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El-Atawi K, De Luca D, Ramanathan R, Sanchez Luna M, Alsaedi S, Abdul Wahab MG, Hamdi M, Saleh M. Efficacy and Safety of Palivizumab as a Prophylaxis for Respiratory Syncytial Virus (RSV) Disease: An Updated Systemic Review and Meta-Analysis. Cureus 2023; 15:e51375. [PMID: 38292946 PMCID: PMC10825387 DOI: 10.7759/cureus.51375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/01/2024] Open
Abstract
This systematic review and meta-analysis aimed to summarize the current evidence regarding the efficacy and safety of palivizumab as a prophylaxis for respiratory syncytial virus (RSV) disease. We searched MEDLINE via PubMed, Scopus, Cochrane, Web of Science, Embase, and Science Direct from inception till November 2023. Studies that assessed the efficacy and safety of palivizumab in infants aged between 28 days and three months of age were included. We analyzed the data using Review Manager 5.4 software, with results pooled across studies and expressed as risk ratios (RR) with 95% confidence intervals (CI). A total of 10 studies were included. The effect estimates favored palivizumab over placebo regarding the hospitalization for RSV infection (RR=0.51, 95% CI: 0.40 to 0.65; P<0.00001) and ICU admission (RR=0.49, 95% CI: 0.30 to 0.81; P=0.005). On the other hand, the effect estimate showed no significant difference between palivizumab and placebo regarding all-cause mortality (RR=0.69, 95% CI: 0.42 to 1.15; P=0.16), lower respiratory tract infection (RR=0.42, 95% CI: 0.11 to 1.69; P=0.22), and need for mechanical ventilation (RR=0.75, 95% CI: 0.34 to 1.67; P=0.48). Palivizumab can be considered a prophylaxis for RSV disease in young children as it is safe, well-tolerated, and effective in reducing RSV hospitalizations. However, further research through high-quality randomized controlled trials is required to determine its efficacy as a therapeutic agent for established RSV infections.
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Affiliation(s)
- Khaled El-Atawi
- Department of Pediatrics, Latifa Women and Children Hospital, Dubai, ARE
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "Antoine Béclère" Hospital, Paris Saclay University Hospitals, APHP (Assistance Publique Hôpitaux de Paris), Paris, FRA
- Physiopathology and Therapeutic Innovation Unit, INSERM (Institut National de la Santé Et de la Recherche Médicale) U999, Paris Saclay University, Paris, FRA
| | - Ranagasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, Los Angeles General Medical Center, Keck School of Medicine of USC (University of Southern California), Los Angeles, USA
| | - Manuel Sanchez Luna
- Department of Neonatology, University Hospital Gregorio Marañón, Madrid, ESP
| | - Saad Alsaedi
- Department of Pediatrics and Neonatology, King Faisal Specialist Hospital & Research Centre, Jeddah, SAU
| | | | - Moataz Hamdi
- Department of Pediatrics, Al Jalila Children's Speciality Hospital, Dubai, ARE
| | - Maysa Saleh
- Department of Pediatrics and Child Health, Al Jalila Children's Speciality Hospital, Dubai, ARE
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2
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Brackenborough K, Ellis H, Flight WG. Respiratory Viruses and Cystic Fibrosis. Semin Respir Crit Care Med 2023; 44:196-208. [PMID: 36535663 DOI: 10.1055/s-0042-1758728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The threat of respiratory virus infection to human health and well-being has been clearly highlighted by the coronavirus disease 2019 (COVID-19) pandemic. For people with cystic fibrosis (CF), the clinical significance of viral infections long predated the emergence of severe acute respiratory syndrome coronavirus 2. This article reviews the epidemiology, diagnosis, and treatment of respiratory virus infection in the context of CF as well as the current understanding of interactions between viruses and other microorganisms in the CF lung. The incidence of respiratory virus infection in CF varies by age with young children typically experiencing more frequent episodes than adolescents and adults. At all ages, respiratory viruses are very common in CF and are associated with pulmonary exacerbations. Respiratory viruses are identified at up to 69% of exacerbations, while viruses are also frequently detected during clinical stability. The full impact of COVID-19 in CF is yet to be established. Early studies found that rates of COVID-19 were lower in CF cohorts than in the general population. The reasons for this are unclear but may be related to the effects of shielding, infection control practices, maintenance CF therapies, or the inflammatory milieu in the CF lung. Observational studies have consistently identified that prior solid organ transplantation is a key risk factor for poor outcomes from COVID-19 in CF. Several key priorities for future research are highlighted. First, the impact of highly effective CFTR modulator therapy on the epidemiology and pathophysiology of viral infections in CF requires investigation. Second, the impact of respiratory viruses on the development and dynamics of the CF lung microbiota is poorly understood and viral infection may have important interactions with bacteria and fungi in the airway. Finally, bacteriophages represent a key focus of future investigation both for their role in transmission of antimicrobial resistance and as a promising treatment modality for multiresistant pathogens.
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Affiliation(s)
- Kate Brackenborough
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Huw Ellis
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - William G Flight
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom.,Research and Development, GlaxoSmithKline plc, Brentford, United Kingdom
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3
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Wang B, Liu H. Identification of potential immune/diagnosis related gene-immunocyte subtype networks in extracellular immune response to respiratory syncytial virus infection. Virus Res 2022; 321:198906. [PMID: 36044931 DOI: 10.1016/j.virusres.2022.198906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/27/2022] [Accepted: 08/27/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Respiratory syncytial virus (RSV) is one of the important pathogenic agents of pediatric respiratory tract infection. Weighted gene co-expression network analysis (WGCNA) is used to study autoimmune diseases, which can find potential hub genes. The diagnostic model based on hub genes and machine learning makes it possible to diagnose the extracellular immune response to RSV infection early. OBJECTIVE The aim of the present study was to identify potential immune, diagnose and treatment related genes expressed in RSV-infected cells. METHODS Firstly, gene expression data were downloaded from the Gene Expression Omnibus (GEO) to identify differentially expressed genes (DEGs). Secondly, WGCNA was performed based on DEGs to obtain hub genes related to immunity score. Thirdly, protein-protein interaction (PPI) and the immune infiltration analysis of hub immune related genes were performed. Finally, diagnostic and immune related genes were identified by machine learning, followed by functional analysis. RESULTS Totally, 2063 DEGs were identified in the extracellular immune response to RSV infection. Among which, 10 key immune and diagnosis related genes were identified, including ITGA2B, GP9, ITGB3, SELP, PPBP, MPL, CXCL8, NFE2, PTGS1 and LY6G6F. Several immune/diagnosis related gene-immunocyte subtype networks were identified, such as CXCL8-Type 17 T helper cell, LY6G6F-CD56 bright natural killer cell, PPBP-activated CD4 T cell/T follicular helper cell, NFE2/PTGS1/SELP-activated dendritic cell, GP9/ITGA2B/MPL-activated CD8 T cell. ITGB3, MPL and PTGS1 could be considered as therapeutic targets. Some significantly enriched signaling pathways were identified, including hematopoietic cell lineage (involving GP9 and ITGA2B), cytokine-cytokine receptor interaction (involving MPL), chemokine signaling pathway (involving PPBP) and arachidonic acid metabolism (involving PTGS1). CONCLUSIONS The 10-immune related gene signature may be used as potential diagnostic markers for the extracellular immune response to RSV infection, which may provide a new field in searching for diagnostic and therapeutic molecules in the extracellular immune response to RSV infection.
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Affiliation(s)
- Baohong Wang
- Department of Pediatrics, Yantai Yuhuangding Hospital, No.20, East Road Yuhuangding, Zhifu District, Yantai, Shandong 264000, PR China
| | - Hongbo Liu
- Department of Pediatrics, Yantai Yuhuangding Hospital, No.20, East Road Yuhuangding, Zhifu District, Yantai, Shandong 264000, PR China.
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4
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Bloomfield A, DeVincenzo JP, Ambrose CS, Krilov LR. RSV and non-RSV illness hospitalization in RSV immunoprophylaxis recipients: A systematic literature review. J Clin Virol 2020; 129:104339. [PMID: 32512375 DOI: 10.1016/j.jcv.2020.104339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/05/2020] [Accepted: 03/25/2020] [Indexed: 11/26/2022]
Abstract
Respiratory syncytial virus (RSV) immunoprophylaxis (IP) has been shown to reduce RSV hospitalization rates in high-risk infants; however, it is unclear whether RSV IP is associated with increased risk of non-RSV disease, particularly non-RSV hospitalizations. We conducted a systematic literature review to understand the occurrences of non-RSV disease and/or non-RSV hospitalizations in published studies of RSV IP. Cochrane, Embase, and PubMed databases were searched and reviewed to summarize data regarding the incidence of RSV and non-RSV respiratory disease among RSV IP recipients and controls in randomized and non-randomized studies. Independent investigators screened and selected studies for inclusion. Risk-of-bias assessment was conducted to assess strength/validity of the data using the Jadad scoring system and Downs and Black quality assessment tool, where appropriate. Twenty studies were included for review (5 randomized controlled trials [RCTs]; 15 non-randomized studies). RCTs of RSV IP demonstrated reductions in RSV hospitalizations and all-cause hospitalizations, with no increase in hospitalizations for non-RSV disease. Non-randomized studies also demonstrated reduced RSV hospitalizations in RSV IP recipients but had mixed results in assessments of hospitalizations for non-RSV disease. When RSV IP recipients and controls were more similar in disease severity risk, results of non-randomized studies aligned more closely with RCTs. Observations of increased non-RSV hospitalization rates among RSV IP recipients in some non-randomized studies could be primarily explained by differences in the clinical characteristics between RSV IP recipients and controls.
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Affiliation(s)
| | - John P DeVincenzo
- Children's Foundation Research Institute at Le Bonheur Children's Hospital, Memphis, TN, USA
| | | | - Leonard R Krilov
- Children's Medical Center, NYU Winthrop Hospital and NYU Long Island School of Medicine, Mineola, NY, USA.
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5
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Fink AK, Graff G, Byington CL, Loeffler DR, Rosenfeld M, Saiman L. Palivizumab and Long-term Outcomes in Cystic Fibrosis. Pediatrics 2019; 144:peds.2018-3495. [PMID: 31239289 DOI: 10.1542/peds.2018-3495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The American Academy of Pediatrics does not recommend routine use of palivizumab prophylaxis for infants with cystic fibrosis (CF) but recommends consideration in infants with clinical evidence of chronic lung disease or nutritional compromise. However, the beneficial impact of palivizumab on longer-term outcomes is uncertain. METHODS We used Cystic Fibrosis Foundation Patient Registry data to assess the association of receiving palivizumab during the first 2 years of life with longer-term outcomes, including lung function at 7 years old, time to first positive Pseudomonas respiratory culture, and pulmonary-related hospitalizations during the first 7 years of life. Eligible infants were born from 2008 to 2015 and diagnosed with CF during the first 6 months of life. Demographic and clinical confounders of association between palivizumab receipt and outcomes were explored. We created propensity scores to adjust for potential confounding by indication (ie, sicker infants were more likely to receive palivizumab). For each outcome, we performed regression analyses adjusted by propensity scores. RESULTS The sample included 4267 infants; 1588 (37%) received palivizumab. Mean percent forced expiratory volume in 1 second predicted at 7 years old was similar among those who did (98.2; 95% confidence interval: 96.9-99.5) and did not (97.3; 95% confidence interval: 96.1-98.5) received palivizumab, adjusting for propensity scores. Time to first positive Pseudomonas aeruginosa culture and annual risk of hospitalization were similar among those who did and did not receive palivizumab. CONCLUSIONS At the population level, palivizumab receipt was not associated with improved longer-term outcomes in children with CF.
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Affiliation(s)
| | - Gavin Graff
- Penn State Children's Hospital, Hershey, Pennsylvania
| | | | | | | | - Lisa Saiman
- Columbia University Herbert and Florence Irving Medical Center, New York, New York
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6
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Kiedrowski MR, Bomberger JM. Viral-Bacterial Co-infections in the Cystic Fibrosis Respiratory Tract. Front Immunol 2018; 9:3067. [PMID: 30619379 PMCID: PMC6306490 DOI: 10.3389/fimmu.2018.03067] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/11/2018] [Indexed: 12/15/2022] Open
Abstract
A majority of the morbidity and mortality associated with the genetic disease Cystic Fibrosis (CF) is due to lung disease resulting from chronic respiratory infections. The CF airways become chronically colonized with bacteria in childhood, and over time commensal lung microbes are displaced by bacterial pathogens, leading to a decrease in microbial diversity that correlates with declining patient health. Infection with the pathogen Pseudomonas aeruginosa is a major predictor of morbidity and mortality in CF, with CF individuals often becoming chronically colonized with P. aeruginosa in early adulthood and thereafter having an increased risk of hospitalization. Progression of CF respiratory disease is also influenced by infection with respiratory viruses. Children and adults with CF experience frequent respiratory viral infections with respiratory syncytial virus (RSV), rhinovirus, influenza, parainfluenza, and adenovirus, with RSV and influenza infection linked to the greatest decreases in lung function. Along with directly causing severe respiratory symptoms in CF populations, the impact of respiratory virus infections may be more far-reaching, indirectly promoting bacterial persistence and pathogenesis in the CF respiratory tract. Acquisition of P. aeruginosa in CF patients correlates with seasonal respiratory virus infections, and CF patients colonized with P. aeruginosa experience increased severe exacerbations and declines in lung function during respiratory viral co-infection. In light of such observations, efforts to better understand the impact of viral-bacterial co-infections in the CF airways have been a focus of clinical and basic research in recent years. This review summarizes what has been learned about the interactions between viruses and bacteria in the CF upper and lower respiratory tract and how co-infections impact the health of individuals with CF.
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Affiliation(s)
| | - Jennifer M. Bomberger
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Schögler A, Caliaro O, Brügger M, Oliveira Esteves BI, Nita I, Gazdhar A, Geiser T, Alves MP. Modulation of the unfolded protein response pathway as an antiviral approach in airway epithelial cells. Antiviral Res 2018; 162:44-50. [PMID: 30550797 DOI: 10.1016/j.antiviral.2018.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/07/2018] [Accepted: 12/10/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Rhinovirus (RV) infection is a major cause of cystic fibrosis (CF) lung morbidity with limited therapeutic options. Various diseases involving chronic inflammatory response and infection are associated with endoplasmic reticulum (ER) stress and subsequent activation of the unfolded protein response (UPR), an adaptive response to maintain cellular homeostasis. Recent evidence suggests impaired ER stress response in CF airway epithelial cells, this might be a reason for recurrent viral infection in CF. Therefore, assuming that ER stress inducing drugs have antiviral properties, we evaluated the activation of the UPR by selected ER stress inducers as an approach to control virus replication in the CF bronchial epithelium. METHODS We assessed the levels of UPR markers, namely the glucose-regulated protein 78 (Grp78) and the C/EBP homologous protein (CHOP), in primary CF and control bronchial epithelial cells and in a CF and control bronchial epithelial cell line before and after infection with RV. The cells were also pretreated with ER stress-inducing drugs and RV replication and shedding was measured by quantitative RT-PCR and by a TCID50 assay, respectively. Cell death was assessed by a lactate dehydrogenate (LDH) activity test in supernatants. RESULTS We observed a significantly impaired induction of Grp78 and CHOP in CF compare to control cells following RV infection. The ER stress response could be significantly induced in CF cells by pharmacological ER stress inducers Brefeldin A, Tunicamycin, and Thapsigargin. The chemical induction of the UPR pathway prior to RV infection of CF and control cells reduced viral replication and shedding by up to two orders of magnitude and protected cells from RV-induced cell death. CONCLUSION RV infection causes an impaired activation of the UPR in CF cells. Rescue of the ER stress response by chemical ER stress inducers reduced significantly RV replication in CF cells. Thus, pharmacological modulation of the UPR might represent a strategy to control respiratory virus replication in the CF bronchial epithelium.
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Affiliation(s)
- Aline Schögler
- Division of Respiratory Medicine, Department of Paediatrics, University Hospital Bern, Bern, Switzerland
| | - Oliver Caliaro
- Division of Respiratory Medicine, Department of Paediatrics, University Hospital Bern, Bern, Switzerland
| | - Melanie Brügger
- Graduate School for Cellular and Biomedical Sciences, University of Bern, Bern, Switzerland; Institute of Virology and Immunology, Bern, Switzerland; Department of Infectious Diseases and Pathobiology, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Blandina I Oliveira Esteves
- Institute of Virology and Immunology, Bern, Switzerland; Department of Infectious Diseases and Pathobiology, Vetsuisse Faculty, University of Bern, Bern, Switzerland
| | - Izabela Nita
- Department of Pulmonary Medicine, University Hospital Bern, Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Amiq Gazdhar
- Department of Pulmonary Medicine, University Hospital Bern, Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Thomas Geiser
- Department of Pulmonary Medicine, University Hospital Bern, Bern, Switzerland; Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Marco P Alves
- Division of Respiratory Medicine, Department of Paediatrics, University Hospital Bern, Bern, Switzerland; Institute of Virology and Immunology, Bern, Switzerland; Department of Infectious Diseases and Pathobiology, Vetsuisse Faculty, University of Bern, Bern, Switzerland.
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8
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Mirra V, Ullmann N, Cherchi C, Onofri A, Paglietti MG, Cutrera R. Respiratory syncytial virus prophylaxis and the "special population". Minerva Pediatr 2018; 70:589-599. [PMID: 30334623 DOI: 10.23736/s0026-4946.18.05316-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Bronchiolitis is the most frequent airway infection in the first 2 years of life, and the respiratory syncytial virus (RSV) is the most frequently responsible virus. In selected high-risk groups, RSV may cause severe respiratory disease leading to hospitalization, need for mechanical ventilation, and even death. These high-risk groups include children with congenital heart disease, infants with neuromuscular impairment, cystic fibrosis, Down Syndrome, immunodeficiency syndromes and others specific conditions. In these high-risk populations defined in literature as "special population", a 3- to 10-fold increase in the rate of RSV hospitalization has been observed, justifying RSV specific prophylaxis with palivizumab, a monoclonal antibody that binds a viral glycoprotein epitope and blocks the link between RSV and target cell. Evidence of safety and efficacy of RSV prophylaxis in these populations is lacking. Given the low incidence of these conditions, randomized clinical trials are not feasible. The purpose of this paper is to give an update from the literature of various conditions at higher risk to develop severe RSV infection, and to offer an overview of the efficacy of palivizumab in preventing RSV infection in these specific populations.
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Affiliation(s)
- Virginia Mirra
- Unit of Paediatric Pulmonology and Respiratory Intermediate Care, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy.,Unit of Sleep and Long-term Ventilation, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
| | - Nicola Ullmann
- Unit of Paediatric Pulmonology and Respiratory Intermediate Care, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy - .,Unit of Sleep and Long-term Ventilation, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
| | - Claudio Cherchi
- Unit of Paediatric Pulmonology and Respiratory Intermediate Care, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy.,Unit of Sleep and Long-term Ventilation, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
| | - Alessandro Onofri
- Unit of Paediatric Pulmonology and Respiratory Intermediate Care, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy.,Unit of Sleep and Long-term Ventilation, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
| | - Maria G Paglietti
- Unit of Paediatric Pulmonology and Respiratory Intermediate Care, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy.,Unit of Sleep and Long-term Ventilation, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
| | - Renato Cutrera
- Unit of Paediatric Pulmonology and Respiratory Intermediate Care, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy.,Unit of Sleep and Long-term Ventilation, Academic Department of Paediatrics, Paediatric Hospital "Bambino Gesù" Research Institute, Rome, Italy
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9
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Palivizumab prophylaxis for respiratory syncytial virus in infants with cystic fibrosis: is there a need? Eur J Clin Microbiol Infect Dis 2018; 37:1113-1118. [PMID: 29557081 DOI: 10.1007/s10096-018-3225-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/06/2018] [Indexed: 02/03/2023]
Abstract
Respiratory syncytial virus (RSV) infection in cystic fibrosis (CF) infants is associated with significant morbidities. This study's objective is to evaluate the effectiveness and adverse events related to palivizumab (PVZ) in CF infants. Data on respiratory-related illness (RIH) and RSV hospitalizations (RSVH) were collected retrospectively in CF infants aged < 2 years in Alberta, Canada, from 2000 to 2017. Logistic regression models were used to compare the odds of RSVH or RIH in PVZ infants from the Canadian registry of palivizumab (CARESS) versus untreated (UPVZ) infants from Alberta, after adjusting for potential confounders. Illness severity was compared between cohorts using χ2 and t tests. A total of 267 CF infants were included: 183 (PVZ) and 84 (UPVZ). A total of 53.3% were tested for RSV. Fifty-five infants experienced a RIH and 10 had a RSVH. The PVZ cohort experienced similar odds of RSVH but decreased odds of RIH versus UPVZ, adjusting for gestational age, birth weight, birth during RSV peak months, and presence of siblings (Exp(B) = 0.23 [0.11-0.49], p < 0.0005). In RSVH-related subjects, PVZ subjects experienced shorter length of overall stay (LOS; t = 2.39 [df = 7], p = 0.048). In those with a RIH, the PVZ group had shorter overall intensive care unit (t = 3.52 [df = 15], p = 0.003) and hospital LOS (t = 2.11 [df = 52], p = 0.04). No serious adverse events were related to PVZ. The odds of RSVH were similar between groups, but PVZ subjects had decreased odds of RIH. The low number of RSV tests performed may explain the similarity in RSVH rates. Significant differences in LOS may indicate decreased RSVH and RIH illness severity in the PVZ versus UPVZ groups.
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10
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Simões EAF, Bont L, Manzoni P, Fauroux B, Paes B, Figueras-Aloy J, Checchia PA, Carbonell-Estrany X. Past, Present and Future Approaches to the Prevention and Treatment of Respiratory Syncytial Virus Infection in Children. Infect Dis Ther 2018; 7:87-120. [PMID: 29470837 PMCID: PMC5840107 DOI: 10.1007/s40121-018-0188-z] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION The REGAL (RSV Evidence - A Geographical Archive of the Literature) series has provided a comprehensive review of the published evidence in the field of respiratory syncytial virus (RSV) in Western countries over the last 20 years. This seventh and final publication covers the past, present and future approaches to the prevention and treatment of RSV infection among infants and children. METHODS A systematic review was undertaken of publications between January 1, 1995 and December 31, 2017 across PubMed, Embase and The Cochrane Library. Studies reporting data on the effectiveness and tolerability of prophylactic and therapeutic agents for RSV infection were included. Study quality and strength of evidence (SOE) were graded using recognized criteria. A further nonsystematic search of the published literature and Clinicaltrials.gov on antiviral therapies and RSV vaccines currently in development was also undertaken. RESULTS The systematic review identified 1441 studies of which 161 were included. Management of RSV remains centered around prophylaxis with the monoclonal antibody palivizumab, which has proven effective in reducing RSV hospitalization (RSVH) in preterm infants < 36 weeks' gestational age (72% reduction), children with bronchopulmonary dysplasia (65% reduction), and infants with hemodynamically significant congenital heart disease (53% reduction) (high SOE). Palivizumab has also shown to be effective in reducing recurrent wheezing following RSVH (high SOE). Treatment of RSV with ribavirin has conflicting success (moderate SOE). Antibodies with increased potency and extended half-life are currently entering phase 3 trials. There are approximately 15 RSV vaccines in clinical development targeting the infant directly or indirectly via the mother. CONCLUSION Palivizumab remains the only product licensed for RSV prophylaxis, and only available for high-risk infants. For the general population, there are several promising vaccines and monoclonal antibodies in various stages of clinical development, with the aim to significantly reduce the global healthcare impact of this common viral infection. FUNDING AbbVie.
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Affiliation(s)
- Eric A F Simões
- Center for Global Health, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, CO, USA
| | - Louis Bont
- University Medical Center Utrecht, Utrecht, The Netherlands
- ReSViNET (Respiratory Syncytial Virus Network), Utrecht, The Netherlands
| | - Paolo Manzoni
- ReSViNET (Respiratory Syncytial Virus Network), Utrecht, The Netherlands
- Neonatology and NICU, Sant'Anna Hospital, Turin, Italy
| | - Brigitte Fauroux
- Necker University Hospital and Paris 5 University, Paris, France
| | - Bosco Paes
- Department of Paediatrics (Neonatal Division), McMaster University, Hamilton, Canada
| | - Josep Figueras-Aloy
- Hospital Clínic, Catedràtic de Pediatria, Universitat de Barcelona, Barcelona, Spain
| | - Paul A Checchia
- Baylor College of Medicine, Texas Children's Hospital Houston, Houston, TX, USA
| | - Xavier Carbonell-Estrany
- Hospital Clinic, Institut d'Investigacions Biomediques August Pi Suñer (IDIBAPS), Barcelona, Spain.
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11
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Cantey JB. Respiratory Viruses in the Neonatal Intensive Care Unit. NEONATAL INFECTIONS 2018. [PMCID: PMC7123251 DOI: 10.1007/978-3-319-90038-4_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Joseph B. Cantey
- University of Texas Health Science Center San Antonio, San Antonio, Texas USA
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12
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Respiratory Syncytial Virus Infection-associated Hospitalization Rates in Infants and Children With Cystic Fibrosis. Pediatr Infect Dis J 2017; 36:545-548. [PMID: 28005688 DOI: 10.1097/inf.0000000000001501] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infections with respiratory syncytial virus (RSV) are the leading cause for hospital admissions in infants and young children. The incidence of RSV-related hospitalizations in patients with cystic fibrosis (CF) is unclear. To date, no effective treatment for RSV infections is available. Thus, prophylaxis with the monoclonal antibody palivizumab is an important option. METHODS In a retrospective, single-center study at the Department of Pediatrics and Adolescent Medicine of the Medical University Graz, Austria, we analyzed all CF patients born between 1995 and 2012, who were admitted for respiratory problems between 1995 and 2014. We also defined a group of hypothetical RSV infections with the following criteria: admission caused by a respiratory infection during the first RSV season of life when no test for RSV was performed. Furthermore, we assessed the effectiveness of palivizumab as a prevention of RSV-related hospitalizations. RESULTS A total of 51 patients with CF were identified. The RSV-related hospitalization rate for the first RSV season was 0. Two patients (3.9%) were hospitalized 3 and 4 times, respectively, caused by RSV infections. The mean age at the time of admission was 12.4 ± 2.5 years. One case (1.9%) met our criteria for hypothetical RSV infections. There was no difference in RSV-related hospitalization rates between patients who received palivizumab and those who did not. CONCLUSIONS We found a low rate of RSV-related hospitalizations and could not demonstrate a benefit of palivizumab prophylaxis regarding a decrease of RSV-related hospital admissions. The role of RSV reinfections in CF patients beyond infancy appears to be underestimated.
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Kua KP, Lee SWH. Systematic Review of the Safety and Efficacy of Palivizumab among Infants and Young Children with Cystic Fibrosis. Pharmacotherapy 2017; 37:755-769. [PMID: 28423192 DOI: 10.1002/phar.1936] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) is a common pathogen in infants with cystic fibrosis (CF). The use of palivizumab prophylaxis for RSV infection as the standard of care for infants with CF remains controversial. OBJECTIVE To evaluate the efficacy of palivizumab in reducing the incidence of RSV hospitalization in children with CF who are younger than 2 years. METHODS Four electronic databases (PubMed, Embase, CINAHL, and CENTRAL) were searched from inception until January 31, 2017, for clinical studies investigating the use of palivizumab in infants with CF aged less than 2 years. The primary outcome was hospitalization rate due to RSV infection. Secondary outcomes included hospitalization for respiratory illness, length of hospital stay, safety (adverse effects), and cost-effectiveness of palivizumab prophylaxis. RESULTS The review included a total of 10 studies (six cohort studies, two before-and-after studies, one cross-sectional study, and one randomized controlled trial) involving 3891 patients with CF. Seven studies reported that palivizumab prophylaxis had a positive impact on the rate of RSV hospitalization. Five studies (n=3404) reported that palivizumab prophylaxis significantly reduced the rate of hospitalization due to RSV infection compared to no prophylaxis. One study (n=5) demonstrated patients with CF who received palivizumab had no RSV hospitalization. Another study showed infants with CF receiving palivizumab (n=117) had a lower risk of hospitalization for RSV infection compared with premature infants (gestational age < 35 completed weeks) who received palivizumab (n=4880). CONCLUSIONS Evidence from the literature suggests that palivizumab may have a potential role in reducing RSV hospitalization in children aged less than 2 years with CF. Given the lack of overall data, additional research is warranted to better understand the efficacy and safety of prophylactic palivizumab in infants with CF.
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Affiliation(s)
- Kok Pim Kua
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia.,Department of Pharmacy, Petaling District Health Office (Ministry of Health Malaysia), Petaling Jaya, Selangor Darul Ehsan, Malaysia
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor Darul Ehsan, Malaysia
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McGirr AA, Schwartz KL, Allen U, Solomon M, Sander B. The cost-effectiveness of palivizumab in infants with cystic fibrosis in the Canadian setting: A decision analysis model. Hum Vaccin Immunother 2017; 13:599-606. [PMID: 27768505 PMCID: PMC5360124 DOI: 10.1080/21645515.2016.1235670] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/25/2016] [Accepted: 09/08/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Children with cystic fibrosis (CF) are at higher risk of severe respiratory syncytial virus (RSV) infection, which can lead to a decline in lung function. A monoclonal antibody, palivizumab (PMB), effectively prevents RSV hospitalizations; however, the high cost of PMB, approximately C$10,000 per patient per RSV season, limits its widespread use. We assess the cost-effectiveness of PMB prophylaxis in CF children less than 2 y of age from the Canadian healthcare payer's perspective. METHODS In 2014, a Markov cohort model of CF disease and infant RSV infections in the Canadian setting was developed based on literature data. Infants were treated with monthly PMB injections over the 5-month RSV season. Lifetime health outcomes, quality-adjusted life years (QALYs) and 2013 $CAD costs, discounted at 5%, were estimated. Findings are summarized as incremental cost-effectiveness ratios (ICERs) and budget impact. Deterministic sensitivity analysis was conducted to assess parameter uncertainty. RESULTS Implementation of a hypothetical Canadian RSV prophylaxis program resulted in ICERs of C$652,560 (all CF infants) and C$157,332 (high-risk CF infants) per QALY gained and an annual budget impact of C$1,400,000 (all CF infants) and C$285,000 (high-risk CF infants). The analysis was highly sensitive to the probability of severe RSV, the degree of lung deterioration following infection, and the cost of PMB. CONCLUSIONS Our results suggest PMB is not cost-effective in Canada by commonly used thresholds. However, given the rarity of CF and relatively small budget impact, consideration may be given for the selective use of PMB for immunoprophylaxis of RSV in high-risk CF infants on a case-by-case scenario basis.
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Affiliation(s)
- Ashleigh A. McGirr
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Kevin L. Schwartz
- Division of Infectious Disease, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Upton Allen
- Division of Infectious Disease, The Hospital for Sick Children, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Melinda Solomon
- Division of Respirology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Beate Sander
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Public Health Ontario, Toronto, ON, Canada
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
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Abstract
BACKGROUND Aboriginal infants are at risk for serious respiratory infection. OBJECTIVE To determine the hazard rate (HR) for respiratory-related illness (RIH) and respiratory syncytial virus (RSV) specific infection hospitalization (RSVH) in Aboriginal versus non-Aboriginal children receiving palivizumab and the effect of adherence on hospitalization. METHODS Palivizumab recipients in the Canadian registry from 2005 to 2014 were included. Adherence was determined by the number of palivizumab doses received during the RSV season and interdose time interval. Adherence proportions between groups were compared by χ test. Cox proportional hazard analysis determined the effect of Aboriginal status and adherence on the risk of RIH and RSVH. RESULTS Aboriginal infants comprised 3.6% (701/19,235) of the registry. HR was 1.6 [95% confidence interval (CI): 1.3-2.0, P < 0.001] and 1.2 (95% CI: 0.7-2.2, P = 0.383) for RIH and RSVH. Aboriginal infants were 62.8% and 63.3% adherent with all recommended injections and within stipulated time intervals, respectively, whereas 81.9% (χ = 162.45, df = 1, P < 0.001) and 72.4% (χ = 27.35, df = 1, P = 0.002) of non-Aboriginal infants were correspondingly adherent. Only 39.9% of Aboriginals were perfectly adherent (adherent to total number and injection intervals), compared with 61.7% of non-Aboriginals (χ = 133.89, df = 1, P < 0.001). Even after adjustment for known risk factors, being Aboriginal and nonadherent was associated with higher RIH hazard (HR = 1.4, 95% CI: 1.1-1.8; HR = 1.3, 95% CI: 1.1-1.4, P = 0.004), respectively. Aboriginals nonadherent with interdose intervals had a 2.2-fold increased HR for RSVH (HR = 2.2, 95% CI: 1.2-4.2, P = 0.015). CONCLUSIONS Prophylaxed Aboriginal infants have a significantly increased RIH and RSVH hazard than non-Aboriginal infants. Improving adherence especially interdose frequency may further reduce hospitalizations in this vulnerable population.
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Pignotti MS, Carmela Leo M, Pugi A, De Masi S, Biermann KP, Galli L, Vitali Rosati G, Buonocore G, Mugelli A, Dani C, Lucenteforte E, Bellini F, Donzelli G. Consensus conference on the appropriateness of palivizumab prophylaxis in respiratory syncytial virus disease. Pediatr Pulmonol 2016; 51:1088-1096. [PMID: 27618642 DOI: 10.1002/ppul.23561] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/22/2016] [Accepted: 08/10/2016] [Indexed: 11/11/2022]
Abstract
Respiratory syncytial virus infection represents a clinical burden among young children under 24 months. Palivizumab is the only drug licensed in Italy for the prevention of serious lower respiratory tract disease requiring hospitalization caused by respiratory syncytial virus in children at high risk. However recommendations for palivizumab prophylaxis are heterogeneous. Not all the published documents agree about the clinical indications of palivizumab; this could lead to different clinical practices and concerns about the appropriateness of prophylaxis. These issues and the lack of evidence about palivizumab prophylaxis efficacy in specific medical conditions brought on the idea of a consensus conference on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications. The goal was to perform a review of the evidence regarding the efficacy and the safety of palivizumab and give recommendations in order to harmonize its use. A structured and validated method to conduct the consensus process was adopted. The consensus conference recommends palivizumab prophylaxis in infants born before 29 weeks and younger than 12 months at the start of the epidemic season. According to evidence from literature and experts' opinion, palivizumab prophylaxis is not recommended in preterm infants of gestational age ≥29 weeks, without co-morbidity (i.e., cardiac, bronchopulmonary diseases). The experts identified some clinical rare conditions for which the decision of prophylaxis should be entrusted to the specialists. The evaluation of the appropriateness of palivizumab prophylaxis in the single patient should be documented by the specialists. Pediatr Pulmonol. 2016;51:1088-1096. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | | | - Alessandra Pugi
- Meyer Children's Hospital, Viale Pieraccini 24, Florence, Italy
| | | | | | - Luisa Galli
- Meyer Children's Hospital, Viale Pieraccini 24, Florence, Italy
| | | | | | - Alessandro Mugelli
- Department of Neurosciences, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Carlo Dani
- Department of Neurosciences, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - Ersilia Lucenteforte
- Department of Neurosciences, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
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Robinson KA, Odelola OA, Saldanha IJ. Palivizumab for prophylaxis against respiratory syncytial virus infection in children with cystic fibrosis. Cochrane Database Syst Rev 2016; 7:CD007743. [PMID: 27439110 PMCID: PMC6457857 DOI: 10.1002/14651858.cd007743.pub6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Respiratory syncytial virus infection causes acute lung infection in infants and young children worldwide, resulting in considerable morbidity and mortality. Children with cystic fibrosis are prone to recurrent lung inflammation, bacterial colonisation and subsequent chronic airway disease, putting them at risk for severe respiratory syncytial virus infections requiring intensive care and respiratory support. No treatment currently exists, hence prevention is important. Palivizumab is effective in reducing respiratory syncytial virus hospitalisation rates and is recommended for prophylaxis in high-risk children with other conditions. It is unclear if palivizumab can prevent respiratory syncytial virus hospitalisations and intensive care unit admissions in children with cystic fibrosis. This is an update of a previously published review. OBJECTIVES To determine the efficacy and safety of palivizumab (Synagis(®)) compared with placebo, no prophylaxis or other prophylaxis, in preventing hospitalisation and mortality from respiratory syncytial virus infection in children with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register and scanned references of the eligible study and related reviews.Date of last search: 05 May 2016. SELECTION CRITERIA Randomised and quasi-randomised studies. DATA COLLECTION AND ANALYSIS The authors independently extracted data and assessed risk of bias. MAIN RESULTS One study (186 infants up to two years old) comparing five monthly doses of palivizumab (N = 92) to placebo (N = 94) over one respiratory syncytial virus season was identified and met our inclusion criteria. We judged there to be a low risk of bias with respect to the concealment of the randomization schedule (although it was not clear how this was generated) and to blinding of participants and study personnel. There is also a low risk of bias with regards to incomplete outcome data. However, we judged there to be a high risk of bias from selective reporting (summary statements presented but no data) and the fact that this industry-supported study has not been published as a full report in a peer-reviewed journal.At six months follow-up, one participant in each group was hospitalised due to respiratory syncytial virus; there were no deaths in either group. In the palivizumab and placebo groups, 86 and 90 children experienced any adverse event, while five and four children had related adverse events respectively. Nineteeen children receiving palivizumab and 16 receiving placebo suffered serious adverse events; one participant receiving palivizumab discontinued due to this. At 12 months follow-up, there were no significant differences between groups in number of Pseudomonas bacterial colonisations or change in weight-to-height ratio. AUTHORS' CONCLUSIONS We identified one randomised controlled trial comparing five monthly doses of palivizumab to placebo in infants up to two years old with cystic fibrosis. While the overall incidence of adverse events was similar in both groups, it is not possible to draw firm conclusions on the safety and tolerability of respiratory syncytial virus prophylaxis with palivizumab in infants with cystic fibrosis. Six months after treatment, the authors reported no clinically meaningful differences in outcomes. Additional randomised studies are needed to establish the safety and efficacy of palivizumab in children with cystic fibrosis.
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Affiliation(s)
- Karen A Robinson
- Department of Medicine, Johns Hopkins University, 1830 E. Monument St., Suite 8068, Baltimore, MD, USA, 21287
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18
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Groves HE, Jenkins L, Macfarlane M, Reid A, Lynn F, Shields MD. Efficacy and long-term outcomes of palivizumab prophylaxis to prevent respiratory syncytial virus infection in infants with cystic fibrosis in Northern Ireland. Pediatr Pulmonol 2016; 51:379-85. [PMID: 26808981 DOI: 10.1002/ppul.23376] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 12/03/2015] [Accepted: 12/15/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND RSV causes considerable morbidity and mortality in children. In cystic fibrosis (CF) viral infections are associated with worsening respiratory symptoms and bacterial colonization. Palivizumab is effective in reducing RSV hospitalization in high risk patient groups. Evidence regarding its effectiveness and safety in CF is inconclusive. CF screening in N. Ireland enabled timely palivizumab prophylaxis, becoming routine in 2002. OBJECTIVES To determine the effect of palivizumab on RSV-related hospitalization and compare lung function and bacterial colonization at age 6 years for those born pre- and post-introduction of palivizumab prophylaxis. METHODS A retrospective audit was conducted for all patients diagnosed with CF during the period from 1997 to 2007 inclusive. RSV-related hospitalization, time to Pseudomonas aeruginosa (PA) 1st isolate, lung function and growth parameters were recorded. Comparisons were made for outcomes pre- and post-introduction of routine palivizumab administration in 2002. A cost evaluation was also performed. RESULTS Ninety-two children were included; 47 pre- and 45 post-palivizumab introduction. The overall RSV-positive hospitalization rate was 13%. The relative risk of RSV infection in palivizumab non-recipients versus recipients was 4.78 (95%CI: 1.1-20.7), P = 0.027. Notably, PA 1st isolate was significantly earlier in the palivizumab recipient cohort versus non-recipient cohort (median 57 vs. 96 months, P < 0.025) with a relative risk of 2.5. Chronic PA infection at 6 years remained low in both groups, with similar lung function and growth parameters. Total costs were calculated at £96,127 ($151,880) for the non-recipient cohort versus £137,954 ($217,967) for the recipient cohort. CONCLUSION Palivizumab was effective in reducing RSV-related hospitalization infection in CF patients. Surprisingly, we found a significantly earlier time to 1st isolate of PA in palivizumab recipients which we could not explain by altered or improved diagnostic tests.
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Affiliation(s)
- H E Groves
- Department of Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, United Kingdom
| | - L Jenkins
- Department of Cystic Fibrosis, Royal Belfast Hospital for Sick Children, Belfast, United Kingdom
| | - M Macfarlane
- Department of Cystic Fibrosis, Royal Belfast Hospital for Sick Children, Belfast, United Kingdom
| | - A Reid
- Department of Cystic Fibrosis, Royal Belfast Hospital for Sick Children, Belfast, United Kingdom
| | - F Lynn
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, United Kingdom
| | - M D Shields
- Department of Paediatrics, Queens University of Belfast, Belfast, United Kingdom
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19
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Linnane B, Kiernan MG, O'Connell NH, Kearse L, Dunne CP. Anti-RSV prophylaxis efficacy for infants and young children with cystic fibrosis in Ireland. Multidiscip Respir Med 2015; 10:32. [PMID: 26473032 PMCID: PMC4607252 DOI: 10.1186/s40248-015-0029-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/31/2015] [Indexed: 12/03/2022] Open
Abstract
Rationale There is limited evidence supporting the routine use of palivizumab in paediatric cystic fibrosis (CF) patients to reduce respiratory syncytial virus (RSV) infection and related hospitalisation. Despite this, anti-RSV prophylaxis is increasingly common. This is the first report from Ireland regarding palivizumab outcomes for children with CF, under 2 years old, despite the greatest prevalence of CF globally. Methods An audit was performed at a tertiary hospital in Ireland’s mid-West to document all children with CF, <24 months old, who received palivizumab over a five year period and comparision made with all eligible children for the prior five year period who had not received the product (also CF patients). Palivizumab was administered to both cohorts in their first year of life. Hospitalisation rates were compared using Fisher’s exact test. Incidence of RSV and Pseudomonas aeruginosa infection was recorded. Results A total of 19 patients who received palivizumab were included in the study; comparision was made with a retrospective control group of 30 patients. Prophylactic palivizumab did not prevent hospitalisation for 10/19 patients, 3 of whom were affected by RSV. This was significantly greater than in the control group, where no hospitalisations were recorded (p < 0.0001). P. aeruginosa was isolated in one case from the study cohort, while no P. aeruginosa was detected in the control group. Conclusions This study, the first of its kind from Ireland where CF prevalence is highest, does not provide unequivocal support for prophylactic use of palivizumab in CF patients under 2 years. Despite being derived from a small sample size, based on these data and complementary clinical observation, we have discontinued such prophylaxis. However, should reported incidence of RSV-related hospitalisation increase, there is scientific plausibility for appropriately powered, randomised, controlled trials of palivizumab.
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Affiliation(s)
- Barry Linnane
- Cystic Fibrosis Unit, University Hospital, Limerick, Ireland ; National Children's Research Centre, Crumlin, Dublin, Ireland ; Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland ; Study of Host Immunity and Early Lung Disease in CF (SHIELD CF), Dublin, Ireland
| | - Miranda G Kiernan
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Nuala H O'Connell
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland ; Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
| | - Linda Kearse
- National Children's Research Centre, Crumlin, Dublin, Ireland ; Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - Colum P Dunne
- Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
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20
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Robinson JL, Le Saux N. Prévenir les hospitalisations pour l’infection par le virus respiratoire syncytial. Paediatr Child Health 2015. [DOI: 10.1093/pch/20.6.327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Robinson JL, Le Saux N. Preventing hospitalizations for respiratory syncytial virus infection. Paediatr Child Health 2015; 20:321-33. [PMID: 26435673 PMCID: PMC4578474 DOI: 10.1093/pch/20.6.321] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Respiratory syncytial virus infection is the leading cause of lower respiratory tract infections in young children. Palivizumab has minimal impact on RSV hospitilization rates as it is only practical to offer it to the highest risk groups. The present statement reviews the published literature and provides updated recommendations regarding palivizumab use in children in Canada.
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Sánchez-Solis M, Gartner S, Bosch-Gimenez V, Garcia-Marcos L. Is palivizumab effective as a prophylaxis of respiratory syncytial virus infections in cystic fibrosis patients? A meta-analysis. Allergol Immunopathol (Madr) 2015; 43:298-303. [PMID: 24231153 DOI: 10.1016/j.aller.2013.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 09/21/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Infections by respiratory syncytial virus (RSV) are more severe in patients with cystic fibrosis (CF), and many CF units use palivizumab as prophylaxis; however, information about palivizumab efficacy in CF patients is almost lacking. METHODS A literature search up to December 2012 on the morbidity of RSV bronchiolitis in CF patients and on the safety and efficacy of palivizumab in those patients was performed. A random-effects meta-analysis was conducted for those studies meeting pre-specified search criteria. Historical controls were allowed. RESULTS The number of patients who received palivizumab was 354 and the hospital admission rate was 0.018 (95% CI 0.0077-0.048). The corresponding number in the non-treated groups was 463 patients with an admission rate of 0.126 (95% CI 0.086-0.182) (Q=13.9; p<0.001). CONCLUSION Palivizumab may have a role in the prevention of severe lower airway infection by RSV in CF patients.
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Schögler A, Kopf BS, Edwards MR, Johnston SL, Casaulta C, Kieninger E, Jung A, Moeller A, Geiser T, Regamey N, Alves MP. Novel antiviral properties of azithromycin in cystic fibrosis airway epithelial cells. Eur Respir J 2014; 45:428-39. [PMID: 25359346 DOI: 10.1183/09031936.00102014] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Virus-associated pulmonary exacerbations, often associated with rhinoviruses (RVs), contribute to cystic fibrosis (CF) morbidity. Currently, there are only a few therapeutic options to treat virus-induced CF pulmonary exacerbations. The macrolide antibiotic azithromycin has antiviral properties in human bronchial epithelial cells. We investigated the potential of azithromycin to induce antiviral mechanisms in CF bronchial epithelial cells. Primary bronchial epithelial cells from CF and control children were infected with RV after azithromycin pre-treatment. Viral RNA, interferon (IFN), IFN-stimulated gene and pattern recognition receptor expression were measured by real-time quantitative PCR. Live virus shedding was assessed by assaying the 50% tissue culture infective dose. Pro-inflammatory cytokine and IFN-β production were evaluated by ELISA. Cell death was investigated by flow cytometry. RV replication was increased in CF compared with control cells. Azithromycin reduced RV replication seven-fold in CF cells without inducing cell death. Furthermore, azithromycin increased RV-induced pattern recognition receptor, IFN and IFN-stimulated gene mRNA levels. While stimulating antiviral responses, azithromycin did not prevent virus-induced pro-inflammatory responses. Azithromycin pre-treatment reduces RV replication in CF bronchial epithelial cells, possibly through the amplification of the antiviral response mediated by the IFN pathway. Clinical studies are needed to elucidate the potential of azithromycin in the management and prevention of RV-induced CF pulmonary exacerbations.
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Affiliation(s)
- Aline Schögler
- Division of Paediatric Respiratory Medicine, University Children's Hospital, Berne, Switzerland Dept of Clinical Research, University of Berne, Berne, Switzerland Graduate School for Cellular and Biomedical Sciences, University of Berne, Berne, Switzerland
| | - Brigitte S Kopf
- Division of Paediatric Respiratory Medicine, University Children's Hospital, Berne, Switzerland Dept of Clinical Research, University of Berne, Berne, Switzerland
| | - Michael R Edwards
- Airway Disease Infection Section, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma and Centre for Respiratory Infection, National Heart and Lung Institute, Imperial College London, London, UK
| | - Sebastian L Johnston
- Airway Disease Infection Section, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma and Centre for Respiratory Infection, National Heart and Lung Institute, Imperial College London, London, UK
| | - Carmen Casaulta
- Division of Paediatric Respiratory Medicine, University Children's Hospital, Berne, Switzerland
| | - Elisabeth Kieninger
- Division of Paediatric Respiratory Medicine, University Children's Hospital, Berne, Switzerland
| | - Andreas Jung
- Division of Respiratory Medicine, University Children's Hospital, Zurich, Switzerland
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital, Zurich, Switzerland
| | - Thomas Geiser
- Dept of Clinical Research, University of Berne, Berne, Switzerland Dept of Pulmonary Medicine, University Hospital Berne, Berne, Switzerland
| | - Nicolas Regamey
- Division of Paediatric Respiratory Medicine, University Children's Hospital, Berne, Switzerland Dept of Clinical Research, University of Berne, Berne, Switzerland These authors contributed equally
| | - Marco P Alves
- Division of Paediatric Respiratory Medicine, University Children's Hospital, Berne, Switzerland Dept of Clinical Research, University of Berne, Berne, Switzerland These authors contributed equally
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Baraldi E, Lanari M, Manzoni P, Rossi GA, Vandini S, Rimini A, Romagnoli C, Colonna P, Biondi A, Biban P, Chiamenti G, Bernardini R, Picca M, Cappa M, Magazzù G, Catassi C, Urbino AF, Memo L, Donzelli G, Minetti C, Paravati F, Di Mauro G, Festini F, Esposito S, Corsello G. Inter-society consensus document on treatment and prevention of bronchiolitis in newborns and infants. Ital J Pediatr 2014; 40:65. [PMID: 25344148 PMCID: PMC4364570 DOI: 10.1186/1824-7288-40-65] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 04/18/2014] [Indexed: 01/14/2023] Open
Abstract
Acute bronchiolitis is the leading cause of lower respiratory tract infection and hospitalization in children less than 1 year of age worldwide. It is usually a mild disease, but some children may develop severe symptoms, requiring hospital admission and ventilatory support in the ICU. Infants with pre-existing risk factors (prematurity, bronchopulmonary dysplasia, congenital heart diseases and immunodeficiency) may be predisposed to a severe form of the disease. Clinical diagnosis of bronchiolitis is manly based on medical history and physical examination (rhinorrhea, cough, crackles, wheezing and signs of respiratory distress). Etiological diagnosis, with antigen or genome detection to identify viruses involved, may have a role in reducing hospital transmission of the infection. Criteria for hospitalization include low oxygen saturation (<90-92%), moderate-to-severe respiratory distress, dehydration and presence of apnea. Children with pre-existing risk factors should be carefully assessed.To date, there is no specific treatment for viral bronchiolitis, and the mainstay of therapy is supportive care. This consists of nasal suctioning and nebulized 3% hypertonic saline, assisted feeding and hydration, humidified O2 delivery. The possible role of any pharmacological approach is still debated, and till now there is no evidence to support the use of bronchodilators, corticosteroids, chest physiotherapy, antibiotics or antivirals. Nebulized adrenaline may be sometimes useful in the emergency room. Nebulized adrenaline can be useful in the hospital setting for treatment as needed. Lacking a specific etiological treatment, prophylaxis and prevention, especially in children at high risk of severe infection, have a fundamental role. Environmental preventive measures minimize viral transmission in hospital, in the outpatient setting and at home. Pharmacological prophylaxis with palivizumab for RSV bronchiolitis is indicated in specific categories of children at risk during the epidemic period. Viral bronchiolitis, especially in the case of severe form, may correlate with an increased incidence of recurrent wheezing in pre-schooled children and with asthma at school age.The aim of this document is to provide a multidisciplinary update on the current recommendations for the management and prevention of bronchiolitis, in order to share useful indications, identify gaps in knowledge and drive future research.
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Affiliation(s)
- Eugenio Baraldi
- />SIMRI-Società Italiana per le Malattie Respiratorie Infantili, Kragujevac, Italy
- />Women’s and Children’s Health Department, Unit of Pediatric Respiratory Medicine and Allergy, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | | | - Paolo Manzoni
- />SIN-Società Italiana di Neonatologia, Kragujevac, Italy
| | - Giovanni A Rossi
- />SIMRI-Società Italiana per le Malattie Respiratorie Infantili, Kragujevac, Italy
| | - Silvia Vandini
- />SIN-Società Italiana di Neonatologia, Kragujevac, Italy
| | - Alessandro Rimini
- />SICP-Società Italiana di Cardiologia Pediatrica, Kragujevac, Italy
| | | | - Pierluigi Colonna
- />SICP-Società Italiana di Cardiologia Pediatrica, Kragujevac, Italy
| | - Andrea Biondi
- />AIEOP - Società Italiana di Ematologia e Oncologia Pediatrica, Kragujevac, Italy
| | - Paolo Biban
- />AMIETIP - Accademia Medica Infermieristica di Emergenza e Terapia Intensiva Pediatrica, Kragujevac, Italy
| | | | - Roberto Bernardini
- />SIAIP - Società Italiana di Allergologia e Immunologia Pediatrica, Kragujevac, Italy
| | - Marina Picca
- />SICuPP - Società Italiana delle Cure Primarie Pediatriche, Kragujevac, Italy
| | - Marco Cappa
- />SIEDP - Società Italiana di Endocrinologia e Diabetologia Pediatrica, Kragujevac, Italy
| | - Giuseppe Magazzù
- />SIFC - Società Italiana per lo studio della Fibrosi Cistica, Kragujevac, Italy
| | - Carlo Catassi
- />SIGENP - Società Italiana Gastroenterologia Epatologia e Nutrizione Pediatrica, Kragujevac, Italy
| | | | - Luigi Memo
- />SIMGePeD - Società Italiana Malattie Genetiche Pediatriche e Disabilità Congenite, Kragujevac, Italy
| | | | - Carlo Minetti
- />SINP - Società Italiana di Neurologia Pediatrica, Kragujevac, Italy
| | | | - Giuseppe Di Mauro
- />SIPPS - Società Italiana di Pediatria Preventiva e Sociale, Kragujevac, Italy
| | - Filippo Festini
- />SISIP - Società Italiana di Scienze Infermieristiche Pediatriche, Kragujevac, Italy
| | - Susanna Esposito
- />SITIP - Società Italiana di Infettivologia Pediatrica, Kragujevac, Italy
| | | | - on behalf of their respective Scientific Pediatric Societies
- />SIMRI-Società Italiana per le Malattie Respiratorie Infantili, Kragujevac, Italy
- />Women’s and Children’s Health Department, Unit of Pediatric Respiratory Medicine and Allergy, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
- />SIN-Società Italiana di Neonatologia, Kragujevac, Italy
- />SICP-Società Italiana di Cardiologia Pediatrica, Kragujevac, Italy
- />AIEOP - Società Italiana di Ematologia e Oncologia Pediatrica, Kragujevac, Italy
- />AMIETIP - Accademia Medica Infermieristica di Emergenza e Terapia Intensiva Pediatrica, Kragujevac, Italy
- />FIMP - Federazione Italiana Medici Pediatri, Kragujevac, Italy
- />SIAIP - Società Italiana di Allergologia e Immunologia Pediatrica, Kragujevac, Italy
- />SICuPP - Società Italiana delle Cure Primarie Pediatriche, Kragujevac, Italy
- />SIEDP - Società Italiana di Endocrinologia e Diabetologia Pediatrica, Kragujevac, Italy
- />SIFC - Società Italiana per lo studio della Fibrosi Cistica, Kragujevac, Italy
- />SIGENP - Società Italiana Gastroenterologia Epatologia e Nutrizione Pediatrica, Kragujevac, Italy
- />SIMEUP - Società Italiana di Medicina di Emergenza ed Urgenza Pediatrica, Kragujevac, Italy
- />SIMGePeD - Società Italiana Malattie Genetiche Pediatriche e Disabilità Congenite, Kragujevac, Italy
- />SIMP - Società Italiana di Medicina Perinatale, Kragujevac, Italy
- />SINP - Società Italiana di Neurologia Pediatrica, Kragujevac, Italy
- />SIPO - Società Italiana Pediatria Ospedaliera, Kragujevac, Italy
- />SIPPS - Società Italiana di Pediatria Preventiva e Sociale, Kragujevac, Italy
- />SISIP - Società Italiana di Scienze Infermieristiche Pediatriche, Kragujevac, Italy
- />SITIP - Società Italiana di Infettivologia Pediatrica, Kragujevac, Italy
- />SIP-Società Italiana di Pediatria, Kragujevac, Italy
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25
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Updated guidance for palivizumab prophylaxis among infants and young children at increased risk of hospitalization for respiratory syncytial virus infection. Pediatrics 2014; 134:e620-38. [PMID: 25070304 DOI: 10.1542/peds.2014-1666] [Citation(s) in RCA: 250] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Guidance from the American Academy of Pediatrics (AAP) for the use of palivizumab prophylaxis against respiratory syncytial virus (RSV) was first published in a policy statement in 1998. Guidance initially was based on the result from a single randomized, placebo-controlled clinical trial conducted in 1996-1997 describing an overall reduction in RSV hospitalization rate from 10.6% among placebo recipients to 4.8% among children who received prophylaxis. The results of a second randomized, placebo-controlled trial of children with hemodynamically significant heart disease were published in 2003 and revealed a reduction in RSV hospitalization rate from 9.7% in control subjects to 5.3% among prophylaxis recipients. Because no additional controlled trials regarding efficacy were published, AAP guidance has been updated periodically to reflect the most recent literature regarding children at greatest risk of severe disease. Since the last update in 2012, new data have become available regarding the seasonality of RSV circulation, palivizumab pharmacokinetics, the changing incidence of bronchiolitis hospitalizations, the effects of gestational age and other risk factors on RSV hospitalization rates, the mortality of children hospitalized with RSV infection, and the effect of prophylaxis on wheezing and palivizumab-resistant RSV isolates. These data enable further refinement of AAP guidance to most clearly focus on those children at greatest risk.
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MESH Headings
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antiviral Agents/administration & dosage
- Antiviral Agents/pharmacokinetics
- Antiviral Agents/therapeutic use
- Child, Preschool
- Comorbidity
- Cystic Fibrosis/epidemiology
- Down Syndrome/epidemiology
- Gestational Age
- Hospitalization/statistics & numerical data
- Humans
- Immunocompromised Host
- Indians, North American/statistics & numerical data
- Infant
- Infant, Premature
- Injections, Intramuscular
- Neuromuscular Diseases/epidemiology
- Palivizumab
- Respiratory Sounds
- Respiratory Syncytial Virus Infections/epidemiology
- Respiratory Syncytial Virus Infections/ethnology
- Respiratory Syncytial Virus Infections/prevention & control
- Risk Factors
- Seasons
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26
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Robinson KA, Odelola OA, Saldanha IJ. Palivizumab for prophylaxis against respiratory syncytial virus infection in children with cystic fibrosis. Cochrane Database Syst Rev 2014:CD007743. [PMID: 24851825 DOI: 10.1002/14651858.cd007743.pub5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Respiratory syncytial virus infection causes acute lung infection in infants and young children worldwide, resulting in considerable morbidity and mortality. Children with cystic fibrosis are prone to recurrent lung inflammation, bacterial colonisation and subsequent chronic airway disease, putting them at risk for severe respiratory syncytial virus infections requiring intensive care and respiratory support. No treatment currently exists, hence prevention is important. Palivizumab is effective in reducing respiratory syncytial virus hospitalisation rates and is recommended for prophylaxis in high-risk children with other conditions. It is unclear if palivizumab can prevent respiratory syncytial virus hospitalisations and intensive care unit admissions in children with cystic fibrosis. OBJECTIVES To determine the efficacy and safety of palivizumab (Synagis(®)) compared with placebo, no prophylaxis or other prophylaxis, in preventing hospitalisation and mortality from respiratory syncytial virus infection in children with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register and scanned references of the eligible study and related reviews.Date of last search: 17 March 2014. SELECTION CRITERIA Randomised and quasi-randomised studies. DATA COLLECTION AND ANALYSIS The authors independently extracted data and assessed risk of bias. MAIN RESULTS One study (186 infants up to two years old) comparing five monthly doses of palivizumab (N = 92) to placebo (N = 94) over one respiratory syncytial virus season was identified and met our inclusion criteria. We judged there to be a low risk of bias with respect to the concealment of the randomization schedule (although it was not clear how this was generated) and to blinding of participants and study personnel. There is also a low risk of bias with regards to incomplete outcome data. However, we judged there to be a high risk of bias from selective reporting (summary statements presented but no data) and the fact that this industry-supported study has not been published as a full report in a peer-reviewed journal.At six months follow-up, one participant in each group was hospitalised due to respiratory syncytial virus; there were no deaths in either group. In the palivizumab and placebo groups, 86 and 90 children experienced any adverse event, while five and four children had related adverse events respectively. Nineteeen children receiving palivizumab and 16 receiving placebo suffered serious adverse events; one participant receiving palivizumab discontinued due to this. At 12 months follow-up, there were no significant differences between groups in number of Pseudomonas bacterial colonisations or change in weight-to-height ratio. AUTHORS' CONCLUSIONS We identified one randomised controlled trial comparing five monthly doses of palivizumab to placebo in infants up to two years old with cystic fibrosis. While the overall incidence of adverse events was similar in both groups, it is not possible to draw firm conclusions on the safety and tolerability of respiratory syncytial virus prophylaxis with palivizumab in infants with cystic fibrosis. Six months after treatment, the authors reported no clinically meaningful differences in outcomes. Additional randomised studies are needed to establish the safety and efficacy of palivizumab in children with cystic fibrosis.
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Affiliation(s)
- Karen A Robinson
- Department of Medicine, Johns Hopkins University, 1830 E. Monument St., Suite 8068, Baltimore, MD, USA, 21287
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27
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Gaboli M, de la Cruz ÒA, de Agüero MIBG, Moreno-Galdó A, Pérez GP, de Querol MSS. Use of palivizumab in infants and young children with severe respiratory disease: a Delphi study. Pediatr Pulmonol 2014; 49:490-502. [PMID: 23775884 DOI: 10.1002/ppul.22826] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Accepted: 04/21/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To achieve a consensus of opinion among an expert group of pediatric pulmonologists regarding the appropriateness of the off-label use of palivizumab for some pediatric patients with severe respiratory diseases. METHODS A two-round modified Delphi technique was used. A 43-item self-administered questionnaire grouped into seven clinical scenarios was developed. Level of agreement for each statement was ranked on a 0-9 scale with 0 being total disagreement and 9 total agreement. Consensus was sought through the feedback of information and iteration. The final responses were evaluated for median and interquartile range to determine which questions the group had reached consensus about, either affirmatively or negatively. RESULTS Consensus was obtained for 24/43 statements (55.81%), including use of palivizumab for prevention of respiratory syncytial virus (RSV) infection in children with severe respiratory involvement due to neuromuscular disease, congenital or acquired immunodeficiency, storage disease, cystic fibrosis, diseases involving impaired ciliary clearance, patients operated on esophageal atresia and/or tracheoesophageal fistula, diaphragmatic hernia, bronchopulmonary malformations, severe tracheomalacia, lung transplant recipients and patients in the waiting list for lung transplant, patients oxygen-dependent for severe interstitial pulmonary disease and patients with severe pulmonary hypertension. Consensus against the use of palivizumab as prevention of RSV infection was also achieved in almost all the recurrent wheezing/asthma attacks situations. CONCLUSION A set of indication for off-label uses of palivizumab in pediatric pulmonology was developed in accordance with the degree of professional consensus on which they were based. The applicability of the present results to clinical practice should be evaluated individually and reviewed periodically in the light of new emerging evidence. Further studies are needed to add evidence to the most frequent and clinically oriented scenarios that have shown higher levels of uncertainty.
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Affiliation(s)
- Mirella Gaboli
- Pediatric Pulmonology and Pediatric Intensive Care Units, Department of Pediatrics, Hospital Universitario de Salamanca and University of Salamanca, Salamanca, Spain
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28
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Winterstein AG, Eworuke E, Xu D, Schuler P. Palivizumab immunoprophylaxis effectiveness in children with cystic fibrosis. Pediatr Pulmonol 2013; 48:874-84. [PMID: 23139089 PMCID: PMC7167886 DOI: 10.1002/ppul.22711] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 09/27/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Evidence on the effectiveness of respiratory syncytial virus (RSV) immunoprophylaxis with palivizumab in children with cystic fibrosis (CF) is lacking. METHODS We utilized Medicaid Extract files from 27 states from 1999 to 2006 linked to the National Cystic Fibrosis Registry to establish a cohort of children 0-2 years with CF diagnosis. Eligible children entered the cohort after CF diagnosis and after RSV season onset, and were followed until season end, second birthday, death, or hospitalizations for reasons other then the study outcome. Two outcomes were examined: hospitalization for RSV infections (RSV-ha), or hospitalization for acute respiratory infections (ARI-ha). Palivizumab exposure was defined based on pharmacy or procedure claims as current (claim date plus 30 days), former (day 31-60 after a claim), and no exposure (days before the first or >60 days after any claim). Both outcomes were examined in a Cox regression model, adjusting for RSV risk factors and CF severity via exposure propensity score. RESULTS The matched cohort included 1,974 infants (2,875 infant seasons), who experienced 32 RSV-ha and 212 ARI-ha (3.9 and 26.2/1,000 season months, respectively). Compared to periods of no use, the adjusted hazard ratio for current use was 0.57 (95% confidence interval [CI]: 0.20-1.60) for RSV-related hospitalization and 0.85 (95% CI: 0.59-1.21) for ARI-related hospitalization. Each month of increasing age reduced the ARI-ha by 5.8%. CONCLUSION RSV hospitalization incidence was low suggesting either little contribution of the virus to respiratory infections in patients with CF or lack of RSV testing. Unadjusted and adjusted RSV-hospitalization incidence rates suggested potentially positive effects of palivizumab, but results were inconclusive due to small event rates. Hospitalizations for acute respiratory illness with possible RSV contribution showed no association with palivizumab use, suggesting limited overall effect of palivizumab. Younger age greatly increased infection risk.
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Affiliation(s)
- Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida 32610-0494, USA.
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29
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Kieninger E, Singer F, Tapparel C, Alves MP, Latzin P, Tan HL, Bossley C, Casaulta C, Bush A, Davies JC, Kaiser L, Regamey N. High rhinovirus burden in lower airways of children with cystic fibrosis. Chest 2013. [PMID: 23188200 DOI: 10.1378/chest.12-0954] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Rhinovirus (RV)-induced pulmonary exacerbations are common in cystic fibrosis (CF) and have been associated with impaired virus clearance by the CF airway epithelium in vitro. Here, we assess in vivo the association of RV prevalence and load with antiviral defense mechanisms, airway inflammation, and lung function parameters in children with CF compared with a control group and children with other chronic respiratory diseases. METHODS RV presence and load were measured by real-time reverse transcription-polymerase chain reaction in BAL samples and were related to antiviral and inflammatory mediators measured in BAL and to clinical parameters. RESULTS BAL samples were obtained from children with CF (n = 195), non-CF bronchiectasis (n = 40), or asthma (n = 29) and from a control group (n = 35) at a median (interquartile range [IQR]) age of 8.2 (4.0-11.7) years. RV was detected in 73 samples (24.4%). RV prevalence was similar among groups. RV load (median [IQR] x 10(3) copies/mL) was higher in children with CF (143.0 [13.1-1530.0]), especially during pulmonary exacerbations, compared with children with asthma (3.0 [1.3-25.8], P = .006) and the control group (0.5 [0.3-0.5], P < .001), but similar to patients with non-CF bronchiectasis (122.1 [2.7-4423.5], P = not significant). In children with CF, RV load was negatively associated with interferon (IFN)- b and IFN- l , IL-1ra levels, and FEV 1 , and positively with levels of the cytokines CXCL8 and CXCL10. CONCLUSIONS RV load in CF BAL is high, especially during exacerbated lung disease. Impaired production of antiviral mediators may lead to the high RV burden in the lower airways of children with CF. Whether high RV load is a cause or a consequence of inflammation needs further investigation in longitudinal studies.
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Affiliation(s)
- Elisabeth Kieninger
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University Hospital, Bern, Switzerland; Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Florian Singer
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University Hospital, Bern, Switzerland
| | - Caroline Tapparel
- Laboratory of Virology, Division of Infectious Diseases and Division of Laboratory Medicine, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marco P Alves
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University Hospital, Bern, Switzerland; Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Philipp Latzin
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University Hospital, Bern, Switzerland; Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Hui-Leng Tan
- Department of Pediatric Respiratory Medicine, Royal Brompton Hospital, London, England
| | - Cara Bossley
- Department of Pediatric Respiratory Medicine, Royal Brompton Hospital, London, England
| | - Carmen Casaulta
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University Hospital, Bern, Switzerland
| | - Andrew Bush
- Department of Pediatric Respiratory Medicine, Royal Brompton Hospital, London, England
| | - Jane C Davies
- Department of Pediatric Respiratory Medicine, Royal Brompton Hospital, London, England
| | - Laurent Kaiser
- Laboratory of Virology, Division of Infectious Diseases and Division of Laboratory Medicine, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolas Regamey
- Division of Pediatric Respiratory Medicine, Department of Pediatrics, University Hospital, Bern, Switzerland; Department of Clinical Research, University of Bern, Bern, Switzerland.
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30
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Robinson KA, Odelola OA, Saldanha IJ, McKoy NA. Palivizumab for prophylaxis against respiratory syncytial virus infection in children with cystic fibrosis. Cochrane Database Syst Rev 2013:CD007743. [PMID: 23737087 DOI: 10.1002/14651858.cd007743.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Respiratory syncytial virus infection causes acute lung infection in infants and young children worldwide, resulting in considerable morbidity and mortality. Children with cystic fibrosis are prone to recurrent lung inflammation, bacterial colonisation and subsequent chronic airway disease, putting them at risk for severe respiratory syncytial virus infections requiring intensive care and respiratory support. No treatment currently exists, hence prevention is important. Palivizumab is effective in reducing respiratory syncytial virus hospitalisation rates and is recommended for prophylaxis in high-risk children with other conditions. It is unclear if palivizumab can prevent respiratory syncytial virus hospitalisations and intensive care unit admissions in children with cystic fibrosis. OBJECTIVES To determine the efficacy and safety of palivizumab (Synagis(®)) compared with placebo, no prophylaxis or other prophylaxis, in preventing hospitalisation and mortality from respiratory syncytial virus infection in children with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register and scanned references of the eligible study and related reviews.Date of last search: 11 October 2012. SELECTION CRITERIA Randomised and quasi-randomised studies. DATA COLLECTION AND ANALYSIS The authors independently extracted data and assessed risk of bias. MAIN RESULTS One study (186 infants up to two years old) comparing five monthly doses of palivizumab (N = 92) to placebo (N = 94) over one respiratory syncytial virus season was identified and met our inclusion criteria. At six months follow-up, one participant in each group was hospitalised due to respiratory syncytial virus; there were no deaths in either group. In the palivizumab and placebo groups, 86 and 90 children experienced any adverse event, while five and four children had related adverse events respectively. Nineteeen children receiving palivizumab and 16 receiving placebo suffered serious adverse events; one participant receiving palivizumab discontinued due to this. At 12 months follow-up, there were no significant differences between groups in number of Pseudomonas bacterial colonisations or change in weight-to-height ratio. AUTHORS' CONCLUSIONS We identified one randomised controlled trial comparing five monthly doses of palivizumab to placebo in infants up to two years old with cystic fibrosis. While the overall incidence of adverse events was similar in both groups, it is not possible to draw firm conclusions on the safety and tolerability of respiratory syncytial virus prophylaxis with palivizumab in infants with cystic fibrosis. Six months after treatment, the authors reported no clinically meaningful differences in outcomes. Additional randomised studies are needed to establish the safety and efficacy of palivizumab in children with cystic fibrosis.
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Affiliation(s)
- Karen A Robinson
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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31
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Abstract
PURPOSE OF REVIEW This review highlights important observations published in the past 2 years that provide insight regarding the early pathophysiology of cystic fibrosis lung disease and that indicate potentially useful clinical endpoints for disease management and clinical trials. RECENT FINDINGS Lung disease is evident soon after diagnosis even in children diagnosed with cystic fibrosis following newborn screening. Neutrophilic airway inflammation and lower airway infection with Pseudomonas aeruginosa appear to be important factors associated with lung disease including bronchiectasis detected using low-dose computed tomography. Children with cystic fibrosis managed in specialist centres can develop bronchiectasis in the first year of life and computed tomography reveals that bronchiectasis is present in more than 40% of children with cystic fibrosis by 4 years of age. SUMMARY Current management of newly diagnosed children with cystic fibrosis in specialist centres fails to prevent lung damage. In order to better define relations between infection, inflammation and lung damage, simple, sensitive and specific markers of lower airway infection are required. Data emerging from systematic early surveillance programs indicate that measures of lung damage, lung function, airway inflammation and endobronchial infection could be used as outcome measures for early intervention studies to prevent the respiratory sequelae of cystic fibrosis.
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32
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Elnazir B, Oni O, Hassan T, Greally P, Paes B. Does prophylaxis with palivizumab reduce hospitalisation rates for respiratory-syncytial-virus-related infection in cystic fibrosis children less than 2 years of age? J Paediatr Child Health 2012; 48:1033-8. [PMID: 23126393 DOI: 10.1111/j.1440-1754.2012.02593.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Basil Elnazir
- Department of Paediatric Respiratory Medicine, National Children's Hospital, Dublin, Ireland
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33
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Abstract
Respiratory Syncytial Virus (RSV) is a common virus that infects children and adults; however, children younger than two years of age tend to develop more serious respiratory symptoms. RSV is responsible for thousands of outpatient visits (e.g., emergency room/primary care physician), hospitalizations and can result in death. Treatment is primarily supportive care and the illness resolves without complications in most children. RSV prophylaxis with palivizumab is an option for high-risk infants and children, which can decrease hospitalization and length of stay. Immunocompromised patients are a special population of which ribavirin and palivizumab may be used for treatment. Currently, no medication or vaccine available has been able to show a reduction in mortality from RSV. Future vaccines are in the developmental stage and will hopefully decrease the symptomatic and economic burden of this disease.
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Affiliation(s)
- Lea S Eiland
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Huntsville, Alabama
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34
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Frickmann H, Jungblut S, Hirche TO, Groß U, Kuhns M, Zautner AE. Spectrum of viral infections in patients with cystic fibrosis. Eur J Microbiol Immunol (Bp) 2012; 2:161-75. [PMID: 24688762 DOI: 10.1556/eujmi.2.2012.3.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 04/13/2012] [Indexed: 01/05/2023] Open
Abstract
This review explores the extensive influence of viral infections leading to chronic deterioration of lung function in patients with cystic fibrosis (CF). The mechanisms how viral agents affect the pathogenesis as well as the inflammatory and immune response of CF are discussed. Viral infections of the upper and lower respiratory tract due to viruses in CF patients and methods for diagnosis of respiratory viruses are described in detail. The importance of respiratory and non-respiratory viral agents for the pathogenesis, especially for the exacerbation of bacterial lower respiratory tract infections and course of CF, is stressed, especially emphasizing respiratory syncytial virus, influenza virus, rhinovirus, and human herpes viruses. Possible harmful effects of further viruses like adenovirus, bocavirus, coronavirus, metapneumovirus, parainfluenzavirus on the lung function of CF patients are discussed. The potential use of adenovirus-based vectors for somatic gene therapy is mentioned.
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35
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Prescott WA, Hutchinson DJ. Respiratory Syncytial Virus Prophylaxis in Special Populations: Is it Something Worth Considering in Cystic Fibrosis and Immunosuppression? J Pediatr Pharmacol Ther 2012; 16:77-86. [PMID: 22477829 DOI: 10.5863/1551-6776-16.2.77] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Respiratory syncytial virus (RSV) bronchiolitis is the leading cause of infant hospitalization in the United States. Prophylaxis with palivizumab is effective in reducing RSV hospitalizations in premature infants and in infants or children with chronic lung disease or congenital heart disease. Patients with CF or those who are immunocompromised may be at increased risk for RSV infection-related complications; hence, prophylaxis may prove beneficial to these populations. The extent of palivizumab use in the CF and immunocompromised populations is variable. Palivizumab appears to be safe and may be effective in infants and young children with CF and immunocompromise. However, well-designed, randomized, controlled trials published in peer-reviewed journals are lacking, and its routine use can therefore not be recommended at this time. If used in patients with CF or those who are immunocompromised, RSV prophylaxis should be restricted to peak outbreak months in order to optimize the cost benefit of palivizumab.
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36
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Paes B, Mitchell I, Li A, Lanctôt K. Respiratory hospitalizations and respiratory syncytial virus prophylaxis in special populations. Eur J Pediatr 2012; 171:833-41. [PMID: 22203430 PMCID: PMC3327836 DOI: 10.1007/s00431-011-1654-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 12/07/2011] [Indexed: 11/05/2022]
Abstract
Palivizumab utilization, compliance, and outcomes were examined in infants with preexisting medical diseases within the Canadian Registry Database (CARESS) to aid in developing guidelines for potential "at-risk" infants in the future. Infants who received ≥1 dose of palivizumab during the 2006-2010 respiratory syncytial virus (RSV) seasons at 29 sites were recruited and utilization, compliance, and outcomes related to respiratory infection/illness (RI) events were collected monthly. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for premature infants ≤35 completed weeks gestational age (GA) who met standard approval criteria (group 1) compared to those with medical disorders (group 2) using Cox proportional hazards regression models with adjustment for potential confounding factors. Of 7,339 registry infants, 4,880 were in group 1 and 952 in group 2, which included those with Down syndrome (20.3%), upper airway anomalies (18.7%), pulmonary diseases (13.3%), and cystic fibrosis (12.3%). Group 2 were older at enrollment (10.2 ± 9.2 vs. 3.5 ± 3.1 months, p < 0.0005), had higher GA (35.9 ± 6.0 vs. 31.0 ± 5.4 weeks, p < 0.0005), and were less compliant with treatment intervals (69.4% vs. 72.6%, p = 0.048). A greater proportion of group 2 infants were hospitalized for RI (9.0% vs. 4.2%, p < 0.0005) and RSV (2.4% vs. 1.3%, p = 0.003) (unadjusted). Being in group 2 was associated with an increased risk of RI (HR = 2.0, 95%CI 1.5-2.5, p < 0.0005), but not RSV hospitalization (HR = 1.6, 95% CI 0.9-2.8, p = 0.106). In infants receiving palivizumab, those with underlying medical disorders, though not currently approved for prophylaxis, are at higher risk for RI events compared with preterm infants. However, risk of RSV hospitalizations is similar.
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Affiliation(s)
- B. Paes
- Department of Pediatrics, McMaster University, Hamilton, Ontario Canada
| | - I. Mitchell
- Department of Pediatrics, University of Calgary, Calgary, Alberta Canada
| | - A. Li
- Medical Outcomes and Research in Economics (MORE®) Research Group, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room FG-05, Toronto, Ontario M4N 3M5 Canada
| | - K.L. Lanctôt
- Medical Outcomes and Research in Economics (MORE®) Research Group, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room FG-05, Toronto, Ontario M4N 3M5 Canada
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Manzoni P, Paes B, Resch B, Carbonell-Estrany X, Bont L, Carbonell-Estrany X, Bont L. High risk for RSV bronchiolitis in late preterms and selected infants affected by rare disorders: a dilemma of specific prevention. Early Hum Dev 2012; 88 Suppl 2:S34-41. [PMID: 22633511 DOI: 10.1016/s0378-3782(12)70012-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Respiratory syncytial virus (RSV) is the most frequent aetiologic agent that causes bronchiolitis and lower respiratory tract infection in infants. These infections may be severe and even life-threatening in selected high-risk populations. Traditional, well-established, high-risk populations are preterm infants with or without chronic lung disease and children with congenital heart disease. For these children, RSV prophylaxis using palivizumab, a monoclonal anti-RSV humanised antibody against the F-protein of RSV, has proven safe and efficacious in preventing RSV-related hospitalisation. Recently, a number of rare medical conditions have been associated with the risk of severe RSV infections. Evidence of safety and efficacy of RSV prophylaxis in these populations is lacking. Given the low incidence of these conditions, randomised trials are not feasible. A practical, opinion-based approach to this dilemma is offered in this paper. It is proposed that these rare disorders may qualify for RSV prophylaxis if the association between a specific condition and the risk of severe RSV infection is confirmed in at least 3 independent publications, of which at least 1 includes a prospective cohort study. To facilitate pharmaco-economic analyses, at least one of the three studies must also report on the absolute risk of severe RSV infection in the specified illness. The authors believe that qualification criteria will enable caregivers to target RSV prophylaxis more effectively in children with rare conditions and the proposed approach provides direction for future epidemiological studies on the risk of severe RSV infection in children with these uncommon, medical illnesses.
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Affiliation(s)
- P Manzoni
- Neonatology and NICU, S Anna Hospital, ASO OI Regina Margherita-S Anna, Torino, Italy.
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Rochat I, Leis P, Bouchardy M, Oberli C, Sourial H, Friedli-Burri M, Perneger T, Barazzone Argiroffo C. Chest physiotherapy using passive expiratory techniques does not reduce bronchiolitis severity: a randomised controlled trial. Eur J Pediatr 2012; 171:457-62. [PMID: 21927808 DOI: 10.1007/s00431-011-1562-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 08/22/2011] [Accepted: 08/29/2011] [Indexed: 11/27/2022]
Abstract
Chest physiotherapy (CP) using passive expiratory manoeuvres is widely used in Western Europe for the treatment of bronchiolitis, despite lacking evidence for its efficacy. We undertook an open randomised trial to evaluate the effectiveness of CP in infants hospitalised for bronchiolitis by comparing the time to clinical stability, the daily improvement of a severity score and the occurrence of complications between patients with and without CP. Children <1 year admitted for bronchiolitis in a tertiary hospital during two consecutive respiratory syncytial virus seasons were randomised to group 1 with CP (prolonged slow expiratory technique, slow accelerated expiratory flow, rarely induced cough) or group 2 without CP. All children received standard care (rhinopharyngeal suctioning, minimal handling, oxygen for saturation ≥92%, fractionated meals). Ninety-nine eligible children (mean age, 3.9 months), 50 in group 1 and 49 in group 2, with similar baseline variables and clinical severity at admission. Time to clinical stability, assessed as primary outcome, was similar for both groups (2.9 ± 2.1 vs. 3.2 ± 2.8 days, P = 0.45). The rate of improvement of a clinical and respiratory score, defined as secondary outcome, only showed a slightly faster improvement of the respiratory score in the intervention group when including stethoacoustic properties (P = 0.044). Complications were rare but occurred more frequently, although not significantly (P = 0.21), in the control arm. In conclusion, this study shows the absence of effectiveness of CP using passive expiratory techniques in infants hospitalised for bronchiolitis. It seems justified to recommend against the routine use of CP in these patients.
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Affiliation(s)
- Isabelle Rochat
- Pediatric Pulmonology Unit, Children's Hospital, University Hospitals, Geneva, Switzerland.
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Robinson KA, Odelola OA, Saldanha IJ, McKoy NA. Palivizumab for prophylaxis against respiratory syncytial virus infection in children with cystic fibrosis. Cochrane Database Syst Rev 2012:CD007743. [PMID: 22336832 DOI: 10.1002/14651858.cd007743.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Respiratory syncytial virus infection causes acute lung infection in infants and young children worldwide, resulting in considerable morbidity and mortality. Children with cystic fibrosis are prone to recurrent lung inflammation, bacterial colonisation and subsequent chronic airway disease, putting them at risk for severe respiratory syncytial virus infections requiring intensive care and respiratory support. No treatment currently exists, hence prevention is important. Palivizumab is effective in reducing respiratory syncytial virus hospitalisation rates and is recommended for prophylaxis in high-risk children with other conditions. It is unclear if palivizumab can prevent respiratory syncytial virus hospitalisations and intensive care unit admissions in children with cystic fibrosis. OBJECTIVES To determine the efficacy and safety of palivizumab (Synagis(®)) compared with placebo, no prophylaxis or other prophylaxis, in preventing hospitalisation and mortality from respiratory syncytial virus infection in children with cystic fibrosis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register and scanned references of the eligible study and related reviews.Date of last search: 25 October 2011. SELECTION CRITERIA Randomised and quasi-randomised studies. DATA COLLECTION AND ANALYSIS The authors independently extracted data and assessed risk of bias. MAIN RESULTS One study (186 infants up to two years old) comparing five monthly doses of palivizumab (N = 92) to placebo (N = 94) over one respiratory syncytial virus season was identified and met our inclusion criteria. At six months follow-up, one participant in each group was hospitalised due to respiratory syncytial virus; there were no deaths in either group. In the palivizumab and placebo groups, 86 and 90 children experienced any adverse event, while 5 and 4 children had related adverse events respectively. Nineteeen children receiving palivizumab and 16 receiving placebo suffered serious adverse events; one participant receiving palivizumab discontinued due to this. At 12 months follow-up, there were no significant differences between groups in number of Pseudomonas bacterial colonisations or change in weight-to-height ratio. AUTHORS' CONCLUSIONS We identified one randomised controlled trial comparing five monthly doses of palivizumab to placebo in infants up to two years old with cystic fibrosis. While the overall incidence of adverse events was similar in both groups, it is not possible to draw conclusions on the safety and tolerability of respiratory syncytial virus prophylaxis with palivizumab in infants with cystic fibrosis because the trial did not specify how adverse events were classified. Six months after treatment, the authors reported no clinically meaningful differences in outcomes; however no data were provided. Additional randomised studies are needed to establish the safety and efficacy of palivizumab in children with cystic fibrosis.
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Affiliation(s)
- Karen A Robinson
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.
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Zacharasiewicz A, Berger A, Eber E, Frischer T, Kurz H, Resch B, Zach M. Kommentar zur Post-RSV-Atemwegserkrankung. Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2590-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Shadman KA, Wald ER. A review of palivizumab and emerging therapies for respiratory syncytial virus. Expert Opin Biol Ther 2011; 11:1455-67. [PMID: 21831008 DOI: 10.1517/14712598.2011.608062] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Respiratory syncytial virus (RSV) is an important pathogen in children and adults; however, current treatment options are primarily supportive. Palivizumab, the only approved specific monoclonal antibody for RSV is used prophylactically to reduce morbidity in a select population of high-risk children. AREAS COVERED The development and current use of palivizumab; the potential role of palivizumab as preventive therapy in patients with cystic fibrosis, asthma and compromised immune systems; and explores the limited research in which palivizumab has been used for treatment of RSV. The modified recommendations for the use of palivizumab espoused by the American Academy of Pediatrics and research on the cost-effectiveness of this product are presented. In addition, the authors discuss the development of enhanced monoclonal antibodies including motavizumab, which was recently denied FDA approval for preventative therapy. The authors explore the historical and current efforts to develop a vaccine targeting RSV. The current status of antiviral drug development is also reviewed. The literature search included RSV-Ig, palivizumab, and emerging drugs and vaccines for the treatment of RSV as keywords and titles from 1997 to 2011. EXPERT OPINION Although there are potential drugs and vaccines in development to prevent or reduce the effects of RSV infection, palivizumab remains the only licensed product to reduce the severity of disease in high-risk pediatric patients.
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Affiliation(s)
- Kristin A Shadman
- University of Wisconsin School of Medicine and Public Health, Department of Pediatrics, 600 Highland Avenue, Box 4108, Madison, WI 53792, USA.
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42
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Epidemiology and prevention of respiratory syncytial virus infections among infants and young children. Pediatr Infect Dis J 2011; 30:510-7. [PMID: 21487331 DOI: 10.1097/inf.0b013e3182184ae7] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since its discovery in 1956, respiratory syncytial virus (RSV) has been recognized as one of the most common causes of serious lower respiratory tract infections in young children worldwide. While considered a high priority, development of a safe and effective vaccine has remained elusive. Prevention of RSV disease relies on infection control and hygiene measures, as well as providing immunoprophylaxis in select infants. The prophylaxis, however, is costly, and so targeting the recipient population and timing of administration is important for optimal effectiveness and judicious use of limited health care resources. This article reviews the epidemiology of RSV infections in infants and young children, including risk factors for severe disease, so as to inform decisions about prevention efforts.
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Paes BA, Mitchell I, Banerji A, Lanctôt KL, Langley JM. A decade of respiratory syncytial virus epidemiology and prophylaxis: translating evidence into everyday clinical practice. Can Respir J 2011; 18:e10-9. [PMID: 21499597 PMCID: PMC3084427 DOI: 10.1155/2011/493056] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Respiratory syncytial virus (RSV) is a common infection in infancy, with nearly all children affected by two years of age. Approximately 0.5% to 2.0% of all children are hospitalized with lower respiratory tract disease, of which 50% to 90% have bronchiolitis and 5% to 40% have pneumonia. Morbidity and mortality are highest in children with nosocomial infection and in those with underlying medical illnesses such as cardiac and chronic lung disease. Aboriginal children residing in remote northern regions are specifically considered to be at high risk for hospitalization due to RSV infection. Thorough hand washing and health education are the principal strategies in primary prevention. In the absence of a vaccine, palivizumab prophylaxis is currently the best intervention to reduce the burden of illness and RSV-related hospitalization in high-risk children. Health care professionals should provide palivizumab prophylaxis cost effectively in accordance with recommendations issued by pediatric societies and national advisory bodies. The present article reviews the epidemiology of RSV infection and the short- and long-term impact of disease in high-risk infants and special populations. Prevention strategies and treatment are discussed based on the existing scientific evidence, and future challenges in the management of RSV infection are addressed.
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Affiliation(s)
- Bosco A Paes
- Department of Pediatrics, McMaster University, Hamilton, Ontario.
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Paes B, Manzoni P. Special populations: do we need evidence from randomized controlled trials to support the need for respiratory syncytial virus prophylaxis? Early Hum Dev 2011; 87 Suppl 1:S55-8. [PMID: 21273012 DOI: 10.1016/j.earlhumdev.2011.01.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Congenital abnormalities and impaired mechanisms that govern the normal coordinated physiology of breathing, sucking, swallowing and airway clearance, place infants with underlying medical disorders at high risk for respiratory morbidity following respiratory syncytial virus (RSV) lower respiratory tract infection. The use of RSV prophylaxis in premature infants' ≤ 35 weeks gestational age, infants with chronic lung and hemodynamically significant heart disease is firmly established through randomized controlled clinical trials (RCT's). RSV prophylaxis in infants with serious medical illnesses must be justified based on emerging scientific literature and the overriding concept of achieving a balance between benefit and harm with treatment. This article will explore the current evidence for palivizumab prophylaxis in a variety of disorders and examine existing differences between pediatric advisory body recommendations and real world practice.
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Affiliation(s)
- Bosco Paes
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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45
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González de Dios J, Ochoa Sangrador C. [Consensus conference on acute bronchiolitis (v): prevention of acute bronchiolitis. Review of scientific evidence]. An Pediatr (Barc) 2010; 72:353.e1-353.e26. [PMID: 20457017 DOI: 10.1016/j.anpedi.2009.12.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2009] [Accepted: 12/21/2009] [Indexed: 12/24/2022] Open
Abstract
A review of the evidence on prevention of acute bronchiolitis is presented. Acute bronchiolitis prevention arises from three basic approaches: preventive treatment to reduce recurrent wheezing following an episode of acute bronchiolitis, preventive treatment to reduce the frequency and severity of RSV bronchiolitis in the population at risk (prematurity, bronchopulmonary dysplasia, congenital heart disease, etc.), and general preventive measures to reduce nosocomial infection with RSV. There is sufficient evidence on the lack of efficacy of inhaled corticosteroids, oral corticosteroids and montelukast. Intravenous RSV immunoglobulin has an unfavorable risk-benefit balance, particularly with the availability of monoclonal antibodies. Palivizumab is effective as preventive treatment of RSV infection in risk populations (high risk preterm infants and hemodynamically significant congenital heart disease), but not in the frequency and severity (ICU admission, need for mechanical ventilation and mortality) of the acute bronchiolitis. The benefits of palivizumab (less admissions) seem to be worth the adverse effects, but we do not know the cost-benefit ratio. The control and prevention measures of nosocomial transmission of RSV infection (isolation, hand washing, use of mask, gloves, cap and shoes) are based on indirect evidence.
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Affiliation(s)
- J González de Dios
- Servicio de Pediatría, Departamento de Pediatría, Hospital de Torrevieja, Universidad Miguel Hernández, Alicante, España.
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46
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Robinson KA, Odelola OA, Saldanha I, McKoy N. Palivizumab for prophylaxis against respiratory syncytial virus infection in children with cystic fibrosis. Cochrane Database Syst Rev 2010:CD007743. [PMID: 20166098 DOI: 10.1002/14651858.cd007743.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Respiratory syncytial virus (RSV) infection causes acute lung infection in infants and young children worldwide, resulting in considerable morbidity and mortality. Children with cystic fibrosis (CF) are prone to recurrent lung inflammation, bacterial colonisation and subsequent chronic airway disease, putting them at risk for severe RSV infections requiring intensive care and respiratory support. No treatment currently exists, hence prevention is important. Palivizumab is effective in reducing RSV hospitalisation rates and is recommended for prophylaxis in high-risk children with other conditions. It is unclear if palivizumab can prevent RSV hospitalisations and intensive care unit admissions in children with CF. OBJECTIVES To determine the efficacy and safety of palivizumab (Synagis((R))) compared with placebo, no prophylaxis or other prophylaxis, in preventing hospitalisation and mortality from RSV infection in children with CF. SEARCH STRATEGY We searched the Cochrane CF and Genetic Disorders Group Trials Register and scanned references of the eligible study and related reviews.Last search: 20 January 2010. SELECTION CRITERIA Randomised and quasi-randomised studies. DATA COLLECTION AND ANALYSIS The authors independently extracted data and assessed risk of bias. MAIN RESULTS One study (186 infants up to two years old) comparing five monthly doses of palivizumab (N=92) to placebo (N=94) over one RSV season was identified and met our inclusion criteria. At six months follow-up, one participant in each group was hospitalised due to RSV; there were no deaths in either group. In the palivizumab and placebo groups, 86 and 90 children experienced any adverse event, while 5 and 4 children had related adverse events respectively. Nineteeen children receiving palivizumab and 16 receiving placebo suffered serious adverse events; one participant receiving palivizumab discontinued due to this. At 12 months follow-up, there were no significant differences between groups in number of Pseudomonas bacterial colonisations or change in weight-to-height ratio. AUTHORS' CONCLUSIONS We identified one randomised controlled trial comparing five monthly doses of palivizumab to placebo in infants up to two years old with CF. While the overall incidence of adverse events was similar in both groups, it is not possible to draw conclusions on the safety and tolerability of RSV prophylaxis with palivizumab in infants with CF because the trial did not specify how adverse events were classified. Six months after treatment, the authors reported no clinically meaningful differences in outcomes; however no data were provided. Additional randomised studies are needed to establish the safety and efficacy of palivizumab in children with CF.
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Affiliation(s)
- Karen A Robinson
- Department of Medicine, Johns Hopkins University, 1830 E. Monument St., Suite 8069, Baltimore, MD, USA, 21287
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47
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de Vrankrijker AMM, Wolfs TFW, Ciofu O, Høiby N, van der Ent CK, Poulsen SS, Johansen HK. Respiratory syncytial virus infection facilitates acute colonization of Pseudomonas aeruginosa in mice. J Med Virol 2010; 81:2096-103. [PMID: 19856469 DOI: 10.1002/jmv.21623] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pseudomonas aeruginosa causes opportunistic infections in immunocompromised individuals and patients ventilated mechanically and is the major pathogen in patients with cystic fibrosis, in which it causes chronic infections. Epidemiological, in vitro and animal data suggest a role for respiratory virus infections in facilitating colonization and infection with P. aeruginosa. A study was undertaken to determine whether respiratory syncytial virus (RSV) infection could facilitate the initiation of an acute infection with P. aeruginosa in vivo. Balb/c mice were infected intranasally with P. aeruginosa, with and without simultaneous inoculation with RSV. Lung function measurements were undertaken using Whole Body Plethysmography and lungs were harvested 24 hr after inoculation. Mice exposed to RSV and P. aeruginosa showed 2,000 times higher colony-forming units (CFU) counts of P. aeruginosa in the lung homogenates when compared to mice which were only infected with P. aeruginosa and lung function changes were more severe in co-infected mice. Control mice receiving RSV alone showed no significant changes in lung function or cytokine production, and no inflammatory changes in the lung parenchyma. These results suggest that RSV can facilitate the initiation of acute P. aeruginosa infection without the RSV infection being clinically apparent. This could have implications for treatment strategies to prevent opportunistic P. aeruginosa lung infection.
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Affiliation(s)
- Angélica M M de Vrankrijker
- Department of Pediatric Respiratory Medicine, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Borowitz D, Robinson KA, Rosenfeld M, Davis SD, Sabadosa KA, Spear SL, Michel SH, Parad RB, White TB, Farrell PM, Marshall BC, Accurso FJ. Cystic Fibrosis Foundation evidence-based guidelines for management of infants with cystic fibrosis. J Pediatr 2009; 155:S73-93. [PMID: 19914445 PMCID: PMC6324931 DOI: 10.1016/j.jpeds.2009.09.001] [Citation(s) in RCA: 260] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Newborn screening for cystic fibrosis (CF) offers the opportunity for early medical and nutritional intervention that can lead to improved outcomes. Management of the asymptomatic infant diagnosed with CF through newborn screening, prenatal diagnosis, or sibling screening is different from treatment of the symptomatically diagnosed individual. The focus of management is on maintaining health by preventing nutritional and respiratory complications. The CF Foundation convened a committee to develop recommendations based on a systematic review of the evidence and expert opinion. These guidelines encompass monitoring and treatment recommendations for infants diagnosed with CF and are intended to help guide families, primary care providers, and specialty care centers in the care of infants with CF.
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49
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Robinson KA, Saldanha IJ, McKoy NA. Management of infants with cystic fibrosis: a summary of the evidence for the cystic fibrosis foundation working group on care of infants with cystic fibrosis. J Pediatr 2009; 155:S94-S105. [PMID: 19914446 DOI: 10.1016/j.jpeds.2009.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To inform the development of Cystic Fibrosis (CF) Foundation guidelines on the care of infants with CF, we systematically reviewed the evidence for diagnosis and assessment of pancreatic and pulmonary disorders; management of pancreatic and pulmonary function; management of nutrition and nutritional disorders; and prevention and control of infections. STUDY DESIGN In May-June 2008, we searched The Cochrane Library for existing reviews; and MEDLINE, the National Guideline Clearinghouse, the CF Foundation Clinical Practice Guidelines and Consensus Statements, and the UK CF Trust for existing guidelines. MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Excerpta Medica Database (EMBASE) were searched for primary studies in January 2008. Bibliographies of eligible articles were searched and expert input was sought. We selected English-language articles of any study design that provided original data on any of our questions on infants up to 2 years of age. RESULTS We identified 14 relevant guidelines and 3 Cochrane reviews. Fifty-nine articles (55 primary studies) were included. Only four of these were randomized controlled trials. Sample sizes of infants ranged from 2 to 768 study participants; the median sample size was 24. Of our 21 review topics, 5 topics had only one study while for 5 we identified no relevant studies. We identified one or no primary studies for 20 of 32 review questions. CONCLUSIONS There is a paucity of evidence on the care of infants diagnosed with CF. For several of the review questions no guidelines or primary studies were identified, but for other questions, studies limited by weak design and small sample sizes were the only studies identified. With increasing numbers of infants with CF being diagnosed by newborn screening there is an opportunity to study the management of infants diagnosed with CF.
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Affiliation(s)
- Karen A Robinson
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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50
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Severe respiratory syncytial virus (RSV) infection in infants with neuromuscular diseases and immune deficiency syndromes. Paediatr Respir Rev 2009; 10:148-53. [PMID: 19651386 DOI: 10.1016/j.prrv.2009.06.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Respiratory syncytial virus (RSV) is an important cause of lower respiratory tract infection (LRTI) in infants and children. There is growing evidence of severe RSV disease in infants with neuromuscular diseases and immune deficiency syndromes. Factors predisposing to a more severe course of RSV disease in neuromuscular diseases include the impaired ability to clear secretions from the airways due to ineffective cough, respiratory muscle weakness, high prevalence of gastro-oesophageal reflux and swallowing dysfunction which leads to aspiration. Similarly, pulmonary disease is a common presenting feature and complication of T-cell immunodeficiency. Infants with severe congenital and acquired immune deficiency syndromes may demonstrate prolonged viral shedding in RSV LRTI and are reported to have increased morbidity and mortality associated with RSV infection. Although not indicated in most guideline statements, palivizumab prophylaxis for these uncommon underlying conditions is under consideration by clinicians. Prospective studies are needed to determine the burden of RSV disease in these children.
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