weak based on the quality of data. CONCLUSIONS The guidelines panel was able to formulate several recommendations for the evaluation of new fever in a critically ill adult patient, acknowledging that most recommendations were based on weak evidence. This highlights the need for the rapid advancement of research in all aspects of this issue-including better noninvasive methods to measure core body temperature, the use of diagnostic imaging, advances in microbiology including molecular testing, and the use of biomarkers.
Collapse
Affiliation(s)
- Naomi P O'Grady
- Internal Medicine Services, National Institutes of Health Clinical Center, Bethesda, MD
| | - Earnest Alexander
- Clinical Pharmacy Services, Department of Pharmacy, Tampa General Hospital, Tampa, FL
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Jennifer Cuellar-Rodriguez
- Laboratory of Clinical Immunology and Microbiology, National Institutes of Allergy and Infectious Diseases, Bethesda, MD
| | - Brian K Jefferson
- Division of Hepatobiliary and Pancreatic Surgery, Department of Internal Medicine-Critical Care Services, Atrium Health Cabarrus, Concord, NC
| | - Andre C Kalil
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, NE
| | - Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Rochester, MN
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC
| | - David J Weber
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, NC
| | - Stanley Deresinski
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
3
|
Saura O, Chommeloux J, Levy D, Assouline B, Lefevre L, Luyt CE. Updates in the management of respiratory virus infections in ICU patients: revisiting the non-SARS-CoV-2 pathogens. Expert Rev Anti Infect Ther 2022; 20:1537-1550. [PMID: 36220790 DOI: 10.1080/14787210.2022.2134116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although viruses are an underestimated cause of community-acquired pneumonias (CAP) and hospital-acquired pneumonias (HAP)/ventilator-associated pneumonias (VAP) in intensive care unit (ICU) patients, they have an impact on morbidity and mortality. AREAS COVERED In this perspective article, we discuss the available data regarding the management of severe influenza CAP and herpesviridae HAP/VAP. We review diagnostic and therapeutic strategies in order to give clear messages and address unsolved questions. EXPERT OPINION Influenza CAP affects yearly thousands of people; however, robust data regarding antiviral treatment in the most critical forms are scarce. While efficacy of oseltamivir has been investigated in randomized controlled trials (RCT) in uncomplicated influenza, only observational data are available in ICU patients. Herpesviridae are an underestimated cause of HAP/VAP in ICU patients. Whilst incidence of herpesviridae identification in samples from lower respiratory tract of ICU patients is relatively high (from 20% to 50%), efforts should be made to differentiate local reactivation from true lung infection. Only few randomized controlled trials evaluated the efficacy of antiviral treatment in herpesviridae reactivation/infection in ICU patients and all were exploratory or negative. Further studies are needed to evaluate the impact of such treatment in specific populations.
Collapse
Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Juliette Chommeloux
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David Levy
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lucie Lefevre
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| |
Collapse
|
4
|
Abstract
Reactivation of herpsviruses, mainly HSV, CMV and EBV, are frequent among critically ill patients. Although they are not immunocompromised from a classical point of view, these patients often present an alteration of their immune system favoring viral reactivation. Seropositive patients with sepsis and under mechanical ventilation are particularly at risk. Herpesviruses have a pulmonary tropism and can be responsible for non-resolving forms of acute respiratory distress syndrome with high mortality. However, the direct causality between herpesviruses reactivation and impaired outcomes among severely ill patients remains under debate.
Collapse
|
5
|
Marandu T, Dombek M, Cook CH. Impact of cytomegalovirus load on host response to sepsis. Med Microbiol Immunol 2019; 208:295-303. [DOI: 10.1007/s00430-019-00603-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/22/2019] [Indexed: 12/24/2022]
|
6
|
Al-Omari A, Aljamaan F, Alhazzani W, Salih S, Arabi Y. Cytomegalovirus infection in immunocompetent critically ill adults: literature review. Ann Intensive Care 2016; 6:110. [PMID: 27813024 PMCID: PMC5095093 DOI: 10.1186/s13613-016-0207-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 10/17/2016] [Indexed: 12/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Awad Al-Omari
- Critical Care and Infection Control Department, Dr. Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia. .,AlFaisal University, Riyadh, Saudi Arabia.
| | - Fadi Aljamaan
- Intensive Care Department, King Khalid University Hospital, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | | | - Samer Salih
- Department of Internal Medicine, Dr. Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Yaseen Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| |
Collapse
|
7
|
Bonizzoli M, Arvia R, di Valvasone S, Liotta F, Zakrzewska K, Azzi A, Peris A. Human herpesviruses respiratory infections in patients with acute respiratory distress (ARDS). Med Microbiol Immunol 2016; 205:371-9. [PMID: 27138606 PMCID: PMC7086591 DOI: 10.1007/s00430-016-0456-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/23/2016] [Indexed: 12/29/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is today a leading cause of hospitalization in intensive care unit (ICU). ARDS and pneumonia are closely related to critically ill patients; however, the etiologic agent is not always identified. The presence of human herpes simplex virus 1, human cytomegalovirus and Epstein–Barr virus in respiratory samples of critically ill patients is increasingly reported even without canonical immunosuppression. The main aim of this study was to better understand the significance of herpesviruses finding in lower respiratory tract of ARDS patients hospitalized in ICU. The presence of this group of herpesviruses, in addition to the research of influenza viruses and other common respiratory viruses, was investigated in respiratory samples from 54 patients hospitalized in ICU, without a known microbiological causative agent. Moreover, the immunophenotype of each patient was analyzed. Herpesviruses DNA presence in the lower respiratory tract seemed not attributable to an impaired immunophenotype, whereas a significant correlation was observed between herpesviruses positivity and influenza virus infection. A higher ICU mortality was significantly related to the presence of herpesvirus infection in the lower respiratory tract as well as to impaired immunophenotype, as patients with poor outcome showed severe lymphopenia, affecting in particular T (CD3+) cells, since the first days of ICU hospitalization. In conclusion, these results indicate that herpesviruses lower respiratory tract infection, which occurs more frequently following influenza virus infection, can be a negative prognostic marker. An independent risk factor for ICU patients with ARDS is an impaired immunophenotype.
Collapse
Affiliation(s)
- Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Rosaria Arvia
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Simona di Valvasone
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Francesco Liotta
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Krystyna Zakrzewska
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alberta Azzi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| |
Collapse
|
8
|
Mansfield S, Dwivedi V, Byrd S, Trgovcich J, Griessl M, Gutknecht M, Cook CH. Broncholaveolar lavage to detect cytomegalovirus infection, latency, and reactivation in immune competent hosts. J Med Virol 2016; 88:1408-16. [PMID: 26762116 DOI: 10.1002/jmv.24472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2016] [Indexed: 12/24/2022]
Abstract
Roughly 1/3rd of immune competent patients will reactivate latent cytomegalovirus (CMV) during critical illness. There are no standard methods to detect reactivation, and some investigators have postulated that presence of DNA in BAL fluid is indicative of viral replication. To test this hypothesis, we used a murine model that allows inclusion of matched healthy controls which is not possible in human studies. BALB/c mice infected with Smith-murine CMV or PBS (mock) had BAL evaluated 7, 14, or 21 days after acute infections, during latency, or during bacterial sepsis. Plaque assay, PCR, and rtPCR were performed on BALs and concomitantly obtained lung tissue. BAL cellular compositions, including tetramer evaluation of CMV-specific T cells were evaluated by flow cytometry. CMV DNA were detected in BAL at all time-points during acute infection, becoming undetectable in all mice during latency, then were detected again during bacterial sepsis, peaking 3 weeks after onset. mCMV specific T-cells were most numerous in BAL after acute viral infections, decreasing to low levels during latency, then fluctuating during bacterial sepsis. Specifically, mCMV-specific T-cells contracted at sepsis onset, expanding 2-4 weeks post-sepsis, presumably in response to increased viral loads at that time point. Altogether, our results support the use of BAL PCR for the diagnosis of CMV replication in immune competent hosts. Additionally, we demonstrate dynamic changes in CMV-specific T cells that occur in BAL during CMV infection and during sepsis induced viral reactivation. J. Med. Virol. 88:1408-1416, 2016. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Sara Mansfield
- Division of Trauma, Critical Care, and Burn, Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Varun Dwivedi
- Division of Trauma, Critical Care, and Burn, Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Sara Byrd
- Division of Trauma, Critical Care, and Burn, Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Joanne Trgovcich
- Division of Trauma, Critical Care, and Burn, Department of Surgery, Ohio State University College of Medicine, Columbus, Ohio
| | - Marion Griessl
- Division of Acute Care Surgery, Trauma and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center-Harvard Medical School, Boston, Massachusetts
| | - Michael Gutknecht
- Division of Acute Care Surgery, Trauma and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center-Harvard Medical School, Boston, Massachusetts
| | - Charles H Cook
- Division of Acute Care Surgery, Trauma and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center-Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
9
|
Mansfield S, Grießl M, Gutknecht M, Cook CH. Sepsis and cytomegalovirus: foes or conspirators? Med Microbiol Immunol 2015; 204:431-7. [PMID: 25788396 PMCID: PMC4928686 DOI: 10.1007/s00430-015-0407-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 03/09/2015] [Indexed: 12/21/2022]
Abstract
Cytomegalovirus (CMV) reactivation in non-immune-suppressed critically ill patients is an area of increasing interest. CMV has long been appreciated as a pathogen in immunocompromised hosts. CMV reactivates in approximately one-third of latently infected non-immune-suppressed hosts during critical illness; however, its role as a pathogen in these patients remains unclear. CMV reactivation has been linked to bacterial sepsis and likely results from inflammation, transient immune compromise, and viral epigenetic changes. While CMV may improve immune response to some bacterial infections, other data suggest that CMV induces exaggerated responses to severe infections that may be harmful to latently infected hosts. These results also suggest that previous infection history may explain significant differences seen between human septic responses and murine models of sepsis. While critically ill human hosts clearly have worse outcomes associated with CMV reactivation, determining causality remains an area of investigation, with randomized control trials currently being performed. Here we review the current literature and highlight areas for future investigation.
Collapse
Affiliation(s)
- Sara Mansfield
- Department of Surgery, The Ohio State University Medical Center, Columbus, OH, 43210, USA
| | | | | | | |
Collapse
|
10
|
Assink-de Jong E, Groeneveld ABJ, Pettersson AM, Koek A, Vandenbroucke-Grauls CMJE, Beishuizen A, Simoons-Smit AM. Clinical correlates of herpes simplex virus type 1 loads in the lower respiratory tract of critically ill patients. J Clin Virol 2013; 58:79-83. [PMID: 23731844 DOI: 10.1016/j.jcv.2013.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 05/05/2013] [Accepted: 05/07/2013] [Indexed: 01/02/2023]
Abstract
BACKGROUND The significance of isolation of herpes simplex virus (HSV) type 1 from the lower respiratory tract in critically ill patients on mechanical ventilation is still unclear. In the current study, we used polymerase chain reaction techniques to quantify HSV-1 to further evaluate its role. OBJECTIVES The hypothesis was that high loads reflect invasive pulmonary disease related to prolonged mechanical ventilation and increased mortality, as opposed to shedding from the upper respiratory tract, which leads to lower viral loads. STUDY DESIGN We prospectively studied 77 consecutive patients admitted to the intensive care unit and analyzed 136 tracheal aspirates or bronchoalveolar lavage fluids, taken when clinically indicated in the diagnostic workup of fever, radiologic pulmonary infiltrates, progressive respiratory insufficiency or combinations. Samples were cultured for bacteria and yeasts according to routine microbiological methods and HSV-1 loads were determined by real time quantitative PCR. Viral loads were expressed per number of cells recovered. RESULTS HSV-1 load was directly related to the simplified acute physiology score II (rs=0.47, P=0.04) when the first specimen taken proved positive for HSV-1. HSV-1 positivity concurred with Candida spp. colonization. Patients with and without a HSV-1 load did not differ with respect to pulmonary and systemic courses and vital outcomes. CONCLUSIONS The data suggest that HSV-1 in the lower respiratory tract originates from shedding in the upper respiratory tract in about 30% of critically ill patients, following immune suppression and reactivation, without invasively infecting the lung. No attributable mortality was observed.
Collapse
|
11
|
Cytomegalovirus and herpes simplex virus effect on the prognosis of mechanically ventilated patients suspected to have ventilator-associated pneumonia. PLoS One 2012; 7:e51340. [PMID: 23236477 PMCID: PMC3517464 DOI: 10.1371/journal.pone.0051340] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 11/07/2012] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Cytomegalovirus (CMV) and herpes simplex virus (HSV) are common viruses that can affect critically ill patients who are not immunocompromised. The aim of this study was to determine whether the identification of CMV and/or HSV in mechanically ventilated critically ill patients suspected of having pneumonia was associated with an increased mortality. DESIGN Prospective epidemiological study. SETTING Medical intensive care unit of a tertiary medical center. PATIENTS Ninety-three patients with suspected pneumonia. INTERVENTIONS Patients with suspected pneumonia had bronchoalveolar lavage and blood samples taken to confirm the diagnosis. Antigenemia was used to detect CMV in the blood. Bronchoalveolar lavage samples were submitted to testing using quantitative real-time Polymerase Chain Reaction. MEASUREMENTS AND MAIN RESULTS We identified 22 patients with a CMV infection, 26 patients with an HSV infection and 45 patients without CMV or HSV infection (control group). Mortality at day 60 was higher in patients with a CMV infection than in patients from the control group (55% vs. 20%, P<0.01). Mortality at day 60 was not significantly increased in the group with HSV infection. Duration of ICU stay and ICU mortality were significantly higher in patients with CMV infections when compared to patients from the control group, whereas ventilator free days were significantly lower in patients with CMV infections when compared to patients from the control group. CONCLUSIONS In critically ill patients, a CMV infection is associated with an increased mortality. Further interventional studies are needed to evaluate whether treatment could improve the prognosis.
Collapse
|