Antiviral Prophylaxis after Transplantation

The post transplant period is dangerous because of immunosuppression and there is high risk of various infections after transplantation. The most dangerous and difficult to treat are viral infections. Post transplantation prophylaxis, however, is not a simple matter because of the potential toxicity of treatments in very ill patients. Ribavirin alone is not currently considered appropriate for post-transplant prophylaxis without evidence of infection. The respiratory viruses (eg, RSV, influenza, parainfluenza, rhinovirus) do not have a standard treatment protocol. Ribavirin treatment has been attempted (15-20 mg/kg/d IV divided q8h or the inhalation form). Success of ribavirin in treating these infections has been inconsistent. Most information on such use is in a case report form.

In two recent studies, the addition of RSV immune globulin (palivizumab at 15 mg/kg IM monthly) to traditional ribavirin therapy has shown promise in preventing the progression of RSV upper respiratory infection (URI) to lower respiratory disease and also in the treatment of RSV pneumonia. The key is being vigilant about URI and making the diagnosis quickly. It is imperative to determine the etiology of a URI in an HCT recipient, if possible, because respiratory syncytial virus (RSV), influenza, parainfluenza, and adenovirus URIs can progress to more serious lower respiratory infections. Appropriate diagnostic samples include nasopharyngeal washes, swabs or aspirates; throat swabs (in combination with nasal samples); and bronchoalveolar lavage (BAL) fluid. Without an URI, prophylactic use of Ribavirin is experimental.

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