1600. An Optimal Respiratory Syncytial Virus (RSV) Treatment in Lung Transplant Recipients: Oral Ribavirin, Inhaled Ribavirin, or Conservative Approach

Abstract

BackgroundRespiratory syncytial virus (RSV) is a common community acquired infection in lung transplant recipients (LTRs). The mortality in RSV-infected LTRs has been reported as 10–20% despite antiviral therapy; however, there is no consensus regarding treatment given limited data.MethodsA retrospective study of all LTRs at Duke University during January 2013 and May 2017 with a positive RSV PCR respiratory specimen was performed. Baseline characteristics, sites of infection, antiviral therapy, side effects, outcomes including all-cause 1-year mortality post RSV infection, and 90-day readmission rates were analyzed. The Cox proportional hazard model was used to adjust the effect of ribavirin (RBV) on mortality.ResultsOne hundred fourteen RSV-infected LTRs were identified: 70 received oral RBV, 32 inhaled RBV and 12 supportive care only. Baseline characteristics were similar between the 3 groups except site of infection and oxygen requirement at diagnosis (see table). Of 32 patients treated with inhaled RBV, 19 had a creatinine clearance <40 mL/minute and 8 were unable to take oral drugs. Unadjusted all-cause 1-year mortality was highest in the supportive care group [33.3% vs. 7.1% (oral RBV) vs. 25% (inhaled RBV), P = 0.01]. There were no significant differences in readmission rates among the 3 groups. The adjusted hazard ratio (HR) for death and oral RBV use was 0.27 ([0.07,1.1], P = 0.07). The adjusted HR for death and inhaled RBV use was 0.90 ([0.22, 3.68], P = 0.88). RBV was stopped prematurely in only 1 patient in the oral group due to nausea and vomiting.ConclusionOral and inhaled RBV appear to be well tolerated in LTRs. Our data support the use of oral RBV as a safe alternative to inhaled RBV in LTRs. Additional studies are required to determine whether LTRs with asymptomatic RSV infection would benefit from RBV therapy.Supportive Care N = 12 (%)Oral RBV N = 70 (%)Inhaled RBV N = 32 (%) P-valueSite of infection0.0004Upper respiratory tract1 (8.3)32 (45.7)11 (34.4)Lower respiratory tract3 (25)24 (34.3)18 (56.3)Asymptomatic8 (66.7)14 (20)3 (9.4)Oxygen requirement at diagnosis0.003None8 (66.7)61 (87.1)18 (56.3)1–2 L/minute2 (16.7)6 (8.6)4 (12.5)>2 L/minute2 (16.7)3 (4.3)10 (31.3)Disclosures R. Miller, scynexis: Investigator, Research support.