Treating HSV and CMV reactivations in critically ill patients who are not immunocompromised: con

Excerpt

Herpesvirus, especially cytomegalovirus (CMV) and herpes simplex virus-1 (HSV-1), are frequently detected in non-immunocompromised critically ill patients hospitalized in the intensive care unit (ICU). Although the exact seroprevalence of herpesvirus at the time of ICU admission is not known, it is often assumed that the production of viral particles is more likely to be determined by viral reactivation rather than by primary infection. This is because of high seroprevalence in the adult population, ranging from 50 to 100 % [1, 2], as well as a limited risk of virus transmission while in the ICU, especially since transfusion of filtered leukocyte-reduced blood products has become the norm [3]. In critically ill patients, the incidence of CMV reactivation during an ICU stay is up to one patient in three for CMV detected in blood samples [4, 5], and one patient in four for HSV-1 detected in upper airway samples [6]. Incidence rates depend highly on identification techniques (antigenaemia, polymerase chain reaction, viral culture) as well as inclusion criteria (systematic screening versus testing in selected patients with specific symptoms) [7]. Reactivation is often associated with a worse outcome in ICU patients [4, 5, 7, 8]. It has been suggested that the higher the reactivation is, the poorer the prognosis for both CMV [4] and HSV-1 [9]. Antiviral treatment is mandatory in case reactivation is associated with a real organ infection, i.e. organ damage due to the virus (curative treatment) but should be discussed when the case organ infection is not proven (pre-emptive treatment). It might also be relevant to avoid any reactivation by giving antiviral drugs even earlier (prophylactic treatment). If there is no doubt that curative treatment is mandatory, clinicians need to consider pre-emptive and prophylactic treatments (which concern most of the cases) with extreme caution, pending the results from ongoing randomised trials designed to answer these questions. …