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Baber A, Calvet L, Vissac C, Salmona M, Legoff J, De Jong A, Mariotte E, Zafrani L, Azoulay E, Darmon M. Cytomegalovirus infection in intensive care unit patients with hematological malignancies: Characteristics and clinical outcomes. J Crit Care 2024; 82:154766. [PMID: 38479298 DOI: 10.1016/j.jcrc.2024.154766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is associated with poor outcome in ICU patients. However, data on immunocompromised patients are scarce. This study aims to describe characteristics and outcomes of critically ill hematological patients and CMV infection. CMV disease characteristics and relationship between CMV viral load, CMV disease, coinfections by other pathogens and outcomes are described. METHODS Retrospective single center study (Jan 2010-Dec 2017). Adult patients, admitted to the ICU, having underlying hematological malignancy and CMV infection were included. Results are reported as median (interquartile) or n (%). Factors associated with hospital mortality or CMV disease were analysed using logistic regression. RESULTS 178 patients were included (median age 55y [42-64], 69.1% male). Hospital mortality was 53% (n = 95). Median viral load was 2.7 Log [2.3-3.5]. CMV disease occurred in 44 (24.7%) patients. Coinfections concerned 159 patients (89.3%). After adjustment for confounders, need for vasopressors (OR 2.53; 95%CI 1.11-5.97) and viral load (OR 1.88 per Log; 95%CI 1.29-2.85) were associated with hospital mortality. However, neither CMV disease nor treatment were associated with outcomes. Allogeneic stem cell transplantation (OR 2.55; 95%CI 1.05-6.16), mechanical ventilation (OR 4.11; OR 1.77-10.54) and viral load (OR 1.77 per Log; 95%CI 1.23-2.61) were independently associated with CMV disease. Coinfections were not associated with CMV disease or hospital mortality. CONCLUSION In critically-ill hematological patients, CMV viral load is independently associated with hospital mortality. Conversely, neither CMV disease nor treatment was associated with outcome suggesting viral load to be a surrogate for immune status rather than a cause of poor outcome.
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Affiliation(s)
- A Baber
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - L Calvet
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - C Vissac
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - M Salmona
- Université de Paris; Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Department of microbiology, Paris, France
| | - J Legoff
- Université de Paris; Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Department of microbiology, Paris, France
| | - A De Jong
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - E Mariotte
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - L Zafrani
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - E Azoulay
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - M Darmon
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France.
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2
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Boers LS, van Someren Gréve F, van Hattem JM, de Brabander J, Zwaan T, van Willigen H, Cornelissen M, de Jong M, van der Poll T, Duitman J, Schinkel J, Bos LDJ. Pulmonary herpes simplex virus and cytomegalovirus in patients with acute respiratory distress syndrome related to COVID-19. Intensive Care Med 2024; 50:1251-1264. [PMID: 39017695 PMCID: PMC11306713 DOI: 10.1007/s00134-024-07529-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 06/14/2024] [Indexed: 07/18/2024]
Abstract
PURPOSE Human herpesviruses, particularly cytomegalovirus (CMV) and herpes simplex virus (HSV), frequently reactivate in critically ill patients, including those with acute respiratory distress syndrome (ARDS) related to coronavirus disease 2019 (COVID-19). The clinical interpretation of pulmonary herpesvirus reactivation is challenging and there is ongoing debate about its association with mortality and benefit of antiviral medication. We aimed to quantify the incidence and pathogenicity of pulmonary CMV and HSV reactivations in critically ill COVID-19 patients. METHODS Mechanically ventilated COVID-19 patients seropositive for CMV or HSV were included in this observational cohort study. Diagnostic bronchoscopy with bronchoalveolar lavage was performed routinely and analyzed for alveolar viral loads and inflammatory biomarkers. Utilizing joint modeling, we explored the dynamic association between viral load trajectories over time and mortality. We explored alveolar inflammatory biomarker dynamics between reactivated and non-reactivated patients. RESULTS Pulmonary reactivation (> 104 copies/ml) of CMV occurred in 6% of CMV-seropositive patients (9/156), and pulmonary reactivation of HSV in 37% of HSV-seropositive patients (63/172). HSV viral load dynamics prior to or without antiviral treatment were associated with increased 90-day mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.04-1.47). The alveolar concentration of several inflammatory biomarkers increased with HSV reactivation, including interleukin (IL)-6, IL-1β, granulocyte colony stimulating factor (G-CSF), and tumor necrosis factor (TNF). CONCLUSION In mechanically ventilated COVID-19 patients, HSV reactivations are common, while CMV reactivations were rare. HSV viral load dynamics prior to or without antiviral treatment are associated with mortality. Alveolar inflammation is elevated after HSV reactivation.
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Affiliation(s)
- Leonoor S Boers
- Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands.
| | - Frank van Someren Gréve
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jarne M van Hattem
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Justin de Brabander
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tom Zwaan
- Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
| | - Hugo van Willigen
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marion Cornelissen
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Menno de Jong
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Infection and Immunity, Inflammatory Diseases, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - JanWillem Duitman
- Infection and Immunity, Inflammatory Diseases, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Pulmonary Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Experimental Immunology (EXIM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Janke Schinkel
- Medical Microbiology, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Lieuwe D J Bos
- Intensive Care Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Room G3-228, 1105 AZ, Amsterdam, The Netherlands
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3
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Bhide M, Singh O, Nasa P, Juneja D. Cytomegalovirus infection in non-immunocompromised critically ill patients: A management perspective. World J Virol 2024; 13:89135. [PMID: 38616856 PMCID: PMC11008403 DOI: 10.5501/wjv.v13.i1.89135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/18/2023] [Accepted: 12/26/2023] [Indexed: 03/11/2024] Open
Abstract
Critically ill patients are a vulnerable group at high risk of developing secondary infections. High disease severity, prolonged intensive care unit (ICU) stay, sepsis, and multiple drugs with immunosuppressive activity make these patients prone to immuneparesis and increase the risk of various opportunistic infections, including cytomegalovirus (CMV). CMV seroconversion has been reported in up to 33% of ICU patients, but its impact on patient outcomes remains a matter of debate. Even though there are guidelines regarding the management of CMV infection in immunosuppressive patients with human immunodeficiency virus/ acquired immuno deficiency syndrome, the need for treatment and therapeutic approaches in immunocompetent critically ill patients is still ambiguous. Even the diagnosis of CMV infection may be challenging in such patients due to non-specific symptoms and multiorgan involvement. Hence, a better understanding of the symptomatology, diagnostics, and treatment options may aid intensive care physicians in ensuring accurate diagnoses and instituting therapeutic interventions.
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Affiliation(s)
- Madhura Bhide
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
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4
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Perret A, Le Marechal M, Germi R, Maubon D, Garnaud C, Noble J, Boignard A, Falque L, Meunier M, Gerster T, Epaulard O. Cytomegalovirus detection is associated with ICU admission in non-AIDS and AIDS patients with Pneumocystis jirovecii pneumonia. PLoS One 2024; 19:e0296758. [PMID: 38198473 PMCID: PMC10781113 DOI: 10.1371/journal.pone.0296758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/05/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVES Cytomegalovirus (CMV) is frequently detected in lung and/or blood samples of patients with Pneumocystis jirovecii pneumonia (PJP), although this co-detection is not precisely understood. We aimed to determine whether PJP was more severe in case of CMV detection. METHODS We retrospectively included all patients with a diagnosis of PJP between 2009 and 2020 in our centre and with a measure of CMV viral load in blood and/or bronchoalveolar lavage (BAL). PJP severity was assessed by the requirement for intensive care unit (ICU) admission. RESULTS The median age of the 249 patients was 63 [IQR: 53-73] years. The main conditions were haematological malignancies (44.2%), solid organ transplantations (16.5%), and solid organ cancers (8.8%). Overall, 36.5% patients were admitted to ICU. CMV was detected in BAL in 57/227 patients; the 37 patients with viral load ≥3 log copies/mL were more frequently admitted to ICU (78.4% vs 28.4%, p<0.001). CMV was also detected in blood in 57/194 patients; the 48 patients with viral load ≥3 log copies/mL were more frequently admitted to ICU (68.7% vs 29.4%, p<0.001). ICU admission rate was found to increase with each log of BAL CMV viral load and each log of blood CMV viral load. CONCLUSIONS PJP is more severe in the case of concomitant CMV detection. This may reflect either the deleterious role of CMV itself, which may require antiviral therapy, or the fact that patients with CMV reactivation are even more immunocompromised.
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Affiliation(s)
- Alexandre Perret
- Infectious Disease Unit, Grenoble-Alpes University Hospital, Grenoble, France
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
| | - Marion Le Marechal
- Infectious Disease Unit, Grenoble-Alpes University Hospital, Grenoble, France
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
| | - Raphaele Germi
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
- Virology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Daniele Maubon
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
- Mycology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Cécile Garnaud
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
- Mycology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Johan Noble
- Nephrology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Aude Boignard
- Cardiology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Loïc Falque
- Pneumology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Mathieu Meunier
- Haematology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Théophile Gerster
- Hepato-Gastro-Enterology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Olivier Epaulard
- Infectious Disease Unit, Grenoble-Alpes University Hospital, Grenoble, France
- GRIC, CIC1408 INSERM-UGA-CHUGA, Bouliac, France
- IBS UMR 5075 CNRS-CEA-UGA, Grenoble, France
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5
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Koos B, Unterberg M, Rahmel T, Adamzik M, Ehrentraut SF. Response to comment on human cytomegalovirus seropositivity is associated with reduced patient survival during sepsis. Crit Care 2023; 27:464. [PMID: 38017441 PMCID: PMC10685458 DOI: 10.1186/s13054-023-04756-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 11/30/2023] Open
Affiliation(s)
- Björn Koos
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany.
| | - Matthias Unterberg
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Tim Rahmel
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Michael Adamzik
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Stefan F Ehrentraut
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn, Germany
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6
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Unterberg M, Ehrentraut SF, Bracht T, Wolf A, Haberl H, von Busch A, Rump K, Ziehe D, Bazzi M, Thon P, Sitek B, Marcus K, Bayer M, Schork K, Eisenacher M, Ellger B, Oswald D, Wappler F, Defosse J, Henzler D, Köhler T, Zarbock A, Putensen CP, Schewe JC, Frey UH, Anft M, Babel N, Steinmann E, Brüggemann Y, Trilling M, Schlüter A, Nowak H, Adamzik M, Rahmel T, Koos B. Human cytomegalovirus seropositivity is associated with reduced patient survival during sepsis. Crit Care 2023; 27:417. [PMID: 37907989 PMCID: PMC10619294 DOI: 10.1186/s13054-023-04713-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/26/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Sepsis is one of the leading causes of death. Treatment attempts targeting the immune response regularly fail in clinical trials. As HCMV latency can modulate the immune response and changes the immune cell composition, we hypothesized that HCMV serostatus affects mortality in sepsis patients. METHODS We determined the HCMV serostatus (i.e., latency) of 410 prospectively enrolled patients of the multicenter SepsisDataNet.NRW study. Patients were recruited according to the SEPSIS-3 criteria and clinical data were recorded in an observational approach. We quantified 13 cytokines at Days 1, 4, and 8 after enrollment. Proteomics data were analyzed from the plasma samples of 171 patients. RESULTS The 30-day mortality was higher in HCMV-seropositive patients than in seronegative sepsis patients (38% vs. 25%, respectively; p = 0.008; HR, 1.656; 95% CI 1.135-2.417). This effect was observed independent of age (p = 0.010; HR, 1.673; 95% CI 1.131-2.477). The predictive value on the outcome of the increased concentrations of IL-6 was present only in the seropositive cohort (30-day mortality, 63% vs. 24%; HR 3.250; 95% CI 2.075-5.090; p < 0.001) with no significant differences in serum concentrations of IL-6 between the two groups. Procalcitonin and IL-10 exhibited the same behavior and were predictive of the outcome only in HCMV-seropositive patients. CONCLUSION We suggest that the predictive value of inflammation-associated biomarkers should be re-evaluated with regard to the HCMV serostatus. Targeting HCMV latency might open a new approach to selecting suitable patients for individualized treatment in sepsis.
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Affiliation(s)
- M Unterberg
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - S F Ehrentraut
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn, Germany
| | - T Bracht
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
- Medizinisches Proteom-Center, Ruhr-University Bochum, 44801, Bochum, Germany
| | - A Wolf
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - H Haberl
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - A von Busch
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - K Rump
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - D Ziehe
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - M Bazzi
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - P Thon
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - B Sitek
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
- Medizinisches Proteom-Center, Ruhr-University Bochum, 44801, Bochum, Germany
| | - K Marcus
- Medizinisches Proteom-Center, Ruhr-University Bochum, 44801, Bochum, Germany
- Medical Proteome Analysis, Center for Proteindiagnostics (PRODI), Ruhr University Bochum, 44801, Bochum, Germany
| | - M Bayer
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
- Medizinisches Proteom-Center, Ruhr-University Bochum, 44801, Bochum, Germany
| | - K Schork
- Medizinisches Proteom-Center, Ruhr-University Bochum, 44801, Bochum, Germany
- Medical Proteome Analysis, Center for Proteindiagnostics (PRODI), Ruhr University Bochum, 44801, Bochum, Germany
| | - M Eisenacher
- Medizinisches Proteom-Center, Ruhr-University Bochum, 44801, Bochum, Germany
- Medical Proteome Analysis, Center for Proteindiagnostics (PRODI), Ruhr University Bochum, 44801, Bochum, Germany
| | - B Ellger
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum Westfalen, Dortmund, Germany
| | - D Oswald
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Klinikum Westfalen, Dortmund, Germany
| | - F Wappler
- Department of Anaesthesiology and Operative Intensive Care Medicine, University of Witten/Herdecke, Cologne Merheim Medical School, Cologne, Germany
| | - J Defosse
- Department of Anaesthesiology and Operative Intensive Care Medicine, University of Witten/Herdecke, Cologne Merheim Medical School, Cologne, Germany
| | - D Henzler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr-University Bochum, Klinikum Herford, Herford, Germany
| | - T Köhler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr-University Bochum, Klinikum Herford, Herford, Germany
- Department of Anesthesiology and Intensive Care Medicine, AMEOS-Klinikum Halberstadt, Halberstadt, Germany
| | - A Zarbock
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Münster, Germany
| | - C P Putensen
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn, Germany
| | - J C Schewe
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn, Germany
| | - U H Frey
- Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Bochum, Germany
| | - M Anft
- Center for Translational Medicine, Medical Clinic I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany
| | - N Babel
- Center for Translational Medicine, Medical Clinic I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Herne, Germany
| | - E Steinmann
- Department of Molecular and Medical Virology, Ruhr University Bochum, 44801, Bochum, Germany
| | - Y Brüggemann
- Department of Molecular and Medical Virology, Ruhr University Bochum, 44801, Bochum, Germany
| | - M Trilling
- Institute for Virology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - A Schlüter
- Knappschaft Kliniken GmbH, Recklinghausen, Germany
| | - H Nowak
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
- Center for Artficial Intelligence, Medical Informatics and Data Science, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - M Adamzik
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - T Rahmel
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - B Koos
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany.
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7
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Schinas G, Moustaka V, Polyzou E, Almyroudi MP, Dimopoulos G, Akinosoglou K. Targeting CMV Reactivation to Optimize Care for Critically Ill COVID-19 Patients: A Review on the Therapeutic Potential of Antiviral Treatment. Viruses 2023; 15:v15051165. [PMID: 37243251 DOI: 10.3390/v15051165] [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: 05/03/2023] [Revised: 05/10/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Cytomegalovirus (CMV) reactivation has been linked to adverse clinical outcomes in critically ill patients, with emerging evidence suggesting a potential connection with severe COVID-19. Mechanisms driving this association may include primary lung injury, amplification of systemic inflammation, and secondary immunosuppression. Diagnostic challenges in detecting and assessing CMV reactivation necessitate a comprehensive approach to improve accuracy and inform treatment decisions. Currently, there is limited evidence on the efficacy and safety of CMV pharmacotherapy in critically ill COVID-19 patients. Although insights from non-COVID-19 critical illness studies suggest a potential role for antiviral treatment or prophylaxis, the risks and benefits must be carefully balanced in this vulnerable patient population. Understanding the pathophysiological role of CMV in the context of COVID-19 and exploring the advantages of antiviral treatment are crucial for optimizing care in critically ill patients. This review provides a comprehensive synthesis of available evidence, emphasizing the need for additional investigation to establish the role of CMV treatment or prophylaxis in the management of severe COVID-19 and to develop a framework for future research on this topic.
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Affiliation(s)
| | - Vasiliki Moustaka
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Eleni Polyzou
- Medical School, University of Patras, 26504 Patras, Greece
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
| | - Maria Panagiota Almyroudi
- Department of Emergency Medicine, University Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - George Dimopoulos
- 3rd Department of Critical Care, EVGENIDIO Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Karolina Akinosoglou
- Medical School, University of Patras, 26504 Patras, Greece
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
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8
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Melenotte C, Aimanianda V, Slavin M, Aguado JM, Armstrong-James D, Chen YC, Husain S, Van Delden C, Saliba F, Lefort A, Botterel F, Lortholary O. Invasive aspergillosis in liver transplant recipients. Transpl Infect Dis 2023:e14049. [PMID: 36929539 DOI: 10.1111/tid.14049] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Liver transplantation is increasing worldwide with underlying pathologies dominated by metabolic and alcoholic diseases in developed countries. METHODS We provide a narrative review of invasive aspergillosis (IA) in liver transplant (LT) recipients. We searched PubMed and Google Scholar for references without language and time restrictions. RESULTS The incidence of IA in LT recipients is low (1.8%), while mortality is high (∼50%). It occurs mainly early (<3 months) after LT. Some risk factors have been identified before (corticosteroid, renal, and liver failure), during (massive transfusion and duration of surgical procedure), and after transplantation (intensive care unit stay, re-transplantation, re-operation). Diagnosis can be difficult and therefore requires full radiological and clinicobiological collaboration. Accurate identification of Aspergillus species is recommended due to the cryptic species, and susceptibility testing is crucial given the increasing resistance of Aspergillus fumigatus to azoles. It is recommended to reduce the dose of tacrolimus (50%) and to closely monitor the trough level when introducing voriconazole, isavuconazole, and posaconazole. Surgery should be discussed on a case-by-case basis. Antifungal prophylaxis is recommended in high-risk patients. Environmental preventative measures should be implemented to prevent outbreaks of nosocomial aspergillosis in LT recipient units. CONCLUSION IA remains a very serious disease in LT patients and should be promptly sought and, if possible, prevented by clinicians when risk factors are identified.
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Affiliation(s)
- Cléa Melenotte
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker Enfants-Malades, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Cité, Paris, France
| | - Vishukumar Aimanianda
- Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, UMR2000, Paris, France
| | - Monica Slavin
- Department of Infectious Diseases, National Center for Infections in Cancer, Sir Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Oncology, Sir Peter MacCallum Cancer Center, University of Melbourne, Melbourne, Australia
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universidad Complutense, Madrid, Spain
| | | | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Shahid Husain
- Department of Transplant Infectious Diseases, Multi-Organ Transplant Program, University Health Network, Toronto, Ontario, Canada
| | - Christian Van Delden
- Transplant Infectious Diseases Unit, University Hospitals Geneva, Geneva, Switzerland
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
| | - Agnès Lefort
- Université de Paris, IAME, UMR 1137, INSERM, Paris, France.,Service de Médecine Interne, Hôpital Beaujon, AP-HP, Clichy, France
| | - Francoise Botterel
- EA Dynamyc 7380 UPEC, ENVA, Faculté de Médecine, Créteil, France.,Unité de Parasitologie-Mycologie, Département de Virologie, Bactériologie-Hygiène, Mycologie-Parasitologie, DHU VIC, CHU Henri Mondor, Créteil, France
| | - Olivier Lortholary
- Service de Maladies Infectieuses et Tropicales, Hôpital Necker Enfants-Malades, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Cité, Paris, France.,Institut Pasteur, CNRS, National Reference Center for Invasive Mycoses and Antifungals, Molecular Mycology Unit, UMR2000, Paris, France.,Paris University, Necker-Pasteur Center for Infectious Diseases and Tropical Medicine, Necker-Enfants Malades Hospital, AP-HP, IHU Imagine, Paris, France
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9
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Saura O, Chommeloux J, Levy D, Assouline B, Lefevre L, Luyt CE. Updates in the management of respiratory virus infections in ICU patients: revisiting the non-SARS-CoV-2 pathogens. Expert Rev Anti Infect Ther 2022; 20:1537-1550. [PMID: 36220790 DOI: 10.1080/14787210.2022.2134116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Although viruses are an underestimated cause of community-acquired pneumonias (CAP) and hospital-acquired pneumonias (HAP)/ventilator-associated pneumonias (VAP) in intensive care unit (ICU) patients, they have an impact on morbidity and mortality. AREAS COVERED In this perspective article, we discuss the available data regarding the management of severe influenza CAP and herpesviridae HAP/VAP. We review diagnostic and therapeutic strategies in order to give clear messages and address unsolved questions. EXPERT OPINION Influenza CAP affects yearly thousands of people; however, robust data regarding antiviral treatment in the most critical forms are scarce. While efficacy of oseltamivir has been investigated in randomized controlled trials (RCT) in uncomplicated influenza, only observational data are available in ICU patients. Herpesviridae are an underestimated cause of HAP/VAP in ICU patients. Whilst incidence of herpesviridae identification in samples from lower respiratory tract of ICU patients is relatively high (from 20% to 50%), efforts should be made to differentiate local reactivation from true lung infection. Only few randomized controlled trials evaluated the efficacy of antiviral treatment in herpesviridae reactivation/infection in ICU patients and all were exploratory or negative. Further studies are needed to evaluate the impact of such treatment in specific populations.
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Affiliation(s)
- Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Juliette Chommeloux
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David Levy
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lucie Lefevre
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, Paris, France.,Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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10
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Zhang Z, Li R, Chen Y, Zhang J, Zheng Y, Xu M, Liang J, Li J, Huang Y, Xu Y, He W, Liu X, Li Y. Association between active cytomegalovirus infection and lung fibroproliferation in adult patients with acute respiratory distress syndrome: a retrospective study. BMC Infect Dis 2022; 22:788. [PMID: 36241980 PMCID: PMC9562065 DOI: 10.1186/s12879-022-07747-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 09/20/2022] [Indexed: 12/05/2022] Open
Abstract
Background Cytomegalovirus (CMV) has high seroprevalence, and its active infection is associated with several adverse prognoses in adult patients with acute respiratory distress syndrome (ARDS). However, the role of active CMV infection in ARDS-associated fibroproliferation is unknown. This study aimed at determining the association between active CMV infection and lung fibroproliferation in adult patients with ARDS. Methods We retrospectively reviewed the medical records of all adult patients with ARDS who were admitted to the intensive care unit (ICU) from January 2018 to December 2020 at a national university-affiliated hospital in China. Study subjects were divided into active and non-active CMV infection groups based on CMV DNAemia within a 28-day ICU hospitalization. Lung fibroproliferation was measured using chest high-resolution computed tomography (HRCT) and N-terminal peptide of serum procollagen III (NT-PCP-III) within the first 28 days of ICU admission. Pulmonary fibrosis, clinical features, laboratory findings, treatment measures, and clinical outcomes were compared between the two groups. Results Among the 87 ARDS patients included in this study, the incidence of active CMV infection was 16.1% within the 28-day ICU admission period. In logistic regression analyze, active CMV infection was found to be associated with higher pulmonary fibrogenesis, pulmonary fibrosis score, and NT-PCP-III level (P < 0.05). The duration of ICU stay in ARDS patients with active CMV infection was significantly higher than in those without active CMV infection (P < 0.05). Conclusions Among adult patients with ARDS, active CMV infection was related to poor clinical outcomes. Active CMV infection was associated with ARDS-associated fibroproliferation. Prophylactic and preemptive use of anti-CMV agents on pulmonary fibrosis should be assessed to determine a consensus therapeutic strategy. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07747-y.
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Affiliation(s)
- Zhihui Zhang
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Rujian Li
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Yubiao Chen
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Jierong Zhang
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Yongxin Zheng
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Minmin Xu
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Jiaqi Liang
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Jiahui Li
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.,Guangzhou Medical University, Guangzhou, 511436, Guangdong, People's Republic of China
| | - Yongbo Huang
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Yonghao Xu
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Weiqun He
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Xiaoqing Liu
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.
| | - Yimin Li
- Department of Critical Care Medicine, State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510120, Guangdong, People's Republic of China.
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11
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Senousy SR, Ahmed ASF, Abdelhafeez DA, Khalifa MMA, Abourehab MAS, El-Daly M. Alpha-Chymotrypsin Protects Against Acute Lung, Kidney, and Liver Injuries and Increases Survival in CLP-Induced Sepsis in Rats Through Inhibition of TLR4/NF-κB Pathway. Drug Des Devel Ther 2022; 16:3023-3039. [PMID: 36105322 PMCID: PMC9467300 DOI: 10.2147/dddt.s370460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
Abstract Inflammation and oxidative stress play a major role in the development of sepsis and its associated complications, leading to multiple organ failure and death. The lungs, liver, and kidneys are among the early affected organs correlated with mortality in sepsis. Alpha-chymotrypsin (α-ch) is a serine protease that exerts anti-inflammatory, anti-edematous, and anti-oxidant properties. Purpose This study was undertaken to elucidate if the anti-inflammatory and anti-oxidant effects of α-ch observed in previous studies can alleviate lung, liver, and kidney injuries in a cecal ligation and puncture (CLP)-induced sepsis model, and thus decrease mortality. Materials and Methods Septic animals were given α-ch 2 h post CLP procedure. Sepsis outcomes were assessed in the lungs, liver, and kidneys. Separate animal groups were investigated for a survival study. Results CLP resulted in 0% survival, while α-chymotrypsin post-treatment led to 50% survival at the end of the study. Administration of α-chymotrypsin resulted in a significant attenuation of sepsis-induced elevated malonaldehyde (MDA) and total nitrite/nitrate (NOx) levels. In addition, there was a significant increase in reduced glutathione (GSH) content and superoxide dismutase (SOD) activity in the lungs, liver, and kidneys. Administration of α-ch reduced elevated tissue expression of toll-like receptor-4 (TLR4), nuclear factor kappa-B (NF-κB), myeloperoxidase (MPO), and inducible nitric oxide synthase (iNOS). Alpha-chymotrypsin resulted in a significant reduction in serum levels of tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and interleukin-6 (IL-6). Alpha-chymotrypsin attenuated the rise in serum creatinine, cystatin C, blood urea nitrogen (BUN), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels that was observed in the septic group. In addition, α-ch significantly reduced the lung wet/dry weight ratio, total protein content, and leukocytic counts in bronchoalveolar lavage fluid (BALF). Histopathological examination of the lungs, liver, and kidneys confirmed the protective effects of α-ch on those organs. Conclusion α-ch has protective potential against sepsis through lowering tissue expression of TLR4, NF-κB, MPO, and iNOS leading to decreased oxidative stress and inflammatory signals induced by sepsis. This effect appeared to alleviate the damage to the lungs, liver, and kidneys and increase survival in rats subjected to sepsis.
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Affiliation(s)
- Shaymaa Ramzy Senousy
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
| | - Al-Shaimaa F Ahmed
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
- Correspondence: Al-Shaimaa F Ahmed, Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, Egypt, Tel +20 1020018842, Email
| | - Dalia A Abdelhafeez
- Department of Pathology, Faculty of Medicine, Minia University, Minia, Egypt
| | | | - Mohammed A S Abourehab
- Department of Pharmaceutics, Faculty of Pharmacy, Umm Al-Qura University, Makkah, 21955, Saudi Arabia
| | - Mahmoud El-Daly
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Minia University, Minia, 61519, Egypt
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12
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Fanning J, Panigada M, Li Bassi G. Nosocomial Pneumonia in the Mechanically Ventilated Patient. Semin Respir Crit Care Med 2022; 43:426-439. [PMID: 35714627 DOI: 10.1055/s-0042-1749448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a common complication occurring in critically ill patients who are mechanically ventilated and is the leading cause of nosocomial infection-related death. Etiologic agents for VAP widely differ based on the population of intensive care unit patients, duration of hospital stay, and prior antimicrobial therapy. VAP due to multidrug-resistant pathogens is associated with the highest morbidity and mortality, likely due to delays in appropriate antimicrobial treatment. International guidelines are currently available to guide diagnostic and therapeutic strategies. VAP can be prevented through various pharmacological and non-pharmacological interventions, which are more effective when grouped as bundles. When VAP is clinically suspected, diagnostic strategies should include early collection of respiratory samples to guide antimicrobial therapy. Empirical treatment should be based on the most likely etiologic microorganisms and antibiotics likely to be active against these microorganisms. Response to therapy should be reassessed after 3 to 5 days and antimicrobials adjusted or de-escalated to reduce the burden of the disease. Finally, considering that drug resistance is increasing worldwide, several novel antibiotics are being tested to efficiently treat VAP in the coming decades.
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Affiliation(s)
- Jonathon Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, Royal Brisbane and Women's Hospital, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Nuffield Department of Population Health, Oxford University, United Kingdom
| | - Mauro Panigada
- Department of Anaesthesiology, Intensive Care and EmergencyFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Queensland University of Technology, Brisbane, Australia.,Intensive Care Unit, The Wesley Hospital, Auchenflower, Queensland, Australia.,Wesley Medical Research, The Wesley Hospital, Auchenflower, Australia
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13
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Ong DSY, Chong GLM, Chemaly RF, Cremer OL. Comparative clinical manifestations and immune effects of cytomegalovirus infections following distinct types of immunosuppression. Clin Microbiol Infect 2022; 28:1335-1344. [PMID: 35709902 DOI: 10.1016/j.cmi.2022.05.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is a well-recognized complication of solid organ and hematopoietic cell transplantation. However, CMV infection also occurs in patients with human immunodeficiency virus (HIV) infection, previously immunocompetent intensive care unit (ICU) patients, and individuals on immunosuppressive medications for various underlying diseases. OBJECTIVES This review describes the comparative effects of CMV infection in distinct types of acquired immunosuppression. SOURCES Selected peer-reviewed publications on CMV infections published until December 2021. CONTENT CMV infection affects various organ systems through direct cytolytic mechanisms, but may also exert indirect effects by promoting pro-inflammatory and immunosuppressive responses. This has been well studied in transplant recipients, for whom antiviral prophylaxis and pre-emptive therapy have now become standard practice. These strategies not only prevent direct CMV disease manifestations, but also mitigate various immunopathological processes to reduce graft-versus-host disease, graft rejection, and the occurrence of secondary bacterial and fungal infections. The efficacy of neither prophylactic nor pre-emptive treatment of CMV infection has been demonstrated for patients with critical illness- or medication-induced immunosuppression. Many observational studies have shown an independent association between CMV reactivation and a prolonged duration of mechanical ventilation or increased mortality in the ICU. Furthermore, data suggest that CMV reactivation may increase pulmonary inflammation and prolong the duration of mechanical ventilation. IMPLICATIONS A large number of observational and experimental studies suggest attributable morbidity and mortality related to CMV infection, not only in transplant recipients and patients with HIV infection but also in patients with critically illness- or medication-induced immunosuppression. Adequately powered randomized controlled trials investigating the efficacy of prophylaxis or pre-emptive treatment of CMV infection in these patients are lacking, with a notable exception for transplant recipients.
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Affiliation(s)
- David S Y Ong
- Department of Medical Microbiology and Infection Control, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands; Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Ga-Lai M Chong
- Erasmus University Medical Center, Department of Medical Microbiology & Infectious Diseases, Rotterdam, the Netherlands
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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14
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Shah D, Gupta E, Baweja S, Pasupuleti SSR, Maiwall R, Ramalingam A, Mitra LG, Sarin SK. CYTOMEGALOVIRUS REACTIVATION IN SEROPOSITIVE CRITICALLY ILL PATIENTS WITH LIVER CIRRHOSIS: A HOSPITAL-BASED LONGITUDINAL STUDY. JOURNAL OF CLINICAL VIROLOGY PLUS 2022. [DOI: 10.1016/j.jcvp.2022.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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15
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Spahn S, Riessen R, Berg CP, Malek NP, Emrich MH, Lohrengel K, Ganzenmueller T, Iftner T, Kleymann G, Hamprecht K. Comprehensive clinical and virological characterization of three cases of fulminant liver failure owing to HSV1 primary infection. Liver Int 2022; 42:1005-1011. [PMID: 35230726 DOI: 10.1111/liv.15215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/23/2021] [Accepted: 01/16/2022] [Indexed: 12/13/2022]
Abstract
Herpes simplex virus 1 (HSV-1) is a frequently unrecognized, yet deadly cause of acute liver failure (ALF). We, therefore, analysed three cases of fatal HSV-1-induced ALF. All patients shared clinical (extremely elevated transaminases, LDH and AST/LDH ratio < 1) and virological characteristics (ratio of viral load in plasma versus throat swabs: 60-700-fold, lack of anti-HSV-1-IgG antibodies or low IgG-avidity during primary infection), which may help to identify patients at risk. Additionally, in vitro chemosusceptibility assays revealed high efficacy of the helicase-primase inhibitors (HPI), pritelivir and drug-candidate IM-250 compared to acyclovir (ACV) using HSV-1-isolates from two patients; hence, ACV/HPI-combinations might offer new therapeutic options for HSV-induced ALF.
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Affiliation(s)
- Stephan Spahn
- Department Internal Medicine I, University Hospital of Tuebingen, Tuebingen, Germany
| | - Reimer Riessen
- Department of Internal Medicine, Medical Intensive Care Unit, University Hospital of Tuebingen, Tübingen, Germany
| | - Christoph P Berg
- Department Internal Medicine I, University Hospital of Tuebingen, Tuebingen, Germany
| | - Nisar P Malek
- Department Internal Medicine I, University Hospital of Tuebingen, Tuebingen, Germany
| | - Marzena H Emrich
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
| | - Kristina Lohrengel
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
| | - Tina Ganzenmueller
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
| | - Thomas Iftner
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
| | - Gerald Kleymann
- University of Tübingen IFIB, Interfaculty Institute for Biochemistry, Tübingen, Germany.,Innovative Molecules GmbH, Bad-Salzuflen, Germany
| | - Klaus Hamprecht
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
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16
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Luyt CE, Hékimian G, Bréchot N, Chastre J. Viral Ventilator-Associated Pneumonia/Hospital-Acquired Pneumonia. Semin Respir Crit Care Med 2022; 43:310-318. [PMID: 35100650 DOI: 10.1055/s-0041-1740981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Among the viruses possibly responsible for hospital-acquired and ventilator-associated pneumonia, herpes simplex virus (HSV) is probably the most often involved: HSV reactivation is frequent in intensive care unit patients, and lung parenchymal infection (HSV bronchopneumonitis) has been well described, either using cytological signs of parenchymal involvement in cells obtained during bronchoalveolar lavage or using HSV virus load in the lower respiratory tract. Although treating patients with HSV bronchopneumonitis may be recommended, based on expert opinion, prophylactic or preemptive treatment of HSV reactivation should be avoided. Ventilator-associated pneumonia due to cytomegalovirus (CMV) is less frequent than HSV bronchopneumonitis, and more difficult to diagnose. No data exists on the impact of antiviral treatment on CMV pneumonia. The involvement of respiratory viruses has been described in patients with healthcare-associated pneumonia and hospital-acquired pneumonia, but their role in ventilator-associated pneumonia is not clear.
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Affiliation(s)
- Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris.,INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris.,INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris
| | - Nicolas Bréchot
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris.,INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris
| | - Jean Chastre
- Service de Médecine Intensive Réanimation, Sorbonne Université, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris.,INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Paris
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17
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Cytomegalovirus reactivation in critically-ill Coronavirus Disease 2019 patients: A case series of 11 patients. IDCases 2022; 27:e01402. [PMID: 35036326 PMCID: PMC8748205 DOI: 10.1016/j.idcr.2022.e01402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/10/2022] [Accepted: 01/10/2022] [Indexed: 12/15/2022] Open
Abstract
The mortality associated with Coronavirus Disease 2019 is greatly influenced by known risk factors such as elderly age, cardiovascular disease, hypertension, diabetes, and immunosuppression. As cytomegalovirus reactivation in critically ill patients has been linked with higher morbidity and mortality in intensive care settings, it has been suggested that cytomegalovirus reactivation might lead to worse clinical outcomes of patients with Coronavirus Disease 2019. Here we describe the clinical course of 11 patients with Coronavirus Disease 2019 and concomitant cytomegalovirus viremia. We conclude that further research is necessary to formulate guidelines on diagnosis and treatment of cytomegalovirus reactivation in Coronavirus Disease 2019 patients.
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Lambe G, Mansukhani D, Khodaiji S, Shetty A, Rodrigues C, Kapadia F. Immune Modulation and Cytomegalovirus Reactivation in Sepsis-induced Immunosuppression: A Pilot Study. Indian J Crit Care Med 2022; 26:53-61. [PMID: 35110845 PMCID: PMC8783232 DOI: 10.5005/jp-journals-10071-24079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction Sepsis is a life-threatening condition caused due to dysregulated immune response to an infection and progressive immunosuppression. Reactivation of cytomegalovirus (CMV) occurs frequently in sepsis and is found associated with adverse outcomes. The study objective was to evaluate the association between incidence of CMV reactivation and immune alteration in sepsis-induced immunosuppression in patients with prolonged sepsis. Patients and methods Patients admitted to intensive care unit (ICU), with severe sepsis and CMV immunoglobulin G (IgG) seropositivity, were prospectively enrolled. Other manifest immune suppression causes were excluded. Samples were collected on enrolment and further once a week until day 21 or death/discharge. CMV viral load was quantified using qPCR. Lymphocyte subset analysis (CD3+, CD4+, CD8+, CD19+, CD16+/CD56+, and CD25+CD127− regulatory T cells), human leukocyte antigen-DR isotype (HLA-DR) expression on monocytes, programmed death-1 (PD-1) expression on T lymphocytes, and proinflammatory (interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and interferon-gamma (IFN-γ)), anti-inflammatory cytokines levels (IL-2, IL-4, and IL-10) were analyzed by flow cytometry as markers for immunosuppression. Results A total of 25 CMV IgG-positive patients and 11 healthy controls were included. CMV reactivation occurred in 20 patients. Patients with CMV reactivation had T-cell lymphopenia. PD-1 expression on CD4+ and CD8+ T cells was markedly elevated (p <0.02) in CMV-reactivated patients compared to nonreactivated patients. HLA-DR expression was significantly low on monocytes in all septic patients (p <0.01) compared to healthy controls. IL-6 levels showed elevation at day 7, whereas IL-10 was found to be significantly higher from day 0 in CMV-reactivated group. Conclusion Our study concluded that immune suppression markers and cytokine levels in patients with severe sepsis were found to be significantly associated with the incidence of CMV reactivation. How to cite this article Lambe G, Mansukhani D, Khodaiji S, Shetty A, Rodrigues C, Kapadia F. Immune Modulation and Cytomegalovirus Reactivation in Sepsis-induced Immunosuppression: A Pilot Study. Indian J Crit Care Med 2022;26(1):53–61.
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Affiliation(s)
- Gaurav Lambe
- Department of Laboratory Medicine, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India; Department of Critical Care, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Dia Mansukhani
- Department of Laboratory Medicine, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Shanaz Khodaiji
- Department of Laboratory Medicine, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
- Shanaz Khodaiji, Department of Laboratory Medicine, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India, Phone: +91 9820551848, e-mail:
| | - Anjali Shetty
- Department of Laboratory Medicine, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Camilla Rodrigues
- Department of Laboratory Medicine, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | - Farhad Kapadia
- Department of Intensive Care, PD Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Abstract
Reactivation of herpsviruses, mainly HSV, CMV and EBV, are frequent among critically ill patients. Although they are not immunocompromised from a classical point of view, these patients often present an alteration of their immune system favoring viral reactivation. Seropositive patients with sepsis and under mechanical ventilation are particularly at risk. Herpesviruses have a pulmonary tropism and can be responsible for non-resolving forms of acute respiratory distress syndrome with high mortality. However, the direct causality between herpesviruses reactivation and impaired outcomes among severely ill patients remains under debate.
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Bai G, Cui N, Wang H, Cheng W, Han W, Chen J, Guo Y, Wang F. T-lymphocyte subtyping: an early warning and a potential prognostic indicator of active cytomegalovirus infection in patients with sepsis. Immunol Cell Biol 2022; 100:777-790. [PMID: 36106958 PMCID: PMC9828035 DOI: 10.1111/imcb.12586] [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] [Received: 07/03/2022] [Revised: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 01/12/2023]
Abstract
Cytomegalovirus (CMV) infection is very common in patients suffering from sepsis and may cause poor prognosis. To explore the relationship between immune status of patients with sepsis and CMV infection, we assessed T lymphocyte subtyping and other commonly used clinical parameters in patients with sepsis upon admission to the intensive care unit (ICU) and evaluated their potential impact on diagnosis and outcomes of active CMV infection. In our study, 82 of 599 patients with sepsis were diagnosed with active CMV infection. The 28-day mortality was higher in active CMV-infected than nonactive CMV-infected patients (20.7% versus 9.9%); 51of 82 active CMV-infected patients with sepsis were assessed to have CMV-DNA-negative conversion, while 31 were persistently positive for CMV DNA. Higher CD8+ CD28+ T-cell counts at presentation were associated with CMV-DNA-negative conversion and lower 28-day mortality. The CMV-DNA-negative conversion and 28-day mortality of active CMV-infected patients with sepsis could be predicted using cutoff values of 151 (74.5% sensitivity and 87.1% specificity) and 64.5 (52.9% sensitivity and 92.3% specificity) CD8+ CD28+ T cells mL-1 at ICU admission, respectively. Higher CD8+ CD28+ T-cell count was significantly associated with active CMV infection, higher CMV-DNA-negative conversion and lower 28-day mortality, which may be a potential marker for early warning of active CMV infection and outcome prediction.
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Affiliation(s)
- Guangxu Bai
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Na Cui
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina,Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical ScienceBeijingChina
| | - Hao Wang
- Department of Critical Care MedicineBeijing Jishuitan HospitalBeijingChina
| | - Wei Cheng
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Wen Han
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Jianwei Chen
- Department of State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical Science and Peking Union Medical CollegeBeijingChina,Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical SciencesBeijingChina
| | - Ye Guo
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical ScienceBeijingChina
| | - Fei Wang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical CollegeChinese Academy of Medical ScienceBeijingChina
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Gu WJ, Huang J, Jiang HY. Efficacy and safety of antiviral therapy in critically ill patients with mechanical ventilation: a meta-analysis with trial sequential analysis of randomized controlled trials. Clin Microbiol Infect 2021; 28:792-800. [PMID: 34910999 DOI: 10.1016/j.cmi.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 11/05/2021] [Accepted: 12/04/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Viral reactivation is frequently detected in critically ill patients with mechanical ventilation and is associated with worse outcomes. However, the efficacy and safety of antiviral therapy in these patients remain unknown. OBJECTIVES To assess the effects of antiviral therapy on mortality, viral reactivation, and adverse events in critically ill patients with mechanical ventilation. DATA SOURCES Medline, Embase, the Cochrane Library, and reference lists. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared antiviral therapy with placebo, standard care, or no treatment. PARTICIPANTS Critically ill patients with mechanical ventilation. INTERVENTIONS Antiviral therapy. ASSESSMENT OF RISK OF BIAS Cochrane risk of bias tool. METHODS OF DATA SYNTHESIS Risk ratios (RR) with 95% confidence intervals (CIs) were pooled using a random-effects model for meta-analysis with trial sequential analysis. RESULTS Nine trials with a broad spectrum of critically ill patients were included. No association was found between antiviral therapy and all-cause mortality at the longest follow-up (nine trials; 1790 patients; RR 0.93, 95% CI 0.79-1.11; I2 = 3%). Trial sequential analysis showed that the cumulative Z-curve crossed the futility boundary establishing sufficient evidence. No association also was found between antiviral therapy and 28-day mortality, in-hospital mortality, 60-day mortality, or 90-day mortality. But antiviral therapy was associated with a reduction in viral reactivation (five trials; 644 patients; RR 0.23, 95% CI 0.14-0.37; I2 = 0%). Trial sequential analysis showed that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit establishing sufficient evidence. Antiviral therapy was not associated with an increased risk of renal insufficiency (eight trials; 1574 patients; RR 0.88, 95% CI 0.73-1.05; I2 =0%). CONCLUSIONS No association between antiviral therapy and mortality was found, but antiviral therapy reduced viral reactivation without increasing the risk of renal insufficiency in critically ill patients with mechanical ventilation.
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Affiliation(s)
- Wan-Jie Gu
- Department of Anaesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, China.
| | - Jiao Huang
- Department of Anaesthesiology, The First Affiliated Hospital, Guangxi Medical University, 22 Shuangyong Road, Nanning 530021, China
| | - Hai-Yin Jiang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Centre for Infectious Diseases, Collaborative Innovation Centre for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China
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Zhang Z, Liu X, Sang L, Chen S, Wu Z, Zhang J, Sun Y, Huang Y, Xu Y, He W, Li Y, Liu X. Cytomegalovirus reactivation in immunocompetent mechanical ventilation patients: a prospective observational study. BMC Infect Dis 2021; 21:1026. [PMID: 34592936 PMCID: PMC8482357 DOI: 10.1186/s12879-021-06698-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 09/15/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) reactivation is associated with adverse prognoses of critically ill patients. However, the epidemiology and predictors of CMV reactivation in immunocompetent patients receiving mechanical ventilation (MV) are not clear. The aim of this study was to investigate the epidemiology and predictors of CMV reactivation in immunocompetent patients requiring MV. METHODS A single-center, prospective observational study (conducted from June 30, 2017 to July 01, 2018) with a follow-up of 90 days (September 29, 2018) that included 71 CMV-seropositive immunocompetent patients with MV at a 37-bed university hospital general intensive care unit (ICU) in China. Routine detection of CMV DNAemia was performed once a week for 28 days (Days 1, 7, 14, 21, and 28). CMV serology, laboratory findings, and clinical data were obtained during hospitalization. RESULTS Among 71 patients, 13 (18.3%) showed CMV reactivation within 28 days in the ICU. The median time to reactivation was 7 days. CMV reactivation was related to various factors, including body mass index (BMI), sepsis, N-terminal pro-b-type natriuretic peptide (NT-proBNP), blood urea nitrogen (BUN), and hemoglobin (Hb) levels (P < 0.05). In the multivariate regression model, BMI, Hb level, and sepsis were independently associated with CMV reactivation patients (P < 0.05). Moreover, the area under the receiver operating characteristic (AUROC) of BMI, Hb, and BMI combined with Hb was 0.69, 0.70, and 0.76, respectively. The duration of MV, hospitalization expense, length of ICU stay, and 90 day all-cause mortality rate in patients with CMV reactivation was significantly higher than in those without CMV reactivation (P < 0.05). CONCLUSIONS Among immunocompetent patients with MV, the incidence of CMV reactivation was 18.3%. CMV reactivation was associated with several adverse prognoses. BMI, Hb, and sepsis were independent risk factors for CMV reactivation. BMI and Hb may predict CMV reactivation.
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Affiliation(s)
- Zhihui Zhang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.,Guangzhou Medical University, Guangzhou, Guangdong, 511436, People's Republic of China
| | - Xuesong Liu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Ling Sang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Sibei Chen
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Zhan Wu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.,Guangzhou Medical University, Guangzhou, Guangdong, 511436, People's Republic of China
| | - Jierong Zhang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.,Guangzhou Medical University, Guangzhou, Guangdong, 511436, People's Republic of China
| | - Yining Sun
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.,Guangzhou Medical University, Guangzhou, Guangdong, 511436, People's Republic of China
| | - Yongbo Huang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Yonghao Xu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Weiqun He
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Yimin Li
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China
| | - Xiaoqing Liu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, People's Republic of China.
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Abstract
Patients with infection can develop sepsis, and their mortality can be high. An important aspect in the treatment of sepsis is adequate management of the infection.
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Waldrop G, Zucker J, Boubour A, Radmard S, Green DA, Thakur KT. Clinical Significance of Positive Results of the BioFire Cerebrospinal Fluid FilmArray Meningitis/Encephalitis Panel at a Tertiary Medical Center in the United States. Arch Pathol Lab Med 2021; 146:194-200. [PMID: 34086848 DOI: 10.5858/arpa.2020-0380-oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The FilmArray Meningitis/Encephalitis (ME) panel is the first US Food and Drug Administration-cleared multiplex polymerase chain reaction panel for the detection of central nervous system infections. While the assay's performance characteristics have been described, the real-world significance of positive results has not been fully characterized. OBJECTIVE.— To evaluate the clinical significance of positive ME panel results in a tertiary care medical center in New York, New York. DESIGN.— Four physicians independently performed retrospective clinical assessments of all positive ME panel results at Columbia University Irving Medical Center, including the Children's Hospital of New York, during an 18-month period. Each reviewer determined the likelihood of central nervous system infection for all cases and whether cases fit Brighton diagnostic criteria for meningitis, encephalitis, or meningoencephalitis. RESULTS.— Among 119 cases, there was 75% positive agreement (95% CI, 54%-89%) between ME panel results and clinical consensus, which varied among panel targets. CONCLUSIONS.— The ME panel showed good agreement with expert clinical consensus for patients presenting with acute meningitis/encephalitis. Factors contributing to clinically insignificant ME positive results included low pretest probability, traumatic lumbar puncture, specimen contamination, and detection of incidental viral targets such as human herpesvirus 6. Notably, the ME panel detected more than twice the number of cases of bacterial meningitis detected by culture alone, particularly among patients receiving empiric antimicrobial therapy before lumbar puncture. Appropriate test use and contextual interpretation of results are critical to leveraging the advantages of the platform while avoiding potential pitfalls.
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Affiliation(s)
- Greer Waldrop
- From the Division of Critical Care and Hospitalist Neurology, Department of Neurology (Waldrop, Radmard, Thakur), Columbia University Irving Medical Center, New York, New York
| | - Jason Zucker
- The Division of Infectious Diseases, Department of Medicine (Zucker), Columbia University Irving Medical Center, New York, New York
| | - Alexandra Boubour
- Barnard College of Columbia University, New York, New York (Boubour)
| | - Sara Radmard
- From the Division of Critical Care and Hospitalist Neurology, Department of Neurology (Waldrop, Radmard, Thakur), Columbia University Irving Medical Center, New York, New York
| | - Daniel A Green
- The Department of Pathology & Cell Biology (Green), Columbia University Irving Medical Center, New York, New York
| | - Kiran T Thakur
- From the Division of Critical Care and Hospitalist Neurology, Department of Neurology (Waldrop, Radmard, Thakur), Columbia University Irving Medical Center, New York, New York
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Park GE, Ki HK, Ko JH. Impact of antiviral treatment on long-term prognosis in non-immunocompromised patients with CMV reactivation. BMC Infect Dis 2021; 21:414. [PMID: 33947335 PMCID: PMC8094573 DOI: 10.1186/s12879-021-06098-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/19/2021] [Indexed: 11/29/2022] Open
Abstract
Background Reactivation of human cytomegalovirus (CMV) occurs in non-immunocompromised patients with or without specific organ involvement, but it is still unknown whether it has a clinical implication on long-term prognosis or not. Methods A retrospective cohort study evaluating non-immunocompromised adult patients with CMV reactivation was conducted during the period between January 2010 and February 2018. Patients were divided into ganciclovir-treated and non-treated groups. Patients who died within 30 days from CMV reactivation were excluded as they died from complex causes of conditions. Survivors were followed for 30-months to evaluate long-term prognosis. Results A total of 136 patients with CMV reactivation was included, consisting of 66 ganciclovir-treated (48.5%) and 70 non-treated (51.5%) patients. Overall, patients were old-aged (median 70 years old) and most were treated with pneumonia of any cause (91.2%). More patients in ganciclovir-treated group were treated at intensive care unit (43.9% vs 24.3%, respectively) and had higher viral load over 5000 copies/ml (48.5% vs 22.9%) than non-treated group (all P < 0.05). Primary and secondary endpoints including 30-months survival (28.0 vs 38.9%, respectively) and 12-months survival (40.3% vs 49.2%) were not statistically different between the ganciclovir-treated and non-treated groups. In the multivariate analyses, ganciclovir treatment was not associated with 30-months survival (HR 1.307, 95% CI 0.759–2.251) and 12-months survival (HR 1.533, 95% CI 0.895–2.624). Conclusion In a retrospective cohort study evaluating non-immunocompromised patients with CMV reactivation, ganciclovir treatment was not associated with long-term prognosis. Antiviral treatment in this condition would not be necessary unless organ involvement is suspected. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06098-4.
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Affiliation(s)
- Ga Eun Park
- Division of Infectious Disease, Konkuk University medical center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hyun Kyun Ki
- Division of Infectious Disease, Konkuk University medical center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Jae-Hoon Ko
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Kuo CW, Wang SY, Tsai HP, Su PL, Cia CT, Lai CH, Chen CW, Shieh CC, Lin SH. Invasive pulmonary aspergillosis is associated with cytomegalovirus viremia in critically ill patients - A retrospective cohort study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2021; 55:291-299. [PMID: 33840605 DOI: 10.1016/j.jmii.2021.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 02/23/2021] [Accepted: 03/08/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND/PURPOSE Cytomegalovirus (CMV) viremia is associated with a higher mortality rate and prolonged intensive care unit (ICU) stay for critically ill patients. CMV infection causes transient but substantial immunosuppression for transplant recipients, increasing risk of fungal infection. The association between CMV viremia and invasive pulmonary aspergillosis (IPA) for critically ill patients is still unknown. METHODS We retrospectively analyzed patients received bronchoalveolar lavage (BAL), galactomannan test, influenza survey and blood CMV viral load test in ICUs of a university hospital between April 2017 and May 2020. Independent risks for IPA were analyzed by multivariable logistic regression. RESULTS A total of 136 patients were included. Twenty-one patients had IPA, 48 patients had CMV viremia and 22 patients had influenza. In a multivariable logistic regression model, patients with CMV viremia or influenza had higher IPA risk (adjusted odds ratio, 3.98 and 8.72; 95% CI, 1.26-12.60 and 2.64-28.82; p value = 0.019 and <0.001, respectively.). Patients with detectable CMV in BAL fluid did not have higher IPA risk (crude odds ratio, 0.95; 95% CI, 0.33-2.79; p value = 0.933). After stratifying patients by CMV viral load, the IPA risk is higher for patients with higher viral loads. There is an additive synergistic effect on IPA risk between CMV viremia and influenza infection. CONCLUSION For critically ill patients, CMV viremia is an independent risk factor of IPA. Patients with higher blood CMV viral loads have a higher risk of IPA. CMV viremia and influenza have an additive synergistic effect for IPA risk in critically ill patients.
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Affiliation(s)
- Chin-Wei Kuo
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Division of Critical Care Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Yuan Wang
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Huey-Pin Tsai
- Department of Pathology, National Cheng Kung University Hospital, Tainan, Taiwan; Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Lan Su
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cong-Tat Cia
- Division of Critical Care Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Han Lai
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chang-Wen Chen
- Division of Chest Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Division of Critical Care Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Chang Shieh
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Sheng-Hsiang Lin
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Biostatistics Consulting Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Papazian L, Jaber S, Hraiech S, Baumstarck K, Cayot-Constantin S, Aissaoui N, Jung B, Leone M, Souweine B, Schwebel C, Bourenne J, Allardet-Servent J, Kamel T, Lu Q, Zandotti C, Loundou A, Penot-Ragon C, Chastre J, Forel JM, Luyt CE. Preemptive ganciclovir for mechanically ventilated patients with cytomegalovirus reactivation. Ann Intensive Care 2021; 11:33. [PMID: 33570708 PMCID: PMC7876264 DOI: 10.1186/s13613-020-00793-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022] Open
Abstract
Background The effect of cytomegalovirus (CMV) reactivation on the length of mechanical ventilation and mortality in immunocompetent ICU patients requiring invasive mechanical ventilation remains controversial. The main objective of this study was to determine whether preemptive intravenous ganciclovir increases the number of ventilator-free days in patients with CMV blood reactivation. Methods This double-blind, placebo-controlled, randomized clinical trial involved 19 ICUs in France. Seventy-six adults ≥ 18 years old who had been mechanically ventilated for at least 96 h, expected to remain on mechanical ventilation for ≥ 48 h, and exhibited reactivation of CMV in blood were enrolled between February 5th, 2014, and January 23rd, 2019. Participants were randomized to receive ganciclovir 5 mg/kg bid for 14 days (n = 39) or a matching placebo (n = 37). Results The primary endpoint was ventilator-free days from randomization to day 60. Prespecified secondary outcomes included day 60 mortality. The trial was stopped for futility based on the results of an interim analysis by the DSMB. The subdistribution hazard ratio for being alive and weaned from mechanical ventilation at day 60 for patients receiving ganciclovir (N = 39) compared with control patients (N = 37) was 1.14 (95% CI from 0.63 to 2.06; P = 0.66). The median [IQR] numbers of ventilator-free days for ganciclovir-treated patients and controls were 10 [0–51] and 0 [0–43] days, respectively (P = 0.46). Mortality at day 60 was 41% in patients in the ganciclovir group and 43% in the placebo group (P = .845). Creatinine levels and blood cells counts did not differ significantly between the two groups. Conclusions In patients mechanically ventilated for ≥ 96 h with CMV reactivation in blood, preemptive ganciclovir did not improve the outcome.
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Affiliation(s)
- Laurent Papazian
- Médecine Intensive Réanimation, Aix-Marseille Université, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Samir Jaber
- Réanimation Chirurgicale, Centre Hospitalier Universitaire de Montpellier, Hôpital St-Eloi, Montpellier, France
| | - Sami Hraiech
- Médecine Intensive Réanimation, Aix-Marseille Université, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Karine Baumstarck
- Laboratoire de Santé Publique, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | | | - Nadia Aissaoui
- Médecine Intensive Réanimation, Hôpital Européen Georges-Pompidou, APHP, Paris, France
| | - Boris Jung
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Montpellier, Hôpital Lapeyronie, Montpellier, France
| | - Marc Leone
- Service d'Anesthésie-Réanimation, Aix-Marseille Université, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Bertrand Souweine
- Réanimation Médicale, CHU Gabriel-Montpied, Clermont-Ferrand, France
| | - Carole Schwebel
- Médecine Intensive Réanimation, CHU Grenoble Alpes, La Tronche, France
| | - Jérémy Bourenne
- Réanimation des Urgences et Médicale, Aix-Marseille Université, Hôpital Timone, APHM, Marseille, France
| | | | - Toufik Kamel
- Médecine Intensive Réanimation, Centre Hospitalier Régional, Orléans, France
| | - Qin Lu
- Réanimation Chirurgicale Polyvalente, Département d'Anesthésie-Réanimation, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, APHP, Paris, France
| | - Christine Zandotti
- Laboratoire de Virologie, IHU Méditerranée Infection, CHU Timone UMR190-Emergence des Pathologies Virales, Marseille, France
| | - Anderson Loundou
- Laboratoire de Santé Publique, Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | | | - Jean Chastre
- Sorbonne Université, INSERM, Médecine Intensive Réanimation, Institut de Cardiologie, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Marie Forel
- Médecine Intensive Réanimation, Aix-Marseille Université, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Charles-Edouard Luyt
- Sorbonne Université, INSERM, Médecine Intensive Réanimation, Institut de Cardiologie, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris, Paris, France
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Imlay H, Dasgupta S, Boeckh M, Stapleton RD, Rubenfeld GD, Chen Y, Limaye AP. Risk Factors for Cytomegalovirus Reactivation and Association With Outcomes in Critically Ill Adults With Sepsis: A Pooled Analysis of Prospective Studies. J Infect Dis 2020; 223:2108-2112. [PMID: 33159200 DOI: 10.1093/infdis/jiaa697] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 11/03/2020] [Indexed: 12/26/2022] Open
Abstract
We performed multivariable analysis of potential risk factors (including cytomegalovirus [CMV] reactivation) for clinical outcomes by day 28 (death or continued hospitalization, ventilator-free days, intensive care unit (ICU)-free days, hospital-free days) from pooled cohorts of 2 previous prospective studies of CMV-seropositive adults with sepsis. CMV reactivation at any level, >100 IU/mL, >1000 IU/mL, peak viral load, and area under the curve were independently associated with the clinical outcomes. We identified the potential effect size of CMV on outcomes that could be used as end points for future interventional trials of CMV prevention using antiviral prophylaxis in ICU patients with sepsis.
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Affiliation(s)
- Hannah Imlay
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Sayan Dasgupta
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Michael Boeckh
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Renee D Stapleton
- Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | | | - Ying Chen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Ajit P Limaye
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
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Clark JM, Durrani H, Hagan JD, Watson C, Richards WT, Taylor D, Ang DN. Statewide Seasonal Variations of Infections Within the Intensive Care Unit Among the Trauma Population. Am Surg 2020; 87:623-630. [PMID: 33135937 DOI: 10.1177/0003134820951496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Infections within intensive care unit (ICU) are a persistent problem among the critically ill. Viral pneumonias have already been established as having a season variations. We attempt to evaluate the seasonal variations of pneumonia among the traumatically injured and the critically ill. MATERIALS AND METHODS A retrospective cohort study among traumatized patients admitted from 1997 to 2017 to an ICU within the state of Florida was performed who were diagnosed with pneumonia. A multivariate regression analysis was performed to adjust for confounders. Time periods were divided into seasons: summer, winter, spring, and fall. A subset analysis of geriatric patients (>65 years) was also performed. RESULTS A total of 869 553 patients were identified. The most common viral infection was influenza with adenovirus the least. The most common bacterial pneumonia was Staphylococcus aureus with Bordetella pertussis the least. Pneumonias had a seasonal variation. Compared to summer, winter had a higher likelihood of pneumonia overall (Adjusted Odds Ratio (AOR)1.13). This was seen in the spring (AOR 1.04) but not in fall (AOR 1.00). Viral infections were more pronounced (AOR 3.79) in all other seasons, while bacterial showed increased likelihood during winter (AOR 1.05). In geriatrics, pneumonia was again more likely in the winter (AOR 1.22) with both viral and bacterial infections being more pronounced during winter (AOR 4.79, AOR 1.09). DISCUSSION Pneumonias are seen more frequently within the ICU during the winter for the traumatized patient. This held true with the critically ill geriatric population as well. This effect was observed in both viral and bacterial pneumonias.
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Affiliation(s)
- Jason M Clark
- Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Medical Education, University of Central Florida, Orlando, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Hamza Durrani
- Department of Medical Education, University of Central Florida, Orlando, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Josh D Hagan
- Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Medical Education, University of Central Florida, Orlando, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Carrie Watson
- Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Medical Education, University of Central Florida, Orlando, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Winston T Richards
- Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Medical Education, University of Central Florida, Orlando, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Dana Taylor
- Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Medical Education, University of Central Florida, Orlando, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
| | - Darwin N Ang
- Department of Surgery, University of South Florida, Tampa, FL, USA.,Department of Medical Education, University of Central Florida, Orlando, FL, USA.,Department of Trauma, Ocala Regional Medical Center, Ocala, FL, USA
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30
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Gu X, Zhou F, Wang Y, Fan G, Cao B. Respiratory viral sepsis: epidemiology, pathophysiology, diagnosis and treatment. Eur Respir Rev 2020; 29:200038. [PMID: 32699026 PMCID: PMC9489194 DOI: 10.1183/16000617.0038-2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/04/2020] [Indexed: 12/11/2022] Open
Abstract
According to the Third International Consensus Definition for Sepsis and Septic Shock, sepsis is a life-threatening organ dysfunction resulting from dysregulated host responses to infection. Epidemiological data about sepsis from the 2017 Global Burden of Diseases, Injuries and Risk Factor Study showed that the global burden of sepsis was greater than previously estimated. Bacteria have been shown to be the predominant pathogen of sepsis among patients with pathogens detected, while sepsis caused by viruses is underdiagnosed worldwide. The coronavirus disease that emerged in 2019 in China and now in many other countries has brought viral sepsis back into the vision of physicians and researchers worldwide. Although the current understanding of the pathophysiology of sepsis has improved, the differences between viral and bacterial sepsis at the level of pathophysiology are not well understood. Diagnosis methods that can broadly differentiate between bacterial and viral sepsis at the initial stage after the development of sepsis are limited. New treatments that can be applied at clinics for sepsis are scarce and this situation is not consistent with the growing understanding of pathophysiology. This review aims to give a brief summary of current knowledge of the epidemiology, pathophysiology, diagnosis and treatment of viral sepsis.
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Affiliation(s)
- Xiaoying Gu
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Fei Zhou
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Yeming Wang
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Guohui Fan
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Bin Cao
- Dept of Pulmonary and Critical Care Medicine, National Clinical Research Center of Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Science, Beijing, China
- Dept of Respiratory Medicine, Capital Medical University, Beijing, China
- Tsinghua University-Peking University Joint Center for Life Sciences, Beijing, China
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Abstract
Immunosuppression is the most commonly used concept to qualify the immune status of patients with either sterile systemic inflammatory response syndrome (SIRS) or sepsis. In this review we attempt to demonstrate that the concept of immunosuppression is an oversimplification of the complex anti-inflammatory response that occurs in patients dealing with a severe sterile or infectious insult. Particularly, the immune status of leukocytes varies greatly depending on the compartment from where they are derived from. Furthermore, although certain functions of immune cells present in the blood stream or in the hematopoietic organs can be significantly diminished, other functions are either unchanged or even enhanced. This juxtaposition illustrates that there is no global defect. The mechanisms called reprogramming or trained innate immunity are probably aimed at preventing a generalized deleterious inflammatory reaction, and work to maintain the defense mechanisms at their due levels.
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32
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Schildermans J, De Vlieger G. Cytomegalovirus: A Troll in the ICU? Overview of the Literature and Perspectives for the Future. Front Med (Lausanne) 2020; 7:188. [PMID: 32500076 PMCID: PMC7243473 DOI: 10.3389/fmed.2020.00188] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/20/2020] [Indexed: 12/12/2022] Open
Abstract
Cytomegalovirus (CMV) is one of the most pathogenic viruses in human. After a primary infection, CMV resides in the host for life as a latent infection. When immunity is reduced, CMV can escape the suppressive effects of the immune system and lead to viremia and antigenemia. This reactivation, first seen in transplant patients, has also been documented in non-immunocompromised CMV-seropositive critically ill patients and is associated with higher morbidity and mortality. In the latter, it is not clear whether CMV reactivation is an innocent bystander or the cause of this observed worse outcome. Two studies showed no difference in the outcome of CMV-seropositive and seronegative patients. In addition, proof-of-concept studies investigating prophylactic antiviral treatment to prevent CMV reactivation during critical illness, failed to show a beneficial effect on interleukin levels or clinical outcome. Further research is necessary to resolve the question whether CMV replication impairs the prognosis in non-immunocompromised critically ill patients. We here give a concise overview on the available data and propose strategies to further unravel this question. First, post-mortem investigation may be useful to evaluate the effect of viral replication on organ inflammation and function. Second, further research should focus on the question whether the level of viremia needs to exceed a threshold to be associated with worse outcome. Third, clinical and biochemical assessments may help to identify patients at high risk for reactivation. Fourth, preemptive treatment based upon early detection of the virus is currently under investigation. Finally, immune-stimulating biologicals may be beneficial in high-risk groups.
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Affiliation(s)
- Jolien Schildermans
- Clinical Division of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greet De Vlieger
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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33
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Cytomegalovirus in Pediatric Sepsis: Should We Care? Pediatr Crit Care Med 2020; 21:396-397. [PMID: 32251188 DOI: 10.1097/pcc.0000000000002209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
OBJECTIVES Reactivation viremia is associated with adverse clinical outcomes and immune dysfunction in adults with sepsis. We determined the incidence of viremia and its association with clinical outcomes and immune paralysis phenotype in children with severe sepsis. DESIGN Prospective cohort study. SETTING Single academic PICU from September 2016 to March 2018. PATIENTS Fifty-nine patients 2-17 years old treated for severe sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed real-time polymerase chain reaction assays on whole blood specimens to determine the incidence of cytomegalovirus. Cytomegalovirus was detected in three patients (5%). All patients with cytomegalovirus viremia were seropositive, with an incidence of 13% in this subset. We additionally performed Epstein-Barr virus and human herpesvirus-6 polymerase chain reaction assays on last available specimens and detected Epstein-Barr virus in 4% and human herpesvirus-6 in 30% of the study population. Overall, viremia was not associated with clinical outcomes or immune function in univariable analyses. However, viremia was associated with lower odds of complicated course (defined as death within 28 d or ≥ 2 organ dysfunctions at 7 d) after controlling for age, Pediatric Risk of Mortality III score, and blood transfusion (adjusted odds ratio, 0.08; 95% CI, 0.01-0.84; p = 0.04). CONCLUSIONS Children with severe sepsis had low rates of detectable viremia, which limited analyses of its association with clinical outcomes or immune paralysis phenotype. Given the rare occurrence of cytomegalovirus viremia, in particular, our study does not support a role for viremia as a biomarker of illness severity or as a modifiable risk factor of clinical outcomes for most patients. Future studies on the role of viremia in pediatric sepsis will need to consider the challenges posed by low rates of viremia in this population.
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35
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Abstract
Cytomegalovirus (CMV) reactivation has been described in adults with critical illness caused by diverse etiologies, especially severe sepsis, and observational studies have linked CMV reactivation with worse clinical outcomes in this setting. In this study, we review observational clinical data linking development of CMV reactivation with worse outcomes in patients in the intensive care unit, discuss potential biologically plausible mechanisms for a causal association, and summarize results of initial interventional trials that examined the effects of CMV prevention. These data, taken together, highlight the need for a randomized, placebo-controlled efficacy trial (1) to definitively determine whether prevention of CMV reactivation improves clinical outcomes of patients with critical illness and (2) to define the underlying mechanism(s).
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Affiliation(s)
- Hannah Imlay
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ajit P Limaye
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
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36
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Hraiech S, Papazian L. Response to Huang et al. "Herpesviridae reactivation for poor outcome in ARDS patients with ECMO: criminal or witness?". Ann Intensive Care 2020; 10:8. [PMID: 31965385 PMCID: PMC6973884 DOI: 10.1186/s13613-020-0627-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/12/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sami Hraiech
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France. .,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France.
| | - Laurent Papazian
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
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37
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Kulkarni A, Bhosale S. Reactivation of Cytomegalovirus: Another thing to worry about? CANCER RESEARCH, STATISTICS, AND TREATMENT 2020. [DOI: 10.4103/crst.crst_95_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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38
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Hraiech S, Bonnardel E, Guervilly C, Fabre C, Loundou A, Forel JM, Adda M, Parzy G, Cavaille G, Coiffard B, Roch A, Papazian L. Herpes simplex virus and Cytomegalovirus reactivation among severe ARDS patients under veno-venous ECMO. Ann Intensive Care 2019; 9:142. [PMID: 31872319 PMCID: PMC6928167 DOI: 10.1186/s13613-019-0616-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 12/09/2019] [Indexed: 12/12/2022] Open
Abstract
Background Herpesviridae reactivation among non-immunocompromised critically ill patients is associated with impaired prognosis, especially during acute respiratory distress syndrome (ARDS). However, little is known about herpes simplex virus (HSV) and Cytomegalovirus (CMV) reactivation occurring in patients with severe ARDS under veno-venous extracorporeal membrane oxygenation (ECMO). We tried to determine the frequency of Herpesviridae reactivation and its impact on patients’ prognosis during ECMO for severe ARDS. Results During a 5-year period, 123 non-immunocompromised patients with a severe ARDS requiring a veno-venous ECMO were included. Sixty-seven patients (54%) experienced HSV and/or CMV reactivation during ECMO course (20 viral co-infection, 40 HSV alone, and 7 CMV alone). HSV reactivation occurred earlier than CMV after the beginning of MV [(6–15) vs. 19 (13–29) days; p < 0.01] and after ECMO implementation [(2–8) vs. 14 (10–20) days; p < 0.01]. In univariate analysis, HSV/CMV reactivation was associated with a longer duration of mechanical ventilation [(22–52.5) vs. 17.5 (9–28) days; p < 0.01], a longer duration of ECMO [15 (10–22.5) vs. 9 (5–14) days; p < 0.01], and a prolonged ICU [29 (19.5–47.5) vs. 16 (9–30) days; p < 0.01] and hospital stay [44 (29–63.5) vs. 24 (11–43) days; p < 0.01] as compared to non-reactivated patients. However, in multivariate analysis, viral reactivation remained associated with prolonged MV only. When considered separately, both HSV and CMV reactivation were associated with a longer duration of MV as compared to non-reactivation patients [29 (19.5–41) and 28 (20.5–37), respectively, vs. 17.5 (9–28) days; p < 0.05]. Co-reactivation patients had a longer duration of MV [58.5 (38–72.3); p < 0.05] and ICU stay [51.5 (32.5–69) vs. 27.5 (17.75–35.5) and 29 (20–30.5), respectively] as compared to patients with HSV or CMV reactivation alone. In multivariate analysis, HSV reactivation remained independently associated with a longer duration of MV and hospital length of stay. Conclusions Herpesviridae reactivation is frequent among patients with severe ARDS under veno-venous ECMO and is associated with a longer duration of mechanical ventilation. The direct causative link between HSV and CMV reactivation and respiratory function worsening under ECMO remains to be confirmed.
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Affiliation(s)
- Sami Hraiech
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France. .,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France.
| | - Eline Bonnardel
- Magellan Medico-Surgical Center, South Department of Anaesthesia and Critical Care, CHU Bordeaux, 33000, Bordeaux, France
| | - Christophe Guervilly
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Cyprien Fabre
- CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Anderson Loundou
- CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Mélanie Adda
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Gabriel Parzy
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Guilhem Cavaille
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Benjamin Coiffard
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Antoine Roch
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Laurent Papazian
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
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Syu SH, Lin YW, Lin KH, Lee LM, Hsiao CH, Wen YC. Risk factors for complications and graft failure in kidney transplant patients with sepsis. Bosn J Basic Med Sci 2019; 19:304-311. [PMID: 30242808 DOI: 10.17305/bjbms.2018.3874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 09/16/2018] [Indexed: 11/16/2022] Open
Abstract
Immunosuppressive therapies decrease the incidence of acute kidney rejection after kidney transplantation, but also increase the risk of infections and sepsis. This study aimed to identify the risk factors associated with complications and/or graft failure in kidney transplant patients with sepsis. A total of 14,658 kidney transplant patients with sepsis, identified in the National Inpatient Sample (NIS) database (data from 2005-2014), were included in the study and classified into three groups: patients without complications or graft failure/dialysis (Group 1), patients with complications only (Group 2), and patients with complications and graft failure/dialysis (Group 3). Multinomial logistic regression analyses were conducted to evaluate factors associated with kidney transplant recipients. Multivariate analysis showed that, compared to Group 1, patients from Group 2 or Group 3 were more likely to be Black and to have cytomegalovirus infection, coagulopathy, and glomerulonephritis (p ≤ 0.041). Also, Group 2 was more likely to have herpes simplex virus infection, and Group 3 was more likely to have hepatitis C infection and peripheral vascular disorders, compared to Group 1 (p ≤ 0.002). In addition, patients in Group 3 were more likely to be Black and to have hepatitis C infection, peripheral vascular disorders, coagulopathy, and hypertension compared to Group 2 (p ≤ 0.039). Age and female gender were associated with lower odds of complications after kidney transplantation regardless of graft rejection/dialysis (p ≤ 0.049). Hyperlipidemia and diabetes decreased the chance of complications and graft failure/dialysis after kidney transplant (p < 0.001). In conclusion, the study highlights that black race, male gender, and specific comorbidities can increase the risk of complications and graft failure in kidney transplant patients with sepsis.
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Affiliation(s)
- Syuan-Hao Syu
- Department of Urology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Mallet F, Perret M, Tran T, Meunier B, Guichard A, Tabone O, Mommert M, Brengel-Pesce K, Venet F, Pachot A, Monneret G, Reynier F, Védrine C, Leissner P, Moucadel V, Lepape A, Textoris J. Early herpes and TTV DNAemia in septic shock patients: a pilot study. Intensive Care Med Exp 2019; 7:28. [PMID: 31104220 PMCID: PMC6525672 DOI: 10.1186/s40635-019-0256-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 05/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Septic shock patients exhibit an increased incidence of viral reactivation. Precise timing of such reactivation-as an early marker of immune suppression, or as a consequence of the later-is not known precisely. Here, using a fully designed nucleic acid extraction automated procedure together with tailored commercial PCR kits, we focused on the description of early reactivation within the first week of ICU admission of several herpes viruses and Torque Teno virus (TTV) in 98 septic shock patients. RESULTS Most of septic shock patients had at least one viremia event during the first week (88%). TTV and herpesviruses were detected in 56% and 53% of septic shock patient, respectively. The two most frequent herpesviruses detected within the first week were EBV (35%) and HSV1 (26%). Different kinetic were observed among herpesviruses, faster for EBV and HSV1 than for CMV and HHV6. Although no association was found between herpes viremia and secondary infections, patients with herpesviridae-related viremia were more severe, e.g., higher SOFA scores and plasma lactate levels. While reactivating only 1 virus was not associated with mortality, patients with multiple viremia events had higher ICU mortality. Surprisingly, EBV + TTV early reactivation seemed associated with a lower D28 mortality. No clear association was observed between viremia and immune biomarkers. CONCLUSION Applying a semi-automated process of viral DNAemia determination to this cohort of 98 patients with septic shock, we observed that the number of patients with positive viremia increased during the first week in the ICU. Of note, there was no improvement in predicting the outcome when using viremia status. Nevertheless, this pilot study, introducing standardized procedures from extraction to detection, provides the basis for future standardized diagnostic criteria. A prospective longitudinal clinical study using these procedures will enable determination of whether such viremia is due to a lack of a latent virus control by the immune system or a true clinical viral infection.
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Affiliation(s)
- François Mallet
- EA 7426 Pathophysiology of Injury-induced Immunosuppression, University of Lyon1-Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 3, France. .,Joint research unit, Hospice Civils de Lyon, bioMérieux, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69310, Pierre-Benite, France.
| | - Magali Perret
- BIOASTER Technology Research Institute, Lyon, France
| | - Trang Tran
- BIOASTER Technology Research Institute, Lyon, France
| | - Boris Meunier
- EA 7426 Pathophysiology of Injury-induced Immunosuppression, University of Lyon1-Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 3, France.,Soladis, Lyon, France
| | - Audrey Guichard
- Joint research unit, Hospice Civils de Lyon, bioMérieux, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69310, Pierre-Benite, France
| | - Olivier Tabone
- EA 7426 Pathophysiology of Injury-induced Immunosuppression, University of Lyon1-Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 3, France
| | - Marine Mommert
- Joint research unit, Hospice Civils de Lyon, bioMérieux, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69310, Pierre-Benite, France
| | - Karen Brengel-Pesce
- Joint research unit, Hospice Civils de Lyon, bioMérieux, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69310, Pierre-Benite, France
| | - Fabienne Venet
- EA 7426 Pathophysiology of Injury-induced Immunosuppression, University of Lyon1-Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 3, France.,Hospices Civils de Lyon, Immunology Laboratory, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Alexandre Pachot
- EA 7426 Pathophysiology of Injury-induced Immunosuppression, University of Lyon1-Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 3, France
| | - Guillaume Monneret
- EA 7426 Pathophysiology of Injury-induced Immunosuppression, University of Lyon1-Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 3, France.,Hospices Civils de Lyon, Immunology Laboratory, Groupement Hospitalier Edouard Herriot, Lyon, France
| | | | | | | | - Virginie Moucadel
- EA 7426 Pathophysiology of Injury-induced Immunosuppression, University of Lyon1-Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 3, France
| | - Alain Lepape
- Intensive Care Unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Bénite, France.,Emerging Pathogens Laboratory, Epidemiology and International Health, International Center for Infectiology Research (CIRI), Lyon, France.,Hospices Civils de Lyon, bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Julien Textoris
- EA 7426 Pathophysiology of Injury-induced Immunosuppression, University of Lyon1-Hospices Civils de Lyon-bioMérieux, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69437, Lyon Cedex 3, France. .,Hospices Civils de Lyon, Department of Anaesthesiology and Critical Care Medicine, Groupement Hospitalier Edouard Herriot, Université Claude Bernard Lyon 1, Lyon, France.
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Marandu T, Dombek M, Cook CH. Impact of cytomegalovirus load on host response to sepsis. Med Microbiol Immunol 2019; 208:295-303. [DOI: 10.1007/s00430-019-00603-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/22/2019] [Indexed: 12/24/2022]
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Gardiner BJ, Herrick KW, Bailey RC, Chow JK, Snydman DR. Reactivation of Latent Cytomegalovirus Infection after Major Surgery: Risk Factors and Outcomes. Surg Infect (Larchmt) 2019; 20:416-423. [PMID: 30912706 DOI: 10.1089/sur.2018.245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Reactivation of latent cytomegalovirus (CMV) infection occurs in previously immunocompetent critically ill individuals and may be associated with increased morbidity and mortality. Our aim was to explore risk factors for and outcomes after CMV reactivation in patients undergoing major surgery. Patients and Methods: We performed a retrospective case control study of patients without underlying immunocompromise who developed post-operative CMV reactivation from 2004-2016. Cases included patients testing positive for CMV by viral load, culture, or histopathology. Controls were matched by age, gender, type, and year of surgery. Results: Sixteen CMV cases were matched to 32 controls. Median age was 65 and median time from surgery to CMV diagnosis was 32 days. Symptoms included fever (94%), hepatitis (75%), myelosuppression (56%), and diarrhea (38%). Despite similar baseline comorbidities, cases were more likely to return to surgery (odds ratio [OR] 6.31; 95% confidence interval [CI], 1.29-30.74), require renal replacement therapy (OR 18.54; 95% CI, 2.36-145.6), total parenteral nutrition (OR 33.0; 95% CI, 6.60-262.37) and corticosteroids (OR 18.78; 95% CI, 4.5-103.9). Length of stay was increased (median 51 vs. 8 days, p = 0.005), co-infections were more common (OR 15.10; 95% CI, 1.89-120.8), and mortality was higher (38% vs. 0%, p < 0.01). Conclusions: Cytomegalovirus reactivation occurs in previously immunocomptent patients post-operatively and is associated with poor outcomes including other infections and mortality. Potential risk factors include prolonged length of stay, surgical complications, and corticosteroid use. It is not clear from our study whether CMV reactivation is a surrogate marker of severe illness and post-operative complications or if CMV reactivation plays a causative role in the development of these adverse outcomes.
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Affiliation(s)
- Bradley J Gardiner
- 1 Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts.,2 Tufts University School of Medicine, Boston, Massachusetts
| | | | | | - Jennifer K Chow
- 1 Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts.,2 Tufts University School of Medicine, Boston, Massachusetts
| | - David R Snydman
- 1 Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts.,2 Tufts University School of Medicine, Boston, Massachusetts.,3 Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
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Li Y, Ren L, Liu X, Zhao X, Hu F, Li Z. Pulse corticosteroids in treatment of rheumatic disease concomitant with cytomegalovirus infection. Int J Rheum Dis 2019; 22:583-591. [PMID: 30740904 DOI: 10.1111/1756-185x.13467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 10/19/2017] [Accepted: 12/19/2018] [Indexed: 11/30/2022]
Abstract
AIM To investigate the impact of corticosteroids on the outcome of antiviral therapy in rheumatic patients with cytomegalovirus (CMV)-emia. METHOD Sixty-two patients with rheumatic disease complicated by CMV infection from 2011 to 2014 were retrospectively analyzed. RESULTS Fifty-five of 62 patients were diagnosed with CMV-DNAemia. Most patients (43/55, 78.2%) achieved viral clearance within 5 weeks. It was shown that, while undergoing active antiviral therapy, there was no significant difference in the CMV-DNAemia clearance rate between the pulse methylprednisolone (MPSL) therapy group and non-pulse group (8/9, 88.9% vs 30/36, 83.3%; OR = 1.600, 95% CI 0.168-15.273, P > 0.05) at the end of the 5-week follow-up. However, pulse MPSL might slightly prolong duration of CMV-DNAemia than non-pulse MPSL patients (20.78 ± 19.18 days vs 14.33 ± 9.01 days, P = 0.1430), especially in the high baseline titer group (33.7 ± 29.1 days in pulse MPSL group vs 18.3 ± 13.1 days in non-pulse group, P = 0.457). But in the low baseline titer group, CMVemia duration in the pulse MPSL group (14.3 ± 10.0 days) was about the same as that in the non-pulse MPSL group (13.4 ± 7.8 days). CONCLUSION With effective antiviral therapy, pulse MPSL is acceptable in rheumatic disease patients with CMV-DNAemia, without significant impact on final clearance of virus. However, duration of CMV-DNAemia may be prolonged, especially in patients with high CMV-DNA titer at baseline.
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Affiliation(s)
- Yan Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Limin Ren
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Xu Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Xiaotao Zhao
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Fanlei Hu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Peking-Tsinghua Center for Life Sciences, Beijing, China
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Specific sequences of infectious challenge lead to secondary hemophagocytic lymphohistiocytosis-like disease in mice. Proc Natl Acad Sci U S A 2019; 116:2200-2209. [PMID: 30674681 DOI: 10.1073/pnas.1820704116] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Secondary hemophagocytic lymphohistiocytosis (sHLH) is a highly mortal complication associated with sepsis. In adults, it is often seen in the setting of infections, especially viral infections, but the mechanisms that underlie pathogenesis are unknown. sHLH is characterized by a hyperinflammatory state and the presence hemophagocytosis. We found that sequential challenging of mice with a nonlethal dose of viral toll-like receptor (TLR) agonist followed by a nonlethal dose of TLR4 agonist, but not other permutations, produced a highly lethal state that recapitulates many aspects of human HLH. We found that this hyperinflammatory response could be recapitulated in vitro in bone marrow-derived macrophages. RNA sequencing analyses revealed dramatic up-regulation of the red-pulp macrophage lineage-defining transcription factor SpiC and its associated transcriptional program, which was also present in bone marrow macrophages sorted from patients with sHLH. Transcriptional profiling also revealed a unique metabolic transcriptional profile in these macrophages, and immunometabolic phenotyping revealed impaired mitochondrial function and oxidative metabolism and a reliance on glycolytic metabolism. Subsequently, we show that therapeutic administration of the glycolysis inhibitor 2-deoxyglucose was sufficient to rescue animals from HLH. Together, these data identify a potential mechanism for the pathogenesis of sHLH and a potentially useful therapeutic strategy for its treatment.
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Xie J, Crepeau RL, Chen CW, Zhang W, Otani S, Coopersmith CM, Ford ML. Sepsis erodes CD8 + memory T cell-protective immunity against an EBV homolog in a 2B4-dependent manner. J Leukoc Biol 2019; 105:565-575. [PMID: 30624806 DOI: 10.1002/jlb.4a0718-292r] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/28/2018] [Accepted: 12/12/2018] [Indexed: 12/20/2022] Open
Abstract
Epstein-Barr virus (EBV) reactivation commonly occurs following sepsis, but the mechanisms underlying this are unknown. We utilized a murine EBV homolog (gHV) and the cecal ligation and puncture model of polymicrobial sepsis to study the impact of sepsis on gHV reactivation and CD8+ T cell immune surveillance following a septic insult. We observed a significant increase in the frequency of gHV-infected germinal center B cells on day 7 following sepsis. This increase in viral load was associated with a concomitant significant decrease in the frequencies of gHV-specific CD8+ T cells, as measured by class I MHC tetramers corresponding to the immunodominant viral epitopes. Phenotypic analysis revealed an increased frequency of gHV-specific CD8+ T cells expressing the 2B4 coinhibitory receptor in septic animals compared with sham controls. We sought to interrogate the role of 2B4 in modulating the gHV-specific CD8+ T cell response during sepsis. Results indicated that in the absence of 2B4, gHV-specific CD8+ T cell populations were maintained during sepsis, and gHV viral load was unchanged in 2B4-/- septic animals relative to 2B4-/- sham controls. WT CD8+ T cells upregulated PD-1 during sepsis, whereas 2B4-/- CD8+ T cells did not. Finally, adoptive transfer studies revealed a T cell-intrinsic effect of 2B4 coinhibition on virus-specific CD8+ T cells and gHV viral load during sepsis. These data demonstrate that sepsis-induced immune dysregulation erodes antigen-specific CD8+ responses against a latent viral infection and suggest that blockade of 2B4 may better maintain protective immunity against EBV in the context of sepsis.
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Affiliation(s)
- Jianfeng Xie
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rebecca L Crepeau
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ching-Wen Chen
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wenxiao Zhang
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shunsuke Otani
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Craig M Coopersmith
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mandy L Ford
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA.,Emory Transplant Center, Emory University School of Medicine, Atlanta, Georgia, USA
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van de Groep K, Nierkens S, Cremer OL, Peelen LM, Klein Klouwenberg PMC, Schultz MJ, Hack CE, van der Poll T, Bonten MJM, Ong DSY. Effect of cytomegalovirus reactivation on the time course of systemic host response biomarkers in previously immunocompetent critically ill patients with sepsis: a matched cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:348. [PMID: 30563551 PMCID: PMC6299562 DOI: 10.1186/s13054-018-2261-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 11/12/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) reactivation in previously immunocompetent critically ill patients is associated with increased mortality, which has been hypothesized to result from virus-induced immunomodulation. Therefore, we studied the effects of CMV reactivation on the temporal course of host response biomarkers in patients with sepsis. METHODS In this matched cohort study, each sepsis patient developing CMV reactivation between day 3 and 17 (CMV+) was compared with one CMV seropositive patient without reactivation (CMVs+) and one CMV seronegative patient (CMVs-). CMV serostatus and plasma loads were determined by enzyme-linked immunoassays and real-time polymerase chain reaction, respectively. Systemic interleukin-6 (IL-6), IL-8, IL-18, interferon-gamma-induced protein-10 (IP-10), neutrophilic elastase, IL-1 receptor antagonist (RA), and IL-10 were measured at five time points by multiplex immunoassay. The effects of CMV reactivation on sequential concentrations of these biomarkers were assessed in multivariable mixed models. RESULTS Among 64 CMV+ patients, 45 could be matched to CMVs+ or CMVs- controls or both. The two baseline characteristics and host response biomarker levels at viremia onset were similar between groups. CMV+ patients had increased IP-10 on day 7 after viremia onset (symmetric percentage difference +44% versus -15% when compared with CMVs+ and +37% versus +4% when compared with CMVs-) and decreased IL-1RA (-41% versus 0% and -49% versus +10%, respectively). However, multivariable analyses did not show an independent association between CMV reactivation and time trends of IL-6, IP-10, IL-10, or IL-1RA. CONCLUSION CMV reactivation was not independently associated with changes in the temporal trends of host response biomarkers in comparison with non-reactivating patients. Therefore, these markers should not be used as surrogate clinical endpoints for interventional studies evaluating anti-CMV therapy.
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Affiliation(s)
- Kirsten van de Groep
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands. .,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
| | - Stefan Nierkens
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Linda M Peelen
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.,Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Peter M C Klein Klouwenberg
- Division of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ , Amsterdam, the Netherlands
| | - C Erik Hack
- Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Tom van der Poll
- Center of Experimental and Molecular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.,Division of Infectious Diseases, Amsterdam University Medical Centers, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Marc J M Bonten
- Division of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - David S Y Ong
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.,Department of Medical Microbiology and Infection Control, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045 PM, Rotterdam, the Netherlands
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Atalan N, Acar L, Yapici N, Kudsioglu T, Ergen A, Yilmaz SG, Isbir T. The Relationship Between Sepsis-induced Immunosuppression and Serum Toll-like Receptor 9 Level. In Vivo 2018; 32:1653-1658. [PMID: 30348730 PMCID: PMC6365731 DOI: 10.21873/invivo.11428] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 07/25/2018] [Accepted: 08/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIM Our aim was to determine serum TLR-9 levels in sepsis and evaluate the relationship between sepsis and serum TLR-9 levels. MATERIALS AND METHODS The study group consisted of 80 consecutive patients with sepsis and 100 healthy individuals. The demographic characteristics, co-morbidities and hemodynamic data of all patients were recorded. RESULTS TLR-9 serum levels in sepsis were statistically significantly lower compared to the control group. It was also seen that when the lactate level was >5 mmol/l in patients in the sepsis group, the serum TLR-9 levels were substantially higher. CONCLUSION There is a relationship between sepsis-induced immunosuppression and serum TLR-9 levels. The host immunity system can be activated by means of TLR-9-related systems, while hyperlactatemia may play a stimulating role in the re-activation of the immune system.
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Affiliation(s)
- Nazan Atalan
- Department of Anesthesiology, Marmara University Vocational School of Health Services, Istanbul, Turkey
| | - Leyla Acar
- Department of Molecular Medicine, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Nihan Yapici
- Department of Anesthesiology, Dr Siyami Ersek Thoracic and Cardiovascular Training and Research Hospital, Istanbul, Turkey
| | - Turkan Kudsioglu
- Department of Anesthesiology, Dr Siyami Ersek Thoracic and Cardiovascular Training and Research Hospital, Istanbul, Turkey
| | - Arzu Ergen
- Department of Molecular Medicine, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Seda Gulec Yilmaz
- Department of Molecular Medicine, Health Science Institute, Yeditepe University, Istanbul, Turkey
| | - Turgay Isbir
- Department of Molecular Medicine, Yeditepe University, Istanbul, Turkey
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Li X, Huang Y, Xu Z, Zhang R, Liu X, Li Y, Mao P. Cytomegalovirus infection and outcome in immunocompetent patients in the intensive care unit: a systematic review and meta-analysis. BMC Infect Dis 2018; 18:289. [PMID: 29954328 PMCID: PMC6027797 DOI: 10.1186/s12879-018-3195-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 06/18/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is common in immunocompetent patients in intensive care units (ICUs). However, whether CMV infection or CMV reactivation contributes to mortality of immunocompetent patients remains unclear. METHODS A literature search was conducted for relevant studies published before May 30, 2016. Studies reporting on CMV infection in immunocompetent patients in ICUs and containing 2 × 2 tables on CMV results and all-cause mortality were included. RESULTS Eighteen studies involving 2398 immunocompetent patients admitted to ICUs were included in the meta-analysis. The overall rate of CMV infection was 27% (95%CI 22-34%, I2 = 89%, n = 2398) and the CMV reactivation was 31% (95%CI 24-39%, I2 = 74%, n = 666). The odds ratio (OR) for all-cause mortality among patients with CMV infection, compared with those without infection, was 2.16 (95%CI 1.70-2.74, I2 = 10%, n = 2239). Moreover, upon exclusion of studies in which antiviral treatment was possibly or definitely provided to some patients, the association of mortality rate with CMV infection was also statistically significant (OR: 1.69, 95%CI 1.01-2.83, I2 = 37%, n = 912,). For CMV seropositive patients, the OR for mortality in patients with CMV reactivation as compared with patients without CMV reactivation was 1.72 (95%CI 1.04-2.85, I2 = 29%, n = 664). Patients with CMV infection required significantly longer mechanical ventilation (mean difference (MD): 9 days (95% CI 5-14, I2 = 81%, n = 875)) and longer duration of ICU stay (MD: 12 days (95% CI 7-17, I2 = 70%, n = 949)) than patients without CMV infection. When analysis was limited to detection in blood, CMV infection without antiviral drug treatment or reactivation was not significantly associated with higher mortality (OR: 1.69, 95%CI 0.81-3.54, I2 = 52%, n = 722; OR: 1.49, I2 = 63%, n = 469). CONCLUSION Critically ill patients without immunosuppression admitted to ICUs show a high rate of CMV infection. CMV infection during the natural unaltered course or reactivation in critically ill patients is associated with increased mortality, but have no effect on mortality when CMV in blood. More studies are needed to clarify the impact of CMV infection on clinical outcomes in those patients.
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Affiliation(s)
- Xi Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University (Guangzhou Medical University), Guangzhou, China.,Intensive Care Unit, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yongbo Huang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University (Guangzhou Medical University), Guangzhou, China.,Intensive Care Unit, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhiheng Xu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University (Guangzhou Medical University), Guangzhou, China.,Intensive Care Unit, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Rong Zhang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University (Guangzhou Medical University), Guangzhou, China.,Intensive Care Unit, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xiaoqing Liu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University (Guangzhou Medical University), Guangzhou, China.,Intensive Care Unit, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yimin Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University (Guangzhou Medical University), Guangzhou, China. .,Intensive Care Unit, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
| | - Pu Mao
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Disease, the First Affiliated Hospital of Guangzhou Medical University (Guangzhou Medical University), Guangzhou, China. .,Department of Infection Control, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
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Demirkol D, Kavgacı U, Babaoğlu B, Tanju S, Oflaz Sözmen B, Tekin S. Cytomegalovirus reactivation in a critically ill patient: a case report. J Med Case Rep 2018; 12:163. [PMID: 29886847 PMCID: PMC5994649 DOI: 10.1186/s13256-018-1681-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 04/07/2018] [Indexed: 11/13/2022] Open
Abstract
Background The aim of this case report is to discuss diagnostic workup and clinical management of cytomegalovirus reactivation in a critically ill immunocompetent pediatric patient. Case presentation A 2-year-old white boy who had no medical history presented with respiratory distress and fever. His Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores were 20 and 11, respectively. Our preliminary diagnosis was multiple organ dysfunction secondary to sepsis. Antibiotic treatment was started; he was intubated and artificially ventilated. Norepinephrine infusion was started. Hemophagocytic lymphohistiocytosis was diagnosed because our patient had elevated levels of serum ferritin, bicytopenia, splenomegaly, fever (> 38.5 °C), and hemophagocytosis shown in a bone marrow sample. Therapeutic plasma exchange and intravenously administered high-dose corticosteroid for hemophagocytic lymphohistiocytosis and continuous renal replacement treatment for acute renal failure were initiated. Following 5-day high-dose corticosteroid administration, therapeutic plasma exchange, and continuous renal replacement treatment, his clinical status and kidney and liver functions improved, and vasoactive requirement and ferritin levels decreased. He was extubated on the seventh day. On the tenth day of hospitalization he had a seizure and was diagnosed as having septic encephalopathy. His immune functions were found to be normal. Although his medical condition improved continuously, he had left spontaneous pneumothorax on the 21st day of admission as a complication of necrotizing pneumonia. Since pneumothorax persisted, left upper lobectomy surgery was performed on the 30th day of hospitalization. In the pathological examination of the excised lung tissue, features of cytomegalovirus infection were observed. Ganciclovir treatment was started. Serological tests indicated that our patient had cytomegalovirus reactivation. Antiviral treatment was stopped after 17 days, when cytomegalovirus deoxyribonucleic acid (DNA) polymerase chain reaction results became negative. He fully recovered and was discharged on the 50th day of admission. Conclusions Cytomegalovirus reactivation in critically ill patients is a prevalent problem and shown to be associated with higher mortality and morbidity. In a case of serologic detection of cytomegalovirus reactivation without any clinical sign of infection, pre-emptive treatment could be considered with assessment of risks and benefits for each patient. Antiviral therapy is highly recommended for patients who have risk factors identified.
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Affiliation(s)
- Demet Demirkol
- Istanbul University Istanbul Faculty of Medicine, Department of Pediatrics, Division of Pediatric Intensive Care, Istanbul, Turkey. .,Koç University School of Medicine, Department of Pediatrics, Division of Pediatric Intensive Care, Istanbul, Turkey.
| | - Umay Kavgacı
- Koç University School of Medicine, Istanbul, Turkey
| | | | - Serhan Tanju
- Koç University School of Medicine, Department of Thoracic Surgery, Istanbul, Turkey
| | - Banu Oflaz Sözmen
- Koç University School of Medicine, Department of Pediatrics, Division of Pediatric Hematology and Oncology, Istanbul, Turkey
| | - Suda Tekin
- Koç University School of Medicine, Department of Infectious Diseases, Istanbul, Turkey
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Alyazidi R, Murthy S, Slyker JA, Gantt S. The Potential Harm of Cytomegalovirus Infection in Immunocompetent Critically Ill Children. Front Pediatr 2018; 6:96. [PMID: 29692984 PMCID: PMC5902572 DOI: 10.3389/fped.2018.00096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/26/2018] [Indexed: 12/17/2022] Open
Abstract
Cytomegalovirus (CMV) is a ubiquitous infection that causes disease in congenitally infected children and immunocompromised patients. Although nearly all CMV infections remain latent and asymptomatic in immunologically normal individuals, numerous studies have found that systemic viral reactivation is common in immunocompetent critically ill adults, as measured by detection of CMV in the blood (viremia). Furthermore, CMV viremia is strongly correlated with adverse outcomes in the adult intensive care unit (ICU), including prolonged stay, duration of mechanical ventilation, and death. Increasing evidence, including from a randomized clinical trial of antiviral treatment, suggests that these effects of CMV may be causal. Therefore, interventions targeting CMV might improve outcomes in adult ICU patients. CMV may have an even greater impact on critically ill children, particularly in low and middle income countries (LMIC), where CMV is regularly acquired in early childhood, and where inpatient morbidity and mortality are inordinately high. However, to date, there are few data regarding the clinical relevance of CMV infection or viremia in immunocompetent critically ill children. We propose that CMV infection should be studied as a potential modifiable cause of disease in critically ill children, and that these studies be conducted in LMIC. Below, we briefly review the role of CMV in immunologically normal critically ill adults and children, outline age-dependent differences in CMV infection that may influence ICU outcomes, and describe an agenda for future research.
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Affiliation(s)
- Raidan Alyazidi
- University of British Columbia and BC Children's Hospital, Vancouver, BC, Canada.,Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Srinivas Murthy
- University of British Columbia and BC Children's Hospital, Vancouver, BC, Canada
| | | | - Soren Gantt
- University of British Columbia and BC Children's Hospital, Vancouver, BC, Canada
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