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 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.

/pdf/cytomegalovirus-reactivation-in-critically-ill-2hag5uqd8t.pdf

Cytomegalovirus reactivation in critically ill immunocompetent patients.

The incidence of burn injury has declined steadily over the past several decades in the United States and in some other developed countries. In-hospital fatality rates have also declined and are now only about 4 percent among patients with major injuries who are treated in specialized burn units.1,2 Despite this declining incidence, about 1.25 million persons are still treated for burns annually in the United States, and 50,000 are hospitalized each year for the treatment of burns.3 Seventy-five percent of those hospitalized have burns covering less than 10 percent of the body-surface area.1 Such burns rarely cause hemodynamic problems . . .

Initial management of burns.

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.

Cytomegalovirus Reactivation in Critically Ill Immunocompetent Patients

The precise role of cytomegalovirus (CMV) infection in contributing to outcomes in critically ill immunocompetent patients has not been fully defined. Studies in which critically ill immunocompetent adults were monitored for CMV infection in the intensive care unit (ICU) were reviewed. CMV infection occurs in 0 to 36% of critically ill patients, mostly between 4 and 12 days after ICU admission. Potential risk factors for CMV infection include sepsis, requirement of mechanical ventilation, and transfusions. Prolonged mechanical ventilation (21 to 39 days vs. 13 to 24 days) and duration of ICU stay (33 to 69 days vs. 22 to 48 days) correlated significantly with a higher risk of CMV infection. Mortality rates in patients with CMV infection were higher in some but not all studies. Whether CMV produces febrile syndrome or end-organ disease directly in these patients is not known. CMV infection frequently occurs in critically ill immunocompetent patients and may be associated with poor outcomes. Further studies are warranted to identify subsets of patients who are likely to develop CMV infection and to determine the impact of antiviral agents on clinically meaningful outcomes in these patients.

/pdf/cytomegalovirus-infection-in-critically-ill-patients-a-3a4t28jmda.pdf

Cytomegalovirus infection in critically ill patients: a systematic review.

Infectious disease transmission through cell, tissue, and organ transplantation: reducing the risk through donor selection.

BACKGROUND The potential role of cadaver skin as a vehicle for CMV transmission to burn patients has never been clearly defined We sought to determine if a cytomegalovirus (CMV)-positive cadaver allograft transmits CMV infections to CMV-seronegative burn patients STUDY DESIGN All patients in this study were CMV seronegative on admission They received CMV-seronegative blood products, and cadaver allografts for temporary wound closure and management without regard to the donor's CMV serum status (positive or negative) RESULTS Of 493 patients admitted from 1989 to 1993, 22 were CMV seronegative on admission and required cadaver allografts for their burn wounds Five (227 percent) of 22 patients seroconverted during hospitalization: one of five had CMV pneumonia develop, two had CMV viruria develop, and three had persistent fever, abnormal liver enzymes, and diarrhea not ascribable to bacterial or other viral agents CONCLUSIONS Cytomegalovirus infections result from using CMV-seropositive cadaver allografts on seronegative burn patients

Cadaver skin allografts and transmission of human cytomegalovirus to burn patients.

We studied the seroepidemiology of cytomegalovirus (CMV) infection in 59 patients with thermal injuries. Among the 31 patients who were initially CMV seronegative, seven (22.5%) seroconverted. Patients who seroconverted had longer hospital stays (mean, 27 +/- 23.9 days v 14.9 +/- 8.8 days in seronegative patients [P = 0.03]) and they received more blood products (mean, 10.7 +/- 17.9 units v 1.8 +/- 2.8 units [P = 0.02]) than patients who remained seronegative. Among 18 patients who were initially seropositive for CMV, 10 (56%) had a fourfold or greater rise in CMV antibodies, evidence of CMV reactivation. Patients who had reactivated CMV infection tended to be younger, to have a larger burn area, and to have a longer hospital stay. No patient who experienced CMV infection, whether primary or reactivated, had serious complications attributable to CMV.

Cytomegalovirus infection in burn patients.

To determine the epidemiology of cytomegalovirus (CMV) infections among patients with burns, we prospectively studied 120 burn patients admitted to the University of Iowa Burn Center over a two-and-one-half year period. At the time of their admission, 44% of the patients had serologic evidence of prior CMV infection. Among 44 seropositive patients, 23 (52%) had four-fold or greater rises in CMV antibody titers. These patients had more severe burns (mean body surface area burn [BSAB] 26.8%) than those who did not exhibit titer rises (mean BSAB 16.2%, p = .04). Among 43 seronegative patients observed for at least 65 days after discharge from the center, eight (18.6%) seroconverted. Patients who seroconverted had longer hospital stays (p = .03), trends toward more severe burns (p = .08) and a younger age (p = .15) than patients who remained seronegative. Despite frequent serologic evidence of CMV infection, CMV did not contribute, either directly or indirectly, to the morbidity or mortality of burns in these patients.

The epidemiology of cytomegalovirus infection among patients with burns.

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Cadaver skin allografts and transmission of human cytomegalovirus to burn patients.

Cytomegalovirus infection in burn patients.

The epidemiology of cytomegalovirus infection among patients with burns.