Ribavirin Prophylaxis Post-allogeneic Transplant – pro

The immediate post stem cell transplantation period is a dangerous time in which the patient is immunocompromised and susceptible to infections. Viral infections are among the most dangerous because they are difficult to treat. Unfortunately not much is know about prophylaxis. Ribavirin alone is not appropriate for post-transplant prophylaxis without evidence of infection because supporting literature is scant. 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, but it is well reported and it is the only FDA approved treatment for RSV infection.

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 stem cell recipient, if possible, because respiratory syncytial virus (RSV), influenza, parainfluenza, and adenovirus URIs can progress to more serious Lower Respiratory Infection. Appropriate routine diagnostic samples to investigate URO in recent transplant recipients 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 alone is currently experimental. Combinations with immunomodulators appear more effective than ribavirin alone for active infection.

A recent review (Jharna et al) enunciated some concerns about the few available studies of oral ribaviarin for HSCT recipients. Oral ribavirin has been shown be well tolerated in HSCT patients with RSV infection. It is well absorbed, with 50% bioavailability through first-pass metabolism. It is less costly than the intravenous and the aerosolized forms and does not require hospitalization of the patient. However, the use of oral ribavirin has often been associated with the development of anemia, which is usually reversible with no delay in engraftment, and with nausea. Moreover, absorption of oral ribavirin in patients with GVHD may not be optimal and was not studied. This may account for worse outcomes in the studies involving oral ribavirin. Prophylactic ribavivrin is not supported by guidelines after the immediate post transplant period and certainly no longer than a year.

J

Jharna N. Shah and Roy F. Chemaly, Management of RSV infections in adult recipients of hematopoietic stem cell transplantation
Blood March 10, 2011 vol. 117 no. 10 2755-2763

D. McCoy, E. Wong, A.G. Kuyumjian, M.A. Wynd, R. Sebti, G.B. Munk. Treatment of respiratory syncytial virus infection in adult patients with hematologic malignancies based on an institution-specific guideline. Transpl Infect Dis 2011: 13: 117–121.

Marcie Tomblyn, Tom Chiller, Hermann Einsele, Ronald Gress, Kent Sepkowitz, Jan Storek,
John R. Wingard, Jo-Anne H. Young, Michael A. Boeck Guidelines for Preventing Infectious Complications among Hematopoietic Cell Transplantation Recipients: A Global Perspective Biol Blood Marrow Transplant 15: 1143-1238 (2009)

Jharna N. Shah and Roy F. Chemaly Management of RSV infections in adult recipients of hematopoietic stem cell transplantation Blood 10, 2011 vol. 117 no. 10 2755-2763

D. McCoy, E. Wong, A.G. Kuyumjian, M.A. Wynd, R. Sebti, G.B. Munk. Treatment of respiratory syncytial virus infection in adult patients with hematologic malignancies based on an institution-specific guideline. Transpl Infect Dis 2011: 13: 117–121.

Marcie Tomblyn, Tom Chiller, Hermann Einsele, Ronald Gress, Kent Sepkowitz, Jan Storek, John R. Wingard, Jo-Anne H. Young, Michael A. Boeck Guidelines for Preventing Infectious Complications among Hematopoietic Cell Transplantation Recipients: A Global Perspective Biol Blood Marrow Transplant 15: 1143-1238 (2009)

Jharna N. Shah and Roy F. Chemaly, Management of RSV infections in adult recipients of hematopoietic stem cell transplantation
Blood March 10, 2011 vol. 117 no. 10 2755-2763

D. McCoy, E. Wong, A.G. Kuyumjian, M.A. Wynd, R. Sebti, G.B. Munk. Treatment of respiratory syncytial virus infection in adult patients with hematologic malignancies based on an institution-specific guideline. Transpl Infect Dis 2011: 13: 117–121.

Boeckh M, 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.

Ghosh S, et al. Respiratory syncytial virus upper respiratory tract illnesses in adult blood and marrow transplant recipients: combination therapy with aerosolized ribavirin and intravenous immunoglobulin. Bone Marrow Transplant 2000;25:751-5.

Marcie Tomblyn, Tom Chiller, Hermann Einsele, Ronald Gress, Kent Sepkowitz, Jan Storek,
John R. Wingard, Jo-Anne H. Young, Michael A. Boeck Guidelines for Preventing Infectious Complications among Hematopoietic Cell Transplantation Recipients: A Global Perspective Biol Blood Marrow Transplant 15: 1143-1238 (2009)

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