Download and ejection fraction were recovered dur

and ejection fraction were recovered during tigecycline and levosimendan therapy.
It is also of note that, despite the recently
described evolution of resistance of MDR
gram-negative organisms to tigecycline
[1], the tigecycline MIC remained unchanged in all K. pneumoniae isolates during the management of our mediastinitis
case. These data may prove to be essential
for managing serious MDR infections that
require prolonged courses of antimicrobial therapy.
Acknowledgments
We thank Drs. S. Tsiplakou and A. Koutsoukou,
for providing the clinical isolates of the study, and
Drs. A. Ikonomidis and S. Pournaras, for genotyping the isolates.
Potential conflicts of interest. All authors: no
conflicts.
Penelope Evagelopoulou,1 Pavlos Myrianthefs,1
Antonios Markogiannakis,2
George Baltopoulos,1 and Athanassios Tsakris2
1
Intensive Care Unit, KAT Hospital, Nursing School,
University of Athens, Kifissia, and 2Department of
Microbiology, Medical School, University of Athens,
Athens, Greece
References
1. Anthony KB, Fishman NO, Linkin DR, Gasink
LB, Edelstein PH, Lautenbach E. Clinical and
microbiological outcomes of serious infections
with multidrug-resistant gram-negative organisms treated with tigecycline. Clin Infect Dis
2008; 46:567–70.
2. Sjogren J, Malmsjo M, Gustafsson R, Ingemansson R. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation
of the Lund University Hospital mediastinitis
algorithm. Eur J Cardiothorac Surg 2006; 30:
898–905.
3. Babinchak T, Ellis-Grosse E, Dartois N, Rose
GM, Loh E. The efficacy and safety of tigecycline for the treatment of complicated intra-abdominal infections: analysis of pooled clinical
trial data. Clin Infect Dis 2005; 41(Suppl 5):
354–67.
4. Swoboda S, Ober M, Hainer C, et al. Tigecycline
for the treatment of patients with severe sepsis
or septic shock: a drug use evaluation in a surgical intensive care unit. J Antimicrob Chemother 2008; 61:729–33.
Reprints or correspondence: Prof. Athanassios Tsakris, Dept.
of Microbiology, Medical School, University of Athens, 75
Mikras Asias St., 11527 Athens, Greece (atsakris@med
.uoa.gr).
Clinical Infectious Diseases 2008; 46:1932–3
2008 by the Infectious Diseases Society of America. All
rights reserved. 1058-4838/2008/4612-0024$15.00
DOI: 10.1086/588557
Respiratory Syncytial Virus
Infection in Patients with
Cancer: Still More Questions
Than Answers
To the Editor—Khanna et al. [1] recently reported single-center results in a
study of respiratory syncytial virus (RSV)
infection in adult patients with hematological malignancies. The article discusses
the clinical consequences of RSV infection
and its management in severely immunocompromised patients. Here, we add
our experience and comment on some important aspects of this infection.
During a prospective study investigating RSV infection in hospitalized children
[2], 39 microbiologically confirmed RSV
infections were documented among pediatric patients with cancer who received
treatment at our institution. Conclusive
information on these 39 children is given
in table 1. In contrast to the 18% attributable mortality rate in the more severely
immunocompromised population studied
by Khanna et al. [1], none of our patients
died secondary to RSV infection. One 8year-old girl with acute myeloid leukemia
experienced acute respiratory failure due
to RSV infection and had to be given mechanical ventilation. She persistently displayed intermittent wheezing and right
upper lobe atelectasis for 3 months. Two
patients were given treatment with oral
ribavirin. One infant with refractory acute
lymphoblastic leukemia received a single
dose of palivizumab (20 mg/kg by intravenous infusion) without any significant
effect on her clinical course.
RSV infection in pediatric patients with
cancer who are currently being given treatment with nonmyeloablative conventional
chemotherapy may result in significant
complications and additional days of inpatient treatment (table 1). It may be the
only cause of fever in a patient, but because of diagnostic uncertainties, intravenous treatment with antibiotics is mandatory, particularly for patients with
neutropenia or pneumonia.
In 25 (64%) of our 39 patients, the next
chemotherapy session had to be postponed because of RSV infection. This may
result in decreased dose intensity, with a
negative impact on the treatment perspective for the underlying malignancy. In
addition, droplet precautions and strict
isolation have to be instituted to avoid
nosocomial transmission [3], which was
the origin of the infection in a significant
number of our patients (9 patients
[23%]). Viral shedding, detected by antigen testing, was prolonged for up to 43
days (data not shown).
Mainly because of safety and compliance issues and technical difficulties, it is
not feasible to give nonintubated infants
and young children treatment with ribavirin inhalation delivered at a concentration of 20 mg/mL for 18 h via a smallparticle aerosol generator unit and
administered via a face mask inside a scavenging tent to prevent environmental contamination [4, 5]. In addition, the objective benefit of this intervention is still
under debate [6]. In patients with severe
pneumonia due to RSV infection, intravenous administration of ribavirin may be
an option [7].
Although Chávez-Bueno et al. [8] reported favorable preliminary data on
combination treatment (ribavirin and intravenous palivizumab), de Fontbrune et
al. [9] could not demonstrate a significant
impact of palivizumab on the clinical
course and survival of 19 allogeneic stem
cell transplant recipients with RSV infection. Considering the very limited options
for highly immunocompromised patients
[5, 10], a prospective, randomized, multicenter study of motavizumab—an ultrapotent, affinity-matured, humanized
CORRESPONDENCE • CID 2008:46 (15 June) • 1933
Table 1.
cancer.
Data on 39 respiratory syncytial virus (RSV)–infected pediatric patients with
Characteristic
Value
4.
Malignancy
Leukemia
Acute lymphoblastic leukemia
25 (64)
17 (44)
Acute myeloid leukemia
Non-Hodgkin lymphoma
8 (21)
5 (13)
Solid tumor (except CNS tumor)
CNS tumor
2 (5)
2 (5)
Other malignancy
Receipt of solid-organ transplant
5.
6.
2 (5)
3 (8)
a
Leukocyte count at diagnosis, 109 leukocytes/L
Median (range)
IQR
3.8 (300–62,500)
1.9–5.5
b
a
Neutropenia at diagnosis
Body temperature
7.
6 (15)
138.5C
21 (54)
139C
14 (36)
a
Tachypnea at diagnosis
c
8.
25 (64)
a
Hypoxemia at diagnosis
Underwent radiologic examination of the chest
Pneumonia confirmed by radiologic examination of the chest
Received antibiotic treatment
5
30
10
26
Received supplemental oxygen
Admitted to pediatric intensive care unit
17 (44)
5 (13)
Received mechanical ventilation
Hospitalization attributed to RSV infection, inpatient days
Median (range)
IQR
Mortality, %
All cause
(13)
(77)
(26)
(67)
9.
1 (3)
10.
7 (2–35)
5–11
5
Related to RSV infection
0
NOTE. Data are no. (%) of patients, unless otherwise indicated. There were 17 male patients and 22
female patients. The median age at diagnosis of RSV infection was 33 months (interquartile range [IQR],
20–72 months; range, 4–217 months).
a
Diagnosis of RSV infection.
Leukocyte count ! 1.0 ⫻ 109 leukocytes/L and no differential blood cell count available or neutrophil
count ! 0.5 ⫻ 109 neutrophils/L.
c
Transcutaneously measured hemoglobin saturation (tcSO2) level !94%.
11.
tion: impact of prospective surveillance and
targeted infection control. Int J Hyg Environ
Health 2006; 209:317–24.
Hicks KL, Chemaly RF, Kontoyiannis DP.
Common community respiratory viruses in
patients with cancer: more than just “common
colds.” Cancer 2003; 97:2576–87.
Hirsch HH, Steffen I, Francioli P, Widmer AF.
Respiratory syncytial virus infections: measures in immunocompromised patients [in
German]. Schweiz Rundsch Med Prax 2006;
95:61–6.
Boeckh M, Englund J, Li Y, et al. Randomized
controlled multicenter trial of aerosolized ribavirin for respiratory syncytial virus upper
respiratory tract infection in hematopoietic
cell transplant recipients. Clin Infect Dis
2007; 44:245–9.
Raza K, Ismailjee SB, Crespo M, et al. Successful outcome of human metapneumovirus
(hMPV) pneumonia in a lung transplant recipient treated with intravenous ribavirin. J
Heart Lung Transplant 2007; 26:862–4.
Chávez-Bueno S, Mejı́as A, Merryman RA,
Ahmad N, Jafri HS, Ramilo O. Intravenous
palivizumab and ribavirin combination for respiratory syncytial virus disease in high-risk
pediatric patients. Pediatr Infect Dis J 2007;
26:1089–93.
de Fontbrune FS, Robin M, Porcher R, et al.
Palivizumab treatment of respiratory syncytial
virus infection after allogeneic hematopoietic
stem cell transplantation. Clin Infect Dis
2007; 45:1019–24.
Whimbey E, Champlin RE, Englund JA, et al.
Combination therapy with aerosolized ribavirin and intravenous immunoglobulin for respiratory syncytial virus disease in adult bone
marrow transplant recipients. Bone Marrow
Transplant 1995; 16:393–9.
Wu H, Pfarr DS, Johnson S, et al. Development of motavizumab, an ultra-potent antibody for the prevention of respiratory syncytial virus infection in the upper and lower
respiratory tract. J Mol Biol 2007; 368:652–65.
b
monoclonal antibody [11]—should be debated for cases of RSV infection.
Acknowledgments
Potential conflicts of interest. The DSM RSV
Paed Study, of which A.S. has been the principal
investigator, has been supported by a grant from
Abbott GmbH. All other authors: no conflicts.
Arne Simon,1 Oliver Schildgen,2
Marcus Panning,2 Udo Bode,1
and Anna Maria Eis-Huebinger2
Children’s Hospital Medical Center and 2Institute
of Virology, University of Bonn, Bonn, Germany
1
References
1. Khanna N, Widmer AF, Decker M, et al. Respiratory syncytial virus infection in patients
with hematological diseases: single-center
study and review of the literature. Clin Infect
Dis 2008; 46:402–12.
2. Simon A, Muller A, Khurana K, et al. Nosocomial infection: a risk factor for a complicated course in children with respiratory syncytial virus infection—results from a
prospective multicenter German surveillance
study. Int J Hyg Environ Health 2007; published online 13 September.
3. Simon A, Khurana K, Wilkesmann A, et al.
Nosocomial respiratory syncytial virus infec-
1934 • CID 2008:46 (15 June) • CORRESPONDENCE
Reprints or correspondence: Dr. Arne Simon, Pediatric Hematology and Oncology, Infectious Diseases, Children’s Hospital Medical Center, University of Bonn, Adenauerallee 119,
53113 Bonn, Germany ([email protected]).
Clinical Infectious Diseases 2008; 46:1933–4
2008 by the Infectious Diseases Society of America. All
rights reserved. 1058-4838/2008/4612-0025$15.00
DOI: 10.1086/588559
Respiratory Syncytial
Virus Infection in
Immunocompromised
Patients Revisited
To the Editor—We read with great interest the letter from Simon et al. [1] reporting respiratory syncytial virus (RSV)
infection in 39 immunocompromised pe-