What is the treatment approach for adenovirus infection in children?

Treatment of Adenovirus Infection in Children

Most adenovirus infections in immunocompetent children require only supportive care with hydration, antipyretics, and respiratory support as needed, while cidofovir (5 mg/kg IV weekly) is reserved for life-threatening infections in severely ill or immunocompromised children. 1

Immunocompetent Children with Mild-Moderate Disease

Supportive care is the cornerstone of management for the vast majority of children with adenovirus infection 1. The infection is typically self-limited, resolving within 7-10 days without specific antiviral therapy 1.

Supportive Measures Include:

• Adequate hydration to maintain fluid balance 1
• Antipyretics for fever management 1
• Respiratory support as clinically indicated (oxygen, nebulizers) 1
• Monitoring for clinical deterioration over the typical 7-10 day illness course 1

What to Avoid:

• Antibiotics should not be routinely prescribed for viral adenovirus infections 2. Studies show that 46% of children with adenovirus receive unnecessary antibiotics at presentation, yet only 1.4% have documented bacterial co-infection 3. This represents a significant opportunity to improve antibiotic stewardship.

Severe or Life-Threatening Infections

Cidofovir is the treatment of choice for severe adenovirus infections, particularly in immunocompromised children or those with disseminated disease 1, 4, 5. While randomized controlled trials are lacking, cidofovir represents the best available option when mortality risk exceeds 50% in untreated severe disease 4, 5.

Cidofovir Dosing and Monitoring:

• Standard regimen: 5 mg/kg IV once weekly for 2 weeks, then every other week 1
• Alternative low-dose regimen: 1 mg/kg three times weekly for preemptive treatment in high-risk patients (e.g., post-hematopoietic stem cell transplant) 6
• Mandatory renal function monitoring is essential due to considerable nephrotoxicity risk 1
• Hydration protocols should accompany cidofovir administration to minimize renal toxicity 1

Indications for Cidofovir:

• Disseminated adenovirus disease 1, 4
• Severe pneumonia with respiratory failure 4, 5
• Immunocompromised hosts (transplant recipients, HIV, congenital immunodeficiency) 4, 5
• Fulminant hepatitis (case reports show potential life-saving benefit) 3
• Life-threatening manifestations (hemorrhagic colitis, myocarditis, encephalitis) 4, 5

Clinical pearl: In one case series, cidofovir was used in 21 PICU patients, including 11 previously healthy children, without attributable side effects when properly monitored 7. This suggests that with appropriate precautions, cidofovir can be safely used even in immunocompetent children with severe disease.

Special Clinical Scenarios

Adenoviral Conjunctivitis (Epidemic Keratoconjunctivitis):

• No proven effective antiviral treatment exists for eradication 2
• Symptomatic relief: artificial tears, topical antihistamines, cold compresses, oral analgesics 2
• Topical corticosteroids are indicated for severe cases with marked chemosis, lid swelling, epithelial sloughing, or membranous conjunctivitis to reduce symptoms and prevent scarring 2
• Membrane debridement should be considered to prevent corneal epithelial abrasions or permanent cicatricial changes 2
• Close follow-up is mandatory for patients on topical corticosteroids, with monitoring for increased intraocular pressure and cataract formation 2

Important caveat: Animal studies show topical corticosteroids prolong viral shedding in adenoviral conjunctivitis, though human data are lacking 2. Balance symptom relief against potential prolonged infectivity.

Suspected Kawasaki Disease:

Rapid adenovirus testing can be life-saving in this context 3. In one series, 100% of children with suspected Kawasaki disease had positive adenovirus testing, and immune globulin was appropriately withheld in 4 of 5 cases 3. This prevents unnecessary expensive treatment and potential complications.

Infection Control Measures

Adenovirus is highly contagious and remarkably hardy, surviving on surfaces for up to 28 days 1.

Key Infection Control Strategies:

• Patients are infectious for 10-14 days from symptom onset 2, 1
• Hand hygiene with soap and water is essential (alcohol-based sanitizers are less effective) 1
• Dilute bleach solution for equipment and surface disinfection 1
• Isolation in hospitals and daycare settings to prevent outbreaks 1
• Minimize contact with others for 10-14 days, particularly challenging for healthcare workers, food service, and sales personnel 2

Prognostic Factors

High-Risk Features:

• Adenovirus serotypes 3 and 7 have worse prognosis 1
• Age under 1 year with myocarditis: 5-year survival only 66% with adenovirus versus 95% without 1
• Immunocompromised status: fatality rates exceed 50% for untreated severe pneumonia or disseminated disease 4, 5

When to Escalate Care:

• Respiratory distress requiring supplemental oxygen or mechanical ventilation 1
• Signs of dissemination (hepatitis, hemorrhagic colitis, encephalitis) 4, 5
• Immunocompromised host with any adenovirus detection 1, 6
• Persistent fever beyond 7-10 days or clinical deterioration 1

Critical pitfall: Nearly half of previously healthy children admitted to PICU with adenovirus were immunocompetent 7. Do not assume severe disease only occurs in immunocompromised hosts—previously healthy children can develop life-threatening adenovirus infections requiring cidofovir.