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Transcript
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-