Good Outcome of RSV Infection without Ribavirin Treatment in Pediatric Bone Marrow Transplantation

Clinicians commonly use inhaled ribavirin to treat HSCT recipients with Respiratory Syncytial Virus (RSV); however, limited data exist to support this therapy. We evaluated 349 consecutive patients transplanted between June, 2008 and December, 2013.  Eighteen (5.2%) pediatric and young adult patients (6 months to 25 years of age) developed an RSV infection. Fifteen (83%) patients presented with an upper respiratory tract infection (URTI) identified a median of 151 (range 3 – 621) days post-HSCT and 3 (17%) presented with, or progressed to, a lower respiratory tract infection (LRTI) identified a median of 33 (range 10 – 117) days post-HSCT.  All 3 patients with LRTI had significant co-infections while 2/3 were less than 1 year of age at the time RSV was identified.  Fifteen (83%, 13/15 with URTI and 2/3 with LRTI) were still receiving immunosuppressants.  All 18 patients were lymphopenic (median 280, range 0 – 2120).   Eleven of 15 (73%) patients with URTI and all 3 patients with LRTI were receiving routine intravenous immunoglobulin (IVIG) supplementation every 1-2 weeks to maintain normal IGG levels after HSCT. RSV-targeted treatment included an increase in frequency or additional IVIG administration for 4/15 and 3/3 URTI and LRTI patients, respectively.  Three URTI patients and 2 LRTI patients receiving IVIG were also given palivizumab. No patients received inhaled ribavirin or died as a direct result of RSV infection suggesting that ribavirin may not be an essential component of RSV treatment in pediatric HSCT recipients.