Cytomegalovirus reactivation in ICU patients

Abstract

Introduction: Approximately 20 years have passed since we reported our results of histologically proven cytomegalovirus (CMV) pneumonia in non-immunocompromised ICU patients. Even if there are more recent reports suggesting that CMV may worsen the outcomes for ICU patients, there is no definite answer to this question: is CMV a potential pathogen for ICU patients or is it simply a bystander?

Methods: We will describe the pathophysiology of active CMV infection and the most recent insights concerning the epidemiological aspects of these reactivations.

Major findings: Cytomegalovirus can be pathogenic by a direct organ insult (such as for the lung), by decreasing host defences against other microorganisms and/or by enhancing the body's inflammatory response (as in acute respiratory distress syndrome). The incidence of active CMV infection is dependent on the diagnostic method used. Using the most sophisticated available biological tools, the incidence can reach 15-20% of ICU patients (20-40% in ICU patients with positive CMV serology). In adequately powered cohorts of patients, active CMV infection appears to be associated with worse outcomes for mechanically ventilated ICU patients.

Discussion: There is no absolute direct proof of a negative impact of active CMV infection on the health outcomes of mechanically ventilated patients. Prospective randomized trials are lacking. Future trials should examine the potential benefits for health outcomes of using antiviral treatments. Such treatments could be prophylactic, pre-emptive or used only when there is an end-organ disease.

Conclusion: Cytomegalovirus infection may affect health outcomes for ICU patients. Additional prospective trials are necessary to confirm this hypothesis.

Keywords: Cytomegalovirus; ICU; Incidence; Mechanical ventilation; Mortality; Reactivation.

Fig. 1

Simplified representation of CMV reactivation physiopathology in ICU patients

Fig. 2

Lung radiological aspects associated with CMV reactivation. a Interstitial and alveolar infiltrates in an ARDS patient under veno-venous ECMO with a positive PCR (BAL and blood). b Predominantly left lung infiltrates in a patient with histological signs of CMV pneumonia. c Pleural effusion, alveolar condensation and ground-glass opacifications of the right upper lobe in a patient with a positive PCR (BAL and blood). d Bilateral pleural effusion without lung infiltrates in a patient with a positive PCR (BAL and blood). There was no clinical sign of active CMV infection

Fig. 3

Criteria for starting ganciclovir in ICU patients with unexplained lung infiltrates and impairment of gas exchange