Is acyclovir effective among critically ill patients with herpes simplex in the respiratory tract?

• The relevance of HSV-1 in the respiratory tract of ICU patients is unclear.
• We retrospectively reviewed ICU patients with a positive respiratory HSV-1 culture.
• Acyclovir treatment was positively linked to in-hospital and ICU-mortality reduction.
• The group with HSV-1 in the BAL-fluid is the sole contributor to this difference.
• These results warrant a prospective trial to prove causality.

Background and objectiveThe relevance of the detection of herpes simplex virus type 1 (HSV-1) in the respiratory tract of patients in the intensive care unit (ICU) is unclear. Therefore, it is uncertain whether treatment with an antiviral agent could be beneficial for these patients.Study designWe retrospectively reviewed the records of ICU patients with a positive HSV-1 culture in the respiratory tract or bronchoalveolar lavage (BAL) fluid. We evaluated whether acyclovir treatment (n = 106) could have a beneficial effect on mortality as compared with the standard treatment (n = 106).ResultsAcyclovir treatment was positively linked to in-hospital and ICU-mortality reduction. This favourable influence remained present after correcting for possible confounders and using propensity-adjusted and propensity-matched cohorts: with an odds ratio in the treated group of 3.19 (95% CI 1.79–5.69, p = 0.001) for ICU survival and of 3.55 (95% CI 2.16–5.85, p < 0.001) for in-hospital survival. The subgroup with HSV-1 detected in the BAL-fluid is the sole contributor to this difference. In the BAL-fluid detected group, 48% (n = 10) of non-treated patients died in the ICU, versus 21% (n = 6) in the acyclovir-treated group (p = 0.033), occurring despite an even longer duration of ventilation or ICU stay.ConclusionsThese data highlight the hypothesis that it might be worthwhile to consider treatment of HSV-1 in ICU patients depending on the type of respiratory sample in which the virus is detected. These results warrant a prospective trial to prove causality.