Cytomegalovirus reactivation in critically ill immunocompetent patients.

Limaye, Ajit P and Kirby, Katharine A and Rubenfeld, Gordon D and Leisenring, Wendy M and Bulger, Eileen M and Neff, Margaret J and Gibran, Nicole S and Huang, Meei-Li and Santo Hayes, Tracy K and Corey, Lawrence and Boeckh, Michael (2008) Cytomegalovirus reactivation in critically ill immunocompetent patients. JAMA : the journal of the American Medical Association, 300 (4). pp. 413-422. ISSN 1538-3598

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Abstract

CONTEXT: Cytomegalovirus (CMV) infection is associated with adverse clinical outcomes in immunosuppressed persons, but the incidence and association of CMV reactivation with adverse outcomes in critically ill persons lacking evidence of immunosuppression have not been well defined. OBJECTIVE: To determine the association of CMV reactivation with intensive care unit (ICU) and hospital length of stay in critically ill immunocompetent persons. DESIGN, SETTING, AND PARTICIPANTS: We prospectively assessed CMV plasma DNAemia by thrice-weekly real-time polymerase chain reaction (PCR) and clinical outcomes in a cohort of 120 CMV-seropositive, immunocompetent adults admitted to 1 of 6 ICUs at 2 separate hospitals at a large US tertiary care academic medical center between 2004 and 2006. Clinical measurements were assessed by personnel blinded to CMV PCR results. Risk factors for CMV reactivation and association with hospital and ICU length of stay were assessed by multivariable logistic regression and proportional odds models. MAIN OUTCOME MEASURES: Association of CMV reactivation with prolonged hospital length of stay or death. RESULTS: The primary composite end point of continued hospitalization (n = 35) or death (n = 10) by 30 days occurred in 45 (35%) of the 120 patients. Cytomegalovirus viremia at any level occurred in 33% (39/120; 95% confidence interval [CI], 24%-41%) at a median of 12 days (range, 3-57 days) and CMV viremia greater than 1000 copies/mL occurred in 20% (24/120; 95% CI, 13%-28%) at a median of 26 days (range, 9-56 days). By logistic regression, CMV infection at any level (adjusted odds ratio [OR], 4.3; 95% CI, 1.6-11.9; P = .005) and at greater than 1000 copies/mL (adjusted OR, 13.9; 95% CI, 3.2-60; P < .001) and the average CMV area under the curve (AUC) in log(10) copies per milliliter (adjusted OR, 2.1; 95% CI, 1.3-3.2; P < .001) were independently associated with hospitalization or death by 30 days. In multivariable partial proportional odds models, both CMV 7-day moving average (OR, 5.1; 95% CI, 2.9-9.1; P < .001) and CMV AUC (OR, 3.2; 95% CI, 2.1-4.7; P < .001) were independently associated with a hospital length of stay of at least 14 days. CONCLUSIONS: These preliminary findings suggest that reactivation of CMV occurs frequently in critically ill immunocompetent patients and is associated with prolonged hospitalization or death. A controlled trial of CMV prophylaxis in this setting is warranted.

Item Type:	Article or Abstract
Additional Information:	This article is subject to a 6-month embargo. Please see http://jama.ama-assn.org/misc/authors.dtl#depositingDepositing for more information on Author Rights including PubMed Central and Repository deposits.
DOI:	10.1001/jama.300.4.413
PubMed ID:	18647984
NIHMSID:	NIHMS76604
PMCID:	PMC2774501
Grant Numbers:	P01 CA018029-33
Keywords or MeSH Headings:	Adult; Aged; Aged, 80 and over; Critical Illness/mortality; Cytomegalovirus/isolation & purification/physiology; Cytomegalovirus Infections/epidemiology/immunology/virology; Female; Humans; Immunocompetence/immunology; Intensive Care Units; Length of Stay; Male; Middle Aged; Recurrence; Risk Factors; Viral Load; Viremia; Virus Activation;
Subjects:	Diseases > Viral diseases Cellular and Organismal Processes > Immune Response
Depositing User:	Library Staff
Date Deposited:	12 Nov 2008 18:18
Last Modified:	14 Feb 2012 14:42
URI:	http://authors.fhcrc.org/id/eprint/91

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