title: Cytomegalovirus reactivation and associated outcome of critically ill patients with severe sepsis.
abstract: BACKGROUND
  Sepsis has been identified as a risk factor for human cytomegalovirus (CMV) reactivation in critically ill patients. However, the contribution of CMV reactivation on morbidity and mortality is still controversial. Therefore, we analyzed the incidence and impact of CMV reactivation on outcome in patients with severe sepsis.
  
  
  METHODS
  In a prospective longitudinal double-blinded observational study, 97 adult nonimmunosuppressed CMV-seropositive patients with new onset of severe sepsis were included. Leukocytes, plasma and tracheal secretions were examined weekly for CMV-DNA by PCR. Tracheal secretions were additionally tested for HSV (Herpes Simplex Virus)-DNA. The influence of CMV-reactivation on the endpoints was analysed by Cox proportional-hazard regression analysis. Time-dependency was evaluated by landmark analysis.
  
  
  RESULTS
  Six out 97 died and five were discharged from the hospital within 72 hours and were excluded of the analysis. CMV reactivation occurred in 35 of the 86 (40.69%) analysed patients. HSV infection occurred in 23 of the 35 (65.7%) CMV reactivators. In 10 patients CMV-plasma-DNAemia appeared with a DNA-content below 600 copies/ml in four cases and a peak amount of 2,830 copies/ml on average. In patients with and without CMV reactivation mortality rates were similar (37.1% vs. 35.3%, P = 0.861), respectively. However, in the multivariate COX regression analyses CMV reactivation was independently associated with increased length of stay in the ICU (30.0, interquartile range 14 to 48 vs. 12.0, interquartile range 7 to 19 days; HR (hazard ratio) 3.365; 95% CI (confidence interval) 1.233 to 9.183, P = 0.018) and in the hospital (33.0, interquartile range 24 to 62 vs. 16.0, interquartile range 10 to 24 days, HR 3.3, 95% CI 1.78 to 6.25, P < 0.001) as well as prolonged mechanical ventilation (22.0, interquartile range 6 to 36 vs. 7.5, interquartile range 5 to 15.5 days; HR 2.6,CI 95% 1.39 to 4.94; P < 0.001) and impaired pulmonary gas exchange (six days, interquartile range 1 to 17, vs. three, interquartile range 1 to 7, days in reactivators vs. non-reactivators, P = 0.038). HSV reactivation proved not to be a risk factor for these adverse effects.
  
  
  CONCLUSIONS
  These data indicate an independent correlation between CMV reactivation and increased morbidity in the well-defined group of nonimmunosuppressed patients with severe sepsis, but CMV reactivation had no impact on mortality in this group with low CMV-DNA plasma levels. Thus, the potential harms and benefits of antiviral treatment have to be weighed cautiously in patients with severe sepsis or septic shock.
authors.affiliation: Klinik für Anaesthesiologie und Intensivmedizin, University Hospital of Tübingen, Hoppe-Seyler-Str.03, 72076 Tübingen, Germany.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Heininger
authors.forename: Helene
authors.initials: H
authors.lastname: Haeberle
authors.forename: Imma
authors.initials: I
authors.lastname: Fischer
authors.forename: Robert
authors.initials: R
authors.lastname: Beck
authors.forename: Reimer
authors.initials: R
authors.lastname: Riessen
authors.forename: Frank
authors.initials: F
authors.lastname: Rohde
authors.forename: Christoph
authors.initials: C
authors.lastname: Meisner
authors.forename: Gerhard
authors.initials: G
authors.lastname: Jahn
authors.forename: Alfred
authors.initials: A
authors.lastname: Koenigsrainer
authors.forename: Klaus
authors.initials: K
authors.lastname: Unertl
authors.forename: Klaus
authors.initials: K
authors.lastname: Hamprecht
mesh_terms: D000368:Aged; D016638:Critical Illness; D003587:Cytomegalovirus / Q000502:physiology*; D003586:Cytomegalovirus Infections / Q000401:mortality / Q000821:virology*; D004311:Double-Blind Method; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012121:Respiration, Artificial; D018805:Sepsis / Q000401:mortality / Q000821:virology*; D016896:Treatment Outcome; D014775:Virus Activation