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Active Cytomegalovirus Infection in Nonimmunosuppressed Patients in the ICUCytomegalovirus Infection in the ICU FREE TO VIEW

David Navarro, MD, PhD
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From the Microbiology Service, Hospital Clínico Universitario, and the Department of Microbiology, School of Medicine, University of Valencia.

Correspondence to: David Navarro, MD, PhD, Microbiology Service, Hospital Clínico Universitario, and Department of Microbiology, School of Medicine, Av. Blasco Ibáñez 17, 46010 Valencia, Spain; e-mail: david.navarro@uv.es


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(1):269-270. doi:10.1378/chest.11-0289
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To the Editor:

The overall rate of active cytomegalovirus (CMV) infection in critically ill patients has been reported to be ∼ 20% when using qualitative polymerase chain reaction (PCR) assays or the pp65 antigenemia test for screening1 and is even higher (> 30%) when using real-time PCR methods.2,3 I read the article in CHEST (February 2011) by Gilbert et al4 with great interest. The authors found a very low prevalence of CMV viremia (∼ 1%) in a cohort of nonimmunocompromised patients admitted to a general ICU and concluded that monitoring for CMV DNAemia (although not used in the original text, the term DNAemia [the presence of DNA in plasma] should have been used instead of viremia) in this setting is not justified in the absence of clinical evidence of CMV infection.

In my opinion, the study has some limitations. First, CMV DNA detection in serum was performed by using the Cobas Amplicor CMV Monitor test (Roche Inc; Basel, Switzerland) (detection threshold, 400 CMV DNA copies/mL). I understand that the ultrasensitive version of the assay (limit of detection, 45 CMV DNA copies/mL) was not used. We previously showed that ICU patients with active CMV infection displayed low levels of plasma CMV DNAemia (median, 67 copies/mL, with CMV DNA loads > 400 copies/mL observed in ∼ 15% of samples), as determined by a real-time PCR assay (Abbott CMV PCR kit; Abbott Molecular; Des Plaines, Illinois), with a limit of detection of ∼ 10 copies/mL.3 Thus, the actual incidence of CMV DNAemia in the cohort of Gilbert et al4 might have been underestimated. Second, studies assessing the incidence and clinical relevance of active CMV infection in ICU patients should primarily include patients who are CMV-seropositive at the time of admission, as reactivation of latent infection rather than acquisition of primary infection is the usual mechanism underlying active CMV infection. Only 51% of patients had CMV-specific IgGs in the study by Gilbert et al.4 Third, the mean length of patients’ hospitalization in the ICU was 20.9 days.4 Earlier studies demonstrated that a relevant fraction of episodes of active CMV infection may develop after 3 weeks of ICU stay.1-3 Fourth, in a previous study,3 CMV reactivation was diagnosed in around 25% of ICU patients solely on the basis of the presence of CMV DNA in tracheal aspirates, indicating that monitoring for the presence of CMV in the blood compartment may underestimate the incidence of active CMV infection in this clinical setting.

A causal link between CMV infection and adverse clinical outcomes in ICU patients is far from proven. Only a randomized controlled trial of antiviral prophylaxis with a drug with specific activity against CMV may shed light on this issue.5 Until then, a debate on whether to screen critically ill patients for active CMV infection is pointless.

Kalil AC, Florescu DF. Prevalence and mortality associated with cytomegalovirus infection in nonimmunosuppressed patients in the intensive care unit. Crit Care Med. 2009;378:2350-2358. [CrossRef] [PubMed]
 
Limaye AP, Kirby KA, Rubenfels GD, et al. Cytomegalovirus reactivation in critically immunocompetent patients. JAMA. 2008;3004:413-422. [CrossRef] [PubMed]
 
Chilet M, Aguilar G, Benet I, et al. Virological and immunological features of active cytomegalovirus infection in nonimmunosuppressed patients in a surgical and trauma intensive care unit. J Med Virol. 2010;828:1384-1391. [CrossRef] [PubMed]
 
Gilbert É, Rico P, Laflamme PJ, Albert M. Low cytomegalovirus viremia prevalence in a general intensive care population. Chest. 2011;1392:478-479. [CrossRef] [PubMed]
 
Cook CH. Cytomegalovirus reactivation in “immunocompetent” patients: a call for scientific prophylaxis. J Infect Dis. 2007;1969:1273-1275. [CrossRef] [PubMed]
 

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References

Kalil AC, Florescu DF. Prevalence and mortality associated with cytomegalovirus infection in nonimmunosuppressed patients in the intensive care unit. Crit Care Med. 2009;378:2350-2358. [CrossRef] [PubMed]
 
Limaye AP, Kirby KA, Rubenfels GD, et al. Cytomegalovirus reactivation in critically immunocompetent patients. JAMA. 2008;3004:413-422. [CrossRef] [PubMed]
 
Chilet M, Aguilar G, Benet I, et al. Virological and immunological features of active cytomegalovirus infection in nonimmunosuppressed patients in a surgical and trauma intensive care unit. J Med Virol. 2010;828:1384-1391. [CrossRef] [PubMed]
 
Gilbert É, Rico P, Laflamme PJ, Albert M. Low cytomegalovirus viremia prevalence in a general intensive care population. Chest. 2011;1392:478-479. [CrossRef] [PubMed]
 
Cook CH. Cytomegalovirus reactivation in “immunocompetent” patients: a call for scientific prophylaxis. J Infect Dis. 2007;1969:1273-1275. [CrossRef] [PubMed]
 
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