Does prevention of cytomegalovirus (CMV) reactivation with ganciclovir reduce plasma interleukin 6 (IL-6) levels among CMV-seropositive adults with critical illness due to sepsis or trauma?
In this multicenter randomized clinical trial of 160 adults, treatment with ganciclovir vs placebo did not significantly reduce plasma IL-6 levels (mean change from days 1 to 14, −0.79 and −0.79 log10 units, respectively).
Treatment with ganciclovir in adults who were critically ill did not significantly reduce IL-6 levels, and these findings do not support routine prophylactic use in this setting.
The role of cytomegalovirus (CMV) reactivation in mediating adverse clinical outcomes in nonimmunosuppressed adults with critical illness is unknown.
To determine whether ganciclovir prophylaxis reduces plasma interleukin 6 (IL-6) levels in CMV-seropositive adults who are critically ill.
Design, Setting, and Participants
Double-blind, placebo-controlled, randomized clinical trial (conducted March 10, 2011-April 29, 2016) with a follow-up of 180 days (November 10, 2016) that included 160 CMV-seropositive adults with either sepsis or trauma and respiratory failure at 14 university intensive care units (ICUs) across the United States.
Patients were randomized (1:1) to receive either intravenous ganciclovir (5 mg/kg twice daily for 5 days), followed by either intravenous ganciclovir or oral valganciclovir once daily until hospital discharge (n = 84) or to receive matching placebo (n = 76).
Main Outcomes and Measures
The primary outcome was change in IL-6 level from day 1 to 14. Secondary outcomes were incidence of CMV reactivation in plasma, mechanical ventilation days, incidence of secondary bacteremia or fungemia, ICU length of stay, mortality, and ventilator-free days (VFDs) at 28 days.
Among 160 randomized patients (mean age, 57 years; women, 43%), 156 patients received 1or more dose(s) of study medication, and 132 patients (85%) completed the study. The mean change in plasma IL-6 levels between groups was −0.79 log10 units (−2.06 to 0.48) in the ganciclovir group and −0.79 log10 units (−2.14 to 0.56) in the placebo group (point estimate of difference, 0 [95% CI, −0.3 to 0.3]; P > .99). Among secondary outcomes, CMV reactivation in plasma was significantly lower in the ganciclovir group (12% [10 of 84 patients] vs 39% [28 of 72 patients]); absolute risk difference, −27 (95% CI, −40 to −14), P < .001. The ganciclovir group had more median VFDs in both the intention-to-treat (ITT) group and in the prespecified sepsis subgroup (ITT group: 23 days in ganciclovir group vs 20 days in the placebo group, P = .05; sepsis subgroup, 23 days in the ganciclovir group vs 20 days in the placebo group, P = .03). There were no significant differences between the ganciclovir and placebo groups in duration of mechanical ventilation (5 days for the ganciclovir group vs 6 days for the placebo group, P = .16), incidence of secondary bacteremia or fungemia (15% for the ganciclovir group vs 15% for the placebo group, P = .67), ICU length of stay (8 days for the ganciclovir group vs 8 days for the placebo group, P = .76), or mortality (12% for the ganciclovir group vs 15% for the placebo group, P = .54).
Conclusions and Relevance
Among CMV-seropositive adults with critical illness due to sepsis or trauma, ganciclovir did not reduce IL-6 levels and the current study does not support routine clinical use of ganciclovir as a prophylactic agent in patients with sepsis. Additional research is necessary to determine the clinical efficacy and safety of CMV suppression in this setting.
clinicaltrials.gov Identifier: NCT01335932
Ajit P. Limaye, Renee D. Stapleton, Lili Peng, Scott R. Gunn, Louise E. Kimball, Robert Hyzy, Matthew C. Exline, D. Clark Files, Peter E. Morris, Stephen K. Frankel, Mark E. Mikkelsen, Duncan Hite, Kyle B. Enfield, Jay Steingrub, James O’Brien, Polly E. Parsons, Joseph Cuschieri, Richard G. Wunderink, David L. Hotchkin, Ying Q. Chen, Gordon D. Rubenfeld, Michael Boeckh. Effect of Ganciclovir on IL-6 Levels Among Cytomegalovirus-Seropositive Adults With Critical IllnessA Randomized Clinical Trial. JAMA. 2017;318(8):731–740. doi:10.1001/jama.2017.10569