Viral Infec,ons in the ICU - iammdelhi.org€¦ · Respiratory Viral Infec,ons in the ICU (3) •...
Transcript of Viral Infec,ons in the ICU - iammdelhi.org€¦ · Respiratory Viral Infec,ons in the ICU (3) •...
ViralInfec,onsintheICU
Dr. Lalit Dar Professor and In-charge Virology Section Department of Microbiology AIIMS
DelhiMicrocon,12December2015,IHC
AnOutbreakofViralDisease• In1952,anoutbreakofpoliomyeli,soccurredinDenmark
• 2722pa,entsdevelopedtheillnessover6months
• 316sufferedrespiratoryparalysis
TheIntensive-CareUnitStartedwithaVirus…
Common Viral Infections in the ICU
• Respiratory infections
• Gastroenteritis
• Hemorrhagic fever
• Neurologicalinfec,ons
• Exogenous • Influenza A (including H1N1, H5N1) and B • RSV • Parainfluenza viruses • Adenovirus • Metapneumovirus • Coronaviruses (OC43, 229E/NL63, SARS, MERS)
• Endogenous (reactivation of latent viruses) • CMV • HSV • VZV
RespiratoryViralInfec,onsintheICU(1)
• Early studies
– Two of 39 patients with suspected VAP were “classical” respiratory virus positive in tracheal aspirates (influenza and enterovirus) (Luyt C-E et al, 2007)
– PCR on BAL positive in 11 of 201 suspected VAP patients for several respiratory viruses, while 42 (28%) patients were positive for HSV and 28 (14%) for CMV (Daubin C et al, 2005)
– Only < 5.5% of non-immunocompromised patients with ventilator associated pneumonia (VAP) had “classical” respiratory viruses, which may even have been acquired before ICU admission
RespiratoryViralInfec,onsintheICU(2)
RespiratoryViralInfec,onsintheICU(3)
• Recent studies – 22.5% to 34% patients in the ICU with health-care
associated pneumonia (HCAP) had one or more respiratory virus in their lower respiratory (BAL, endotracheal aspirate) or nasopharyngeal samples (Hong H-L et al, 2015; Choi SH et al, 2012)
– 14%, in lower respiratory samples (Hong H-L et al, 2015)
– RSV, PIV (27% each) and rhinovirus (25%) most common, followed by influenza (17%), CMV (8.5%) and coronaviruses (7%) (Hong H-L et al, 2015)
– 59.5% had bacterial infection and 8% bacterial-viral coinfection (Hong H-L et al, 2015)
Herpesviridae: HSV in Lower Respiratory Tract of ICU patients
Luyt C-E et al, 2014
Luyt C-E et al, 2014
Herpesviridae: CMV in Lower Respiratory Tract of ICU patients
HSV and CMV Infection in the ICU: Clinical Significance
• Confirmed HSV cases with ARDS have longer periods on ventilators and hospital stay, with a higher mortality rate in some studies
• CMV detected in blood after 12 days median ICU stay; viremia peaks at 26 days; pneumonia seen after average of 3 weeks on ventilator
• HSV or CMV detection in BAL fluid does not necessarily mean viral VAP; may indicate only reactivation not lung parenchyma involvement and true pneumonia
• Innocent bystanders or true pathogens? Pathogenicity of Herpesviridae in respiratory infections in the ICU not clear; decision whether to give antiviral prophylaxis, pre-emptive therapy or neither still remains open
Role of Real-time PCR on BAL (Viral Load)
• Limited studies, but virus quantification by real-time PCR may help to decide treatment
• HSV viral load > 100000 copies/ml in BAL fluid show poorer prognosis, more frequent ARDS, longer stay in the ICU and higher mortality
• CMV viral load of >1000 copies/ml by real-time PCR associated with increased mortality or prolonged ICU stay
• Randomized controlled trials needed
• Zoster(endogenousICUinfec,on)– Latentvaricellazostervirusreac,va,onleadingtozoster– Zostervesicularlesionshaveinfec,ousviruswhichcanleadtoan
outbreakofchickenpox– Earlyclinicaliden,fica,on(dermatomalvesicularrash)and
treatmentwithhighdosesofacylovirinelderlymaypreventpost-herpe,cneuralgia
• VZVpneumonia(exogenousICUinfec,on,rarecomplica,onofchickenpox)– Immunosuppression(malignancy,cor,costeroids,HIV,andsolid-
organtransplant)areriskfactors– Rareinyounghealthyadults– DevelopsinsidiouslyfewdaysaXertheonsetofchickenpoxrash;
mayprogresstorespiratoryfailureandARDSin10%to30%(upto50%,ifrespiratoryfailureensues)
Herpesviridae: VZV in ICU patients
Viral Gastroenteritis Outbreaks in the ICU
• 590 neonatal outbreaks analysed from the outbreak database (http://www.outbreak-database.com) (Civardi E et al, 2013) – 64 (11%) outbreaks due to viruses – 44 (69%) of these reported from neonatal intensive
care units (NICUs) – Rotavirus (23%) most frequent viral agent
• Noroviruses are emerging agents of gastroenteritis outbreaks (including adult ICU) – Mean duration of illness of 12–60 h; vomiting in >50% ;
incubation period of 24–48 h – Multiple modes of transmission facilitate spread
Viral Infections in the Neonatal ICU • 12-year study from a neonatal ICU in The Netherlands, based on culture and PCR (Verboon-Maciolek MA et al, 2005)
• Viral infection was confirmed in 51 of 5396 infants (<1%) • Enterovirus/ parechovirus (EV/PEV) 39%; RSV 29%; rotavirus 10%; CMV 6%; adenovirus/ PIV/ HSV 4% each; rhinovirus/ rubella 2% each
• Clinical presentation in pre-term neonates – Sepsis like illness with seizures and gastrointestinal disease
(EV/PEV) – Respiratory disease (RSV, PIV, rhinovirus, CMV) – Gastrointestinal disease (adenovirus, rotavirus, EV/PEV)
• Mortality (10%) and serious sequelae (15%) were high in patients with EV/PEV
Haemorrhagic Fever
• Viruses causing haemorrhagic fever may require ICU care, e.g., dengue (DSS/ DHF) – Accurate and careful fluid replacement – Monitoring haematocrit (and platelets) – Judicious use of platelet transfusion
• Suspected cases with exotic virus infections require special precautions in ICU care, e.g., Ebola, Crimean Congo haemorrhagic fever, hantaviruses – Strict isolation procedures – Adherence to guidelines for all procedures – Dedicated equipment – PPE (proper training and donning under observation) – Appropriate waste disposal
Neurological Infections
• Pa,entswithneurologicalcondi,onsmayneedtobeadmi]edtotheICU,e.g.,incomatosecondi,onorforrespiratorysupport
• Viruses– HSV,arboviruseslikeJE,etc.
Management
• Rapiddiagnosis• Mainlysuppor,vetreatmentdependingonthepresenta,on
• An,viraldrugs,whereindicated– Acyclovir(HSV,VZV)– Ganciclovir(CMV)– Neuraminidaseinhibitors(influenza)– Ribavirin/Palivizumab(RSV)
Summary• Viralinfec,onsintheICUincluderespiratory,gastrointes,nalandneurologicalinfec,ons,aswellashaemorrhagicfevers
• Bothexogenousandendogenous(reac,vated)infec,onscanoccurintheICU
• Moleculartechniquesareimportantforearlydiagnosisandpreven,on
• Preven,onofspreadrequiresclearlydefinedguidelines,whichmustbeadheredto
• Suppor,vecareisrequired.Specifican,-viraldrugsshouldbeusedwhereindicated.
ThankYou