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Pre-emptive ribavirin for ‘RSV’ in BMT

Bone Marrow Transplantation volume 26, page 113 (2000)Cite this article

The paper by Adams et al1 on the pre-emptive use of aerosolized ribavirin in the treatment of asymptomatic pediatric marrow transplant patients testing positive for RSV deserves clarification and further scrutiny. Specifically, the performance of the RSV ELISA in the hands of the investigators and when applied to the study patients should be clarified. Clearly, if a substantial number of false positive test results occur then the benign clinical outcomes of these potentially misidentified patients would be the rule and would not be the result of the drug treatment employed. The authors state that the ELISA sensitivity is 81.7% and the specificity is 93.6%. This RSV ELISA assay was developed and characterized in symptomatic infants and children. However, the performance of the assay when applied to asymptomatic patients is the critical test characteristic for this study. It would be expected that the likelihood of false positives would increase when this test is applied to such an asymptomatic population. If, for example, the sensitivity and specificity of the ELISA as stated was around 90%, the predictive value of a positive test would only be 0.32 if the prior probability of true infection was 0.05. Since the ratio of positive to negative test results reported in this study was approximately 0.07, it seems possible that most or even all ELISA positive patients in this study could represent false positives. Unfortunately, no confirmatory cultures were performed and DFA back-up was only reportedly used in this study if the RSV ELISA was negative, therefore not addressing this potential problem of ELISA false positivity.

Furthermore, the proportion of RSV positive patients reported in this paper is 3/14 (21%) for 1996 and 8/13 (61%) for 1997. These are much higher than the 8% proportion previously reported in similar symptomatic populations.2 This is also higher than the RSV infected proportion (as defined by culture identification) which we have observed at St Jude Children's Research Hospital (5/274 = 1.8%) over a 4 year observation of successive marrow transplants.3

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References

  1. Adams R, Christenson J, Petersen F, Beatty P . Pre-emptive use of aerosolized ribavirin in the treatment of asymptomatic pediatric marrow transplant patients testing positive for RSV Bone Marrow Transplant 1999 24: 661–664

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  2. Couch R, Englund J, Whimbey E . Respiratory viral infections in immunocompetent and immunocompromised persons Am J Med 1997 102: 2–9

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  3. Lujan-Zilberman J, DeVincenzo J . Respiratory virus infections after pediatric bone marrow transplantation. Interscience Conference on Antimicrobial Agents and Chemotherapy. 1999 (Abstr. 1899)

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  1. Division of Infectious Diseases, Department of Pediatrics, University of Tennessee, Memphis, TN, USA

    J DeVincenzo

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DeVincenzo, J. Pre-emptive ribavirin for ‘RSV’ in BMT. Bone Marrow Transplant 26, 113 (2000). https://doi.org/10.1038/sj.bmt.1702436

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