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.

Keywords: RSV; antiviral therapy; cancer; immunocompromised host; infection prevention.

Figure 1.

Effect of ribavirin (aerosolized or systemic) therapy on respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) and RSV-associated mortality in allogeneic hematopoietic cell transplant (HCT) recipients from retrospective studies at The University of Texas MD Anderson Cancer Center (UTMDACC; n = 280) and Fred Hutchinson Cancer Research Center (FHCRC; n = 118). A and B, Effect of administering aerosolized ribavirin therapy at upper respiratory tract infection stage on RSV LRTI (P < .05) and RSV-associated mortality (P < .001) in 280 allogeneic HCT recipients at UTMDACC [20]. C, Effect of aerosolized or systemic ribavirin administered at lower respiratory tract disease stage on pulmonary deaths (P < .0001) in 118 allogeneic HCT recipients at FHCRC [22]. Figure 1 was reproduced from articles by Shah et al [20] and Waghmare et al [22] with permission of Oxford University Press. Abbreviations: LRTI, lower respiratory tract infection; RSV, respiratory syncytial virus; URTI, upper respiratory tract infection.