Intravenous ribavirin therapy for disseminated adenovirus infection

Combined intravenous ribavirin and recombinant human interferon α1b aerosol inhalation for adenovirus pneumonia with plastic bronchitis in children: a case report and review of literature

Background

Human adenovirus (HAdV) infections in children can lead to profound pulmonary injury and are frequently associated with severe complications, particularly in cases concomitant with plastic bronchitis. Managing this condition presents significant challenges and carries an exceptionally high fatality rate. Regrettably, there are currently no specific antiviral agents that have demonstrated efficacy in treating severe adenovirus pneumonia in children.

Case presentation

We report a 10-month-old infant suffering from severe adenovirus pneumonia combined with plastic bronchitis (PB). He received intravenous ribavirin combined with recombinant human interferon α1b (INFα1b) aerosol inhalation and his condition eventually improved. No side effects occurred during the treatment, and the long-term prognosis was favorable.

Conclusion

In this case, the combination therapy of intravenous ribavirin and INFα1b seems to have contributed to the resolution of illness and may be considered for similar cases until stronger evidence is generated.

Recent Advances in Pharmaceutical Approaches of Antimicrobial Agents for Selective Delivery in Various Administration Routes

Globally, the increase of pathogenic bacteria with antibiotic-resistant characteristics has become a critical challenge in medical treatment. The misuse of conventional antibiotics to treat an infectious disease often results in increased resistance and a scarcity of effective antimicrobials to be used in the future against the organisms. Here, we discuss the rise of antimicrobial resistance (AMR) and the need to combat it through the discovery of new synthetic or naturally occurring antibacterial compounds, as well as insights into the application of various drug delivery approaches delivered via various routes compared to conventional delivery systems. AMR-related infectious diseases are also discussed, as is the efficiency of various delivery systems. Future considerations in developing highly effective antimicrobial delivery devices to address antibiotic resistance are also presented here, especially on the smart delivery system of antibiotics.

Contribution of Nanotechnologies to Vaccine Development and Drug Delivery against Respiratory Viruses

According to the Center for Disease Control and Prevention (CDC), the coronavirus disease 2019, a respiratory viral illness linked to significant morbidity, mortality, production loss, and severe economic depression, was the third-largest cause of death in 2020. Respiratory viruses such as influenza, respiratory syncytial virus, SARS-CoV-2, and adenovirus, are among the most common causes of respiratory illness in humans, spreading as pandemics or epidemics throughout all continents. Nanotechnologies are particles in the nanometer range made from various compositions. They can be lipid-based, polymer-based, protein-based, or inorganic in nature, but they are all bioinspired and virus-like. In this review, we aimed to present a short review of the different nanoparticles currently studied, in particular those which led to publications in the field of respiratory viruses. We evaluated those which could be beneficial for respiratory disease-based viruses; those which already have contributed, such as lipid nanoparticles in the context of COVID-19; and those which will contribute in the future either as vaccines or antiviral drug delivery systems. We present a short assessment based on a critical selection of evidence indicating nanotechnology's promise in the prevention and treatment of respiratory infections.

Use of cidofovir in pediatric patients with adenovirus infection

Background: Adenoviruses contribute to morbidity and mortality among immunocompromised pediatric patients including stem cell and solid organ transplant recipients. Cidofovir (CDV), an antiviral compound approved by the FDA in 1996, is used for treatment of adenoviral (ADV) infections in immunocompromised patients despite concern of potential nephrotoxicity.   Methods: We conducted a retrospective 5-year review at Boston Children's Hospital of 16 patients (mean age = 6.5 years) receiving 19 courses of CDV. During therapy all pertinent data elements were reviewed to characterize potential response to therapy and incidence of renal dysfunction.   Results: Of the 19 CDV courses prescribed, 16 courses (84%) were in patients who had a positive blood ADV Polymerase chain reaction (PCR) alone or in combination with positive ADV PCR/ Direct Immunofluorescence Assay (DFA) at another site. Respiratory symptoms with or without pneumonia were the most common presentation (10/19, 53%). In the majority of blood positive courses (10/16, 63%), viral clearance was also accompanied by clinical response. This was not the case in four courses where patients expired despite viral clearance, including one in which death was directly attributable to adenovirus. There was reversible renal dysfunction observed during the use of CDV. Conclusions:  CDV appeared safe and reasonably tolerated for treatment of ADV in this pediatric population and was associated with viral response and clinical improvement in the majority of patients but reversible renal dysfunction was a side effect. Further studies of the efficacy of CDV for immunocompromised children with ADV infection are warranted.

Use of cidofovir in pediatric patients with adenovirus infection

Background: Adenoviruses contribute to morbidity and mortality among immunocompromised pediatric patients including stem cell and solid organ transplant recipients. Cidofovir (CDV), an antiviral compound approved by the FDA in 1996, is used for treatment of adenoviral (ADV) infections in immunocompromised patients despite concern of potential nephrotoxicity.   Methods: We conducted a retrospective 5-year review at Boston Children's Hospital of 16 patients (mean age = 6.5 years) receiving 19 courses of CDV. During therapy all pertinent data elements were reviewed to characterize potential response to therapy and incidence of renal dysfunction.   Results: Of the 19 CDV courses prescribed, 16 courses (84%) were in patients who had a positive blood ADV Polymerase chain reaction (PCR) alone or in combination with positive ADV PCR/ Direct Immunofluorescence Assay (DFA) at another site. Respiratory symptoms with or without pneumonia were the most common presentation (10/19, 53%). In the majority of blood positive courses (10/16, 63%), viral clearance was also accompanied by clinical response. This was not the case in four courses where patients expired despite viral clearance, including one in which death was directly attributable to adenovirus. There was reversible renal dysfunction observed during the use of CDV. Conclusions:  CDV appeared safe and reasonably tolerated for treatment of ADV in this pediatric population and was associated with viral response and clinical improvement in the majority of patients but reversible renal dysfunction was a side effect. Further studies of the efficacy of CDV for immunocompromised children with ADV infection are warranted.

Clinical features and treatment of adenovirus infections

Adenoviruses (Ads) are common opportunistic pathogens that are rarely associated with severe clinical symptoms in healthy individuals. In contrast, in patients with compromised immunity, Ad infections often result in disseminated and potentially life-threatening disease. Among these are AIDS patients, individuals with hereditary immunodeficiencies and recipients of solid organ or haematopoietic stem cell transplants (HSCT) who receive immunosuppressive therapy. The latter account for the largest number of severe Ad infections. There is currently no formally approved antiviral therapy for the treatment of severe Ad keratoconjunctivitis and life-threatening Ad infections in immunocompromised patients. Here we update current knowledge on Ad biology, the clinical features observed in different patient groups and specific immune responses towards Ad infections. In addition, we review current and future treatment options, including: (i) the antiviral drugs cidofovir, ribavirin and new investigational compounds, as evaluated in the clinic or in relevant animal models, as well as (ii) novel immunotherapeutic strategies.

Virale Infektionen

Adenoviren verursachen im Kindesalter Krankheiten der Atemwege und des Darms, aber auch Krankheiten der Harnwege, der Lymphorgane und kardiologische und neurologische Manifestationen werden beobachtet. Einige typische Krankheitsbilder können klinisch diagnostiziert werden.

Adenovirus infections in transplant recipients

Adenoviruses are increasingly recognized as contributors to morbidity and mortality among stem cell and solid-organ transplant recipients. Clinical presentations range from asymptomatic viremia to respiratory and gastrointestinal disease, hemorrhagic cystitis, and severe disseminated illness. The limited clinical data available support the use of cidofovir for many of these illnesses. Prospective studies are needed to better understand the pathogenesis of and therapeutic options for adenoviral infections in this patient population.

Treatment of respiratory virus infections

Respiratory viral infections (RVIs) can be associated with a wide range of clinical manifestations ranging from self-limited upper respiratory tract infections to more devastating conditions, such as pneumonia. RVIs constitute the most frequent reason for medical consultations in the world and they have a considerable impact on quality of life and productivity. Therefore, the prevention and control of RVIs remain major clinical goals. Currently, there are approximately 200 known respiratory viruses that can be grouped into one family of DNA viruses (Adenoviridae) and four families of RNA viruses (Orthomyxoviridae, Paramyxoviridae, Picornaviridae and Coronaviridae). In this paper, we review the major respiratory viruses that cause disesases in humans, with an emphasis on current treatment options.

Outbreak of adenovirus type 30 in a neonatal intensive care unit

OBJECTIVES

To describe an outbreak of adenovirus, type 30, in a neonatal intensive care unit (NICU).

STUDY DESIGN

This was a retrospective, observational study.

RESULTS

An outbreak of adenovirus infection occurred in an NICU. It lasted 6 months and involved 21 of 333 (6.3%) infants. The introduction of infection control measures controlled the outbreak; however, premature discontinuation of the measures resulted in a second wave of cases. The virus caused pneumonia in 7 infants, conjunctivitis in 7 infants, pneumonia and conjunctivitis in 1 infant, and upper respiratory tract illness in 1 infant. Infection was asymptomatic in 5 infants. Six infants died. Death was associated with the presence of pneumonia ( P = .0001), administration of steroids ( P = .003), and mechanical ventilation ( P = .02). Investigation into the origin of the outbreak suggested that the virus may have been introduced and spread during ophthalmologic procedures.

CONCLUSIONS

Adenovirus type 30 can cause severe disease among premature infants in an NICU. Infants with severe bronchopulmonary dysplasia requiring mechanical ventilation are more likely to have development of adenovirus pneumonia and die. Standard infection control measures are effective in controlling an outbreak. Ophthalmologic procedures continue to be a potential source of adenovirus outbreaks.

Critical care aspects of lung transplantation

Lung transplantation currently is the preferred treatment option for a variety of end-stage pulmonary diseases. Remarkable progress has occurred through refinements in technique and improved understanding of transplant immunology and microbiology. As a result, recipients are surviving longer after their transplant. Despite improvements in short- and intermediate-term survival, long-term success with lung transplantation remains limited by chronic allograft rejection, also known as bronchiolitis obliterans syndrome. Despite its long-term limitations, lung transplantation remains the only hope for many with end-stage pulmonary disease, and during the past 20 years, it has become increasingly accepted and used. As a result, clinicians working in an intensive care unit (ICU) are more likely to be exposed to these patients both in the immediate postoperative period as well as throughout their remaining lives. It is thus important that the ICU team have a working knowledge of the common complications, when these complications are most likely to occur, and how best to treat them when they do arise. The main focus of this review is to address the variety of potential graft and life-threatening problems that may occur in lung transplant recipients. Because the ICU is also the most common setting where a potential donor is identified, donor issues will briefly be addressed.

Comparison of HSV-1 thymidine kinase-dependent and -independent inhibition of replication-competent adenoviral vectors by a panel of drugs

Replication-competent adenoviral vectors hold the promise to be more efficient gene delivery vehicles than their replication-deficient counterparts, but they are also associated with a higher risk for adverse effects, especially in light of the fact that there is no established effective therapy for serious, disseminated adenovirus infection. To assess whether the therapeutic options to inhibit adenoviral replication can be enhanced by expressing a suicide gene, we examined the antiadenoviral effects of 15 drugs against wild-type adenovirus type 5 (Ad5) and an Ad5-based replication-competent vector expressing herpes simplex virus-1 thymidine kinase (HSV-tk) (Ad.OW34) using a real-time polymerase chain reaction -based assay and flow cytometry. Ad5 and Ad.OW34 were highly susceptible to the fluorinated pyrimidine analogs 5-fluoro-2'-deoxyuridine (FUdR), 5-fluorouridine (FUR), and trifluorothymidine (TFT), with a mean 50% inhibitory concentration (IC(50)) ranging from 0.12 to 0.32 microM. The mean IC(50) of ribavirin and cidofovir (CDV) for Ad5, the most frequently used drugs to treat adenovirus disease, was 6.87 and 3.19 microM, respectively. In contrast to Ad5, the Ad.OW34 vector was susceptible to (E)-5-(2-bromovinyl)-2'-deoxyuridine (BVdU, IC(50) 0.09 microM), ganciclovir (GCV, IC(50) 0.19 microM), and acyclovir (ACV, IC(50) 32.04 microM). Additionally, we demonstrated in an animal model that Ad.OW34 vector replication can be inhibited significantly by GCV, CDV, and TFT by 35.2, 7.7, and 3.7-fold, respectively, compared to untreated animals. The observed antiadenoviral effects were primarily not through cell killing, since the in vitro 50% cytotoxic concentrations (CC(50)) were more than 1000 times higher than the antiadenoviral IC(50) of the drugs examined, even in cells stably expressing HSV-tk. Since for HSV-tk-dependent inhibition of adenoviral vectors, stability of HSV-tk expression is crucial, we examined Ad.OW34 vector stability, by passaging the vector 10 times serially in the presence of 10 microM GCV. The HSV-tk/GCV system neither changed the susceptibility of Ad.OW34 to GCV significantly nor detectable vector rearrangements occurred, suggesting that the system might be suitable as a fail-safe mechanism to stop adenoviral vector replication.

Intravenous ribavirin treatment for severe adenovirus disease in immunocompromised children

BACKGROUND

Adenovirus is an important cause of morbidity and mortality in the immunocompromised host. The incidence of severe adenovirus disease in pediatrics is increasing in association with growing numbers of immunocompromised children, where case fatality rates as high as 50% to 80% have been reported. There are no approved antiviral agents with proven efficacy for the treatment of severe adenovirus disease, nor are there any prospective randomized, controlled trials of potentially useful anti-adenovirus therapies. Apparent clinical success in the treatment of severe adenovirus disease is limited to a few case reports and small series. Experience is greatest with intravenous ribavirin and cidofovir. Ribavirin, a guanosine analogue, has broad antiviral activity against both RNA and DNA viruses, including documented activity against adenovirus in vitro. Ribavirin is licensed in aerosol form for the treatment of respiratory syncytial virus infection, and orally in combination with interferon to treat hepatitis C. Intravenous ribavirin is the treatment of choice for infection with hemorrhagic fever viruses. The most common adverse effect of intravenous ribavirin is reversible mild anemia. The use of cidofovir in severe adenovirus infection has been limited by adverse effects, the most significant of which is nephrotoxicity.

OBJECTIVE

We report our experience with intravenous ribavirin therapy for severe adenovirus disease in a series of immunocompromised children and review the literature.

DESIGN/METHODS

We retrospectively reviewed the medical records of 5 children treated with intravenous ribavirin for documented severe adenovirus disease. Two patients developed adenovirus hemorrhagic cystitis after cardiac and bone marrow transplants, respectively. The bone marrow transplant patient also received intravenous cidofovir for progressive disseminated disease. An additional 3 children developed adenovirus pneumonia; 2 were neonates, 1 of whom had partial DiGeorge syndrome. The remaining infant had recently undergone a cardiac transplant. Intravenous ribavirin was administered on a compassionate-use protocol.

RESULTS

Complete clinical recovery followed later by viral clearance was observed in 2 children: the cardiac transplant recipient with adenovirus hemorrhagic cystitis and the immunocompetent neonate with adenovirus pneumonia. The remaining 3 children died of adenovirus disease. Intravenous ribavirin therapy was well tolerated. Use of cidofovir in 1 child was associated with progressive renal failure and neutropenia.

DISCUSSION

Our series of patients is representative of the spectrum of immunocompromised children at greatest risk for severe adenovirus disease, namely solid-organ and bone marrow transplant recipients, neonates, and children with immunodeficiency. Although intravenous ribavirin was not effective for all children with severe adenovirus disease in this series or in the literature, therapy is unlikely to be of benefit if begun late in the course of the infection. Early identification, eg by polymerase chain reaction of those patients at risk of disseminated adenovirus disease may permit earlier antiviral treatment and better evaluation of therapeutic response.

CONCLUSIONS

Two of 5 children with severe adenovirus disease treated with intravenous ribavirin recovered. The availability of newer rapid diagnostic techniques, such as polymerase chain reaction, may make earlier, more effective treatment of adenovirus infection possible. Given the seriousness and increasing prevalence of adenovirus disease in certain hosts, especially children, a large, multicenter clinical trial of potentially useful anti-adenoviral therapies, such as intravenous ribavirin, is clearly required to demonstrate the most effective and least toxic therapy.

Fatal adenovirus type 7b infection in a child with Smith-Lemli-Opitz syndrome

Adenovirus type 7 causes worldwide respiratory tract infections, mainly in children. Severe systemic infections can occur, especially in immunocompromised patients and in patients with underlying chronic diseases. This report describes the first case of a fatal disseminated adenovirus type 7 infection in a child with Smith‐Lemli‐Opitz syndrome, a rare autosomal recessive disorder due to a primary enzymatic defect in cholesterol metabolism. Nasopharyngeal secretions and autopsy specimens including liver, lung, pleural fluid, and rectum were collected for viral culture. Adenovirus serotype 7 strains were obtained from all anatomic sites, except the liver. All these clinical isolates were analyzed using restriction endonuclease digestion of the genome, identifying them as genome type 7b, a virulent type. In this case, the fatal evolution could have been accelerated by the presence of an immunodeficiency although immunodeficiency is not included in the definition of Smith‐Lemli‐Opitz syndrome. The frequent recurrent banal infections in Smith‐Lemli‐Opitz syndrome could be prevented by a cholesterol supplementation regimen. Finally, this report emphasizes the need for efficient therapy for disseminated adenovirus infections, especially for virulent genome types. J. Med. Virol. 65:66–69, 2001. © 2001 Wiley‐Liss, Inc.

Antiviral therapy: respiratory infections, chronic hepatitis

This review focuses on the activity, clinical pharmacology, and clinical indications of antiviral agents used in the management of influenza, respiratory syncytial virus infections, and chronic hepatitis B and C. Two neuraminidase inhibitors, a new class of antiviral agents, were recently approved for the treatment of influenza A and B in children.

Respiratory viral infections in primary immune deficiencies: significance and relevance to clinical outcome in a single BMT unit

Respiratory viral infections are major causes of morbidity and mortality in children with SCID and other primary immunodeficiencies who require BMT. Twenty-two of 73 (30%) such children were admitted with respiratory viral infections, of whom 13/22 (59%) died. All viruses were detected in nasopharyngeal aspirate (NPA). Virus was only found in BAL in those with LRTI. Eleven of 22 (50%) had paramyxovirus infections, all with severe viral pneumonitis which worsened post BMT. Five of 11 (45.5%) survived overall. All 11 received aerosolised ribavirin; five of 11 received additional inhaled immunoglobulin and corticosteroid. Three of 5 (60%) survived compared with two of six (33.3%) not thus treated. Three of 22 (13.6%) had adenoviruses; one died of disseminated disease, including pneumonia despite intravenous ribavirin. Eleven patients had rhinovirus detected; nine of 11 (82%) were asymptomatic or coryzal and survived. Two patients with additional severe lung pathologies had LRT rhinovirus and died. All patients received intravenous immunoglobulin. No treatments resulted in viral clearance without successful T cell engraftment. Respiratory viruses, particularly paramyxoviruses and adenoviruses are common, significant pathogens in these patients, significantly worsening outcome of BMT. NPA is an ideal specimen for diagnosis and monitoring of infection. Aggressive treatments may reduce viral replication and damage. Nebulised immunoglobulin and corticosteroid in LRTI may improve respiratory function and outcome.

Intravenous ribavirin therapy for adenovirus pneumonia

We report on the effectiveness of intravenous ribavirin for severe adenoviral pneumonia in a 10-month-old male following orthotopic liver transplantation. On day 20 post-transplantation, he developed high fever, marked respiratory compromise, and hypoxemia. The chest radiograph showed bilateral pulmonary infiltrates. Samples of bronchoalveolar lavage fluid grew adenovirus, serotype 1. Marked clinical and radiological improvement was noted after intravenous ribavirin therapy. A prospective clinical trial is needed to determine the efficacy of ribavirin therapy for severe adenovirus disease.

Adenovirus infections in hematopoietic stem cell transplant recipients

We report a 12% incidence of adenovirus infections among 532 recipients of hematopoietic stem cell transplant (HSCT) from January 1986 through March 1997. The median time from day of stem cell infusion to first positive culture was 41 days. Recipients of allogeneic stem cells, as opposed to autologous stem cell recipients, were more likely to have a culture positive for adenovirus (16% vs. 3%; P<.0001). Pediatric patients were also more likely than adults to have a positive culture (23% vs. 9%; P<.0001). Among stem cell recipients with partially matched related donors, pediatric recipients appear to be at significantly greater risk for infection than adult recipients (P<.001). Positive cultures were associated with evidence of invasion in 64% of cases (41 of 64). A multiple logistic regression analysis showed that isolating adenovirus from more than 1 site correlated with greater risk for invasive infections (P=.002). Invasive infections were associated with poorer chance of survival.

Community respiratory viral infection in adult lung transplant recipients

STUDY OBJECTIVE

To define the epidemiology, clinical manifestations, and long-term complications of respiratory viral infections in adult lung transplant recipients.

DESIGN

Retrospective review of the records of 122 adult lung transplant recipients over a 5-year period at one institution.

RESULTS

Ten episodes of infection with respiratory syncytial virus, parainfluenza, influenza, or adenovirus were identified. All patients presented with symptoms of respiratory tract infection. Two patients died acutely and four patients subsequently had development of obliterative bronchiolitis (OB).

CONCLUSIONS

These data suggest community respiratory viral infections cause significant morbidity and mortality in lung transplant recipients. Further prospective studies are warranted to clarify the relationship between respiratory viral infection and OB and to define the optimal therapy for these viral infections.

Prevention and treatment recommendations for respiratory syncytial virus infection. Background and clinical experience 40 years after discovery

Though 40 years have passed since its discovery, respiratory syncytial virus (RSV), one of the most ubiquitous viruses known, continues to evade most of our efforts to prevent or treat the clinical disease it causes. Long recognised as the most common cause of lower respiratory tract infections in virtually all children in the first 2 years of life, it has been increasingly recognised as a cause of more serious disease in several 'high risk' populations. These populations include infants with cardiac or pulmonary disease and infants and adults with immunodeficiencies, particularly those undergoing bone marrow transplantation. Early attempts to immunise children with a simple formalin-inactivated vaccine led to severe disease in vaccinated children who subsequently were infected with RSV from the community. Other vaccine constructs have failed for a variety of reasons, although surface glycoprotein subunit vaccines may hold promise. For years, ribavirin, a synthetic nucleoside analogue administered by constant aerosol, has been felt by many to lead to more rapid improvement in clinical disease caused by RSV, but it is still unclear whether its benefits are truly significant. An intravenous immunoglobulin product prepared from donors screened for the presence of high titres of RSV neutralising antibody (known as RSVIG) appears to be well tolerated and relatively effective in protecting high-risk infants against serious RSV disease, although therapeutic use has proven less dramatic. At least one monoclonal antibody undergoing current testing may prove easier to use in similar immunoprophylactic use. Results on the use of corticosteroids as supportive therapy have not been conclusive. In short, RSV will continue to be a challenge for clinicians and researchers well into the next century.

Ribavirin therapy for adenovirus pneumonia in an AIDS patient

We report the effectiveness of ribavirin in an AIDS patient with multinodular pneumonia due to adenovirus. A 38-year-old AIDS patient who experienced multiple opportunistic infections and whose CD4 lymphocyte count was 5/mm3 developed bilateral nodular lung opacities. Lung surgical biopsy yielded necrotizing pneumonitis with characteristic nuclear inclusions and positive immunocytology with adenovirus antibodies. Marked clinical and radiological improvement was obtained after intravenous then oral ribavirin. Ribavirin was discontinued after 40 d because of anemia. Relapse of pneumonia with respiratory distress led to death 8 mo later. This observation illustrates a rarely reported pulmonary opportunistic infection in AIDS and the potential value of ribavirin therapy for adenovirus pneumonia.

Intravenous ribavirin therapy in a neonate with disseminated adenovirus infection undergoing extracorporeal membrane oxygenation: pharmacokinetics and clearance by hemofiltration

Intravenously administered ribavirin (20 mg/kg per day) was given to a neonate with disseminated adenovirus infection requiring extracorporeal membrane oxygenation and hemofiltration. Plasma concentrations at steady state were 4.81 to 8.47 micrograms/ml, hemofiltration sieving-coefficient was 0.85, and hemofiltration clearance (0.046 L/kg per hour) was similar to the renal clearance reported with normal kidney function. Despite low plasma concentrations, results of viral cultures were negative within 48 hours of initiation of ribavirin therapy, suggesting that plasma concentrations may not adequately predict inhibition of adenovirus replication in vivo.