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J Thorac Cardiovasc Surg 1994;108:1152
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Respiratory syncytial virus infection in a cardiac surgery intensive care unit

UMDNJ-Robert Wood Johnson Medical School
New Brunswick, NJ 08903

To the Editor:

Respiratory syncytial virus (RSV) causes lower respiratory tract illness and bronchiolitis in young children and infants with a peak prevalence in the fall and winter In adults, RSV infection typically causes an upper respiratory tract illness characterized by nasal discharge and erythema, sneezing, malaise, mild pharyngitis, cough, and fever. ^{1, 2} Severe RSV infection in adults can be acquired in the community or nosocomially and has been reported in healthy adults or those with chronic medical illness, elderly persons, and immunocompromised persons. ^{3, 4} RSV can infect individuals in medical intensive care units or in general medical departments. We wish to report an outbreak of RSV that occurred during RSV season in a surgical intensive care unit dedicated to patients who had had cardiac operations.

Beginning in October 1992, our clinical virology laboratory tested all respiratory specimens received for viral culture for RSV antigen by enzyme immunoassay (Kallestead EIA, Austin, Tex.). From October 1992 until March 1993, 21 of 46 adults sampled had positive tests for RSV antigen. During this same period, RSV infection was diagnosed in 65% of 127 pediatric patients, either by viral culture or by antigen testing. The prevalence of the infection suggests a broad-based outbreak in the community.

The charts for 20 of the 21 adult patients were available for review. RSV infection developed after a cardiac operation in eight of the 20 patients (40%). Four individuals underwent coronary artery bypass grafting. Three individuals had both valve replacement and bypass grafting. One individual had mitral valve replacement alone. Mean patient age was 67 years. The median time from admission to the hospital to the diagnosis of RSV was 11.5 days (range 2 to 180 days). All patients were febrile and all but one had abnormalities on the chest roentgenogram. After the operation, seven patients required prolonged mechanical ventilation for respiratory failure. Specimens in three patients were obtained with a bronchoscope that was used to evaluate prolonged respiratory failure. In five patients specimens were obtained by tracheal suction (4/5) or by expectorated sputum (1/5). Although all eight specimens were tested for RSV antigen, six were also cultured for viral pathogens. None of the six cultures grew RSV, but this failure may have been due to the lability of the virus and the prolonged transit time to the virology laboratory. Specimens from six patients grew potential pathogens and all patients received broad-spectrum antibiotics. Two patients were treated with aerosolized ribavirin at a dose of 6 gm over 22 hours administered through the ventilator. Treatment lasted 5 days, which is the recommended length of time for pediatric patients. Ribavirin treatment did not appear to alter the patients' courses. Four patients died of respiratory failure including one who received ribavirin.

The identification of RSV antigen in these patients was often unexpected and presented the clinicians with a dilemma as to its significance in patients with prolonged respiratory failure after cardiac operations. Guidry and associates ⁴ have reported isolating RSV from respiratory secretions in five of eleven intubated patients who were screened for RSV in a medical intensive care unit. In their study, the patients who had RSV infection tended to have longer hospital stays than those who did not, although this difference did not reach statistical significance. Also, patients with RSV infections were intubated for a median of 25 days (range 2 to 94 days) compared with 13.5 days (range 6 to 17 days) in patients without RSV infections. This trend toward more severe disease in patients with RSV infection needs to be confirmed in larger studies. In children with severe RSV infections, aerosolized ribavirin has been shown to improve the outcome and shorten the duration of disease. Although the use of aerosol ribavirin in adults has been reported, no prospective, controlled studies that determine efficacy have been conducted. ⁵

In summary, we have reported a series of RSV infections in adults after cardiac operations. This fall or winter pathogen may have contributed to the prolonged respiratory failure that was seen in this group of patients. The role that RSV plays in the respiratory morbidity of these patients and the value of aggressive intervention with ribavirin awaits randomized, controlled trials.

References

1. Hall WJ, Breese Hall C, Speers DM. Respiratory syncytial virus infection in adults—clinical, virologic, and serial pulmonary function studies. Ann Intern Med 1978;88:203-5.
   
2. Kravetz HM, Knight V, Chanock RM, et al. Respiratory syncytial virus. III. Production of illness and clinical observations in adult volunteers. JAMA 1961;176:657-63.
   
3. Takimoto CH, Cram DL, Root RK. Respiratory syncytial virus infections on an adult medical ward. Arch Intern Med 1991;151:706-8.[Abstract]
   
4. Guidry GG, Black-Payne CA, Payne DK, Jamison RM, George RB, Bocchini JA. Respiratory syncytial virus infection among intubated adults in a university medical intensive care unit. Chest 1991;100:1377-84.[Abstract/Free Full Text]
   
5. Aylward RB, Burdge DR. Ribavarin therapy of adult respiratory syncytial virus pneumonitis. Arch Intern Med 1991;151:2303-4.[Abstract]
   

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