Utility of Corticosteroids As Adjunct Therapy for Respiratory Syncytial Virus Infection in Allogeneic Stem Cell Transplant Recipients

Background: Respiratory syncytial virus (RSV) infection causes significant morbidity and mortality in allogeneic stem cell transplant (HCT) recipients. Although ribavirin and immunoglobulin are key components of therapy, the role of adjunct corticosteroids is not established. Corticosteroids may mitigate adverse pulmonary sequelae of RSV infection, although they may also delay viral clearance, and corticosteroid use has been included as a negative factor in recent risk predictors of RSV mortality (RSV ISI-Blood 2014).

Objectives: We sought to evaluate corticosteroid utilization in the setting of post-HCT RSV infection in our center and assess the association of corticosteroid use with morbidity and mortality.

Methods: Patients with a history of RSV infection, seen at Mayo Clinic Rochester from 2008 to 2014, were identified. Treatment and outcome data were retrospectively collected. Forced expiratory volume in one second (FEV1) and carbon monoxide diffusion capacity (DLCO) were collected pre- and post-RSV. Fisher’s exact test was used to compare categorical variables.

Results: Details of therapy were extractable for 45 patients.  Twenty-one (47%) were on corticosteroids prior to RSV diagnosis for treatment of graft versus host disease (GVHD). Eleven (52%) of these patients had their steroid dose increased by a median of 20 mg prednisone equivalents (PE).  An additional 8 (18%) patients were started on corticosteroids with median dosing of 62 mg PE.  There was no difference in objective indices of RSV severity (RSV ISI) or baseline prevalence of bronchiolitis obliterans (BO) between those who did or did not receive corticosteroids.  Dosing ranged from 20 to 1250 mg/day PE.  Most patients were started on corticosteroids within 24 hours of RSV diagnosis and median duration of use was 31 days. There was no difference in post-RSV FEV1 (p = 0.4578) or DLCO (p = 0.4578) decline between patients receiving corticosteroids and those who did not.  Sixteen (84%) patients who received corticosteroids were hospitalized for a median length of 7.5 days (range 3-46),  compared to a 42% hospitalization rate for median of 6 days (range 3-24) for those not receiving corticosteroids (p = 0.0061).  ICU admission was required in 9 (20%) patients (8 received corticosteroids and 1 did not). Five (12%) patients were receiving therapy for BO prior to RSV infection. Following RSV infection, 11/30 (37%) long-term survivors required therapy for BO, eight of whom had received corticosteroids.

Conclusion: Adjunct corticosteroid use in the setting of RSV infection appeared to be related to physician assessment of disease acuity rather than objective indices of severity.  Corticosteroids did not have any discernable effect on RSV-related outcomes. The high ICU admission rate and need for long-term BO therapy highlights the urgent need for better RSV directed therapies.