What is the treatment approach for a patient with adenovirus infection, considering the severity of symptoms and potential underlying health conditions?

Treatment of Adenovirus Infection

For immunocompetent patients with adenovirus infection, treatment is supportive care only, as the vast majority of cases are self-limited and resolve without specific antiviral therapy. 1, 2, 3

Immunocompetent Patients

Supportive Care Approach

• Provide symptomatic relief with artificial tears for conjunctivitis, cold compresses, and oral analgesics for pain management. 4
• Maintain adequate hydration, particularly in patients with gastrointestinal manifestations. 5
• Monitor for secondary bacterial infections, but avoid prophylactic antibiotics as they provide no benefit for viral infections and may cause unnecessary toxicity. 4, 6
• Educate patients about the highly contagious nature of adenovirus, which can survive for weeks on surfaces, and advise minimizing contact with others for 10-14 days from symptom onset. 4, 5

Infection Control Measures

• Implement standard, contact, and droplet precautions in healthcare settings, including hand hygiene with soap and water or alcohol-based hand rubs. 7
• Wear gloves when entering the room of patients with confirmed or suspected adenovirus infection. 7
• Wear gowns when soiling with respiratory secretions is anticipated and change between patients. 7
• Wear a surgical mask and eye protection or face shield when within 3 feet of a patient with suspected or confirmed adenovirus infection. 7
• Place patients in private rooms when possible or cohort with other adenovirus-infected patients without other infections. 7
• Disinfect surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach). 4, 6

Special Considerations for Severe Conjunctivitis

• For severe adenoviral keratoconjunctivitis with subepithelial infiltrates causing blurred vision or photophobia, consider topical corticosteroids (fluorometholone, rimexolone, or loteprednol) with mandatory close ophthalmology follow-up. 4, 6
• Monitor for increased intraocular pressure and cataract formation when using corticosteroids. 4, 6
• Taper slowly to the minimum effective dose, recognizing that corticosteroids may prolong viral shedding. 4
• Debride membranes in membranous conjunctivitis to prevent corneal epithelial abrasions or permanent cicatricial changes. 4

Immunocompromised Patients

Risk Stratification

• Immunocompromised patients, including hematopoietic stem cell transplant recipients, solid organ transplant recipients, and those with HIV infection, are at significantly higher risk for severe disease and dissemination, with fatality rates exceeding 50% for untreated severe pneumonia or disseminated disease. 1, 2, 3

Antiviral Therapy Indications

• For severely ill immunocompromised patients with adenovirus-associated disease (pneumonia, hepatitis, disseminated infection, or severe gastroenteritis), cidofovir is the drug of choice despite lack of prospective randomized trials. 7, 1, 2, 3
• Consider low-dose cidofovir (1 mg/kg three times weekly) or standard dosing (5 mg/kg once weekly for 2 weeks, then once every other week) based on severity and renal function. 7
• Monitor closely for nephrotoxicity, which is the primary limiting adverse effect of cidofovir. 7

Emerging Therapies

• Brincidofovir, an orally bioavailable lipid conjugate of cidofovir, has better safety profile and great in vitro potency against adenovirus but availability may be limited. 8
• Adoptive T-cell therapy has shown promise in achieving viral clearance and improving survival in transplant recipients but is constrained by manufacturing complexity and risk of graft-versus-host disease. 9, 8

Diagnostic Approach for Treatment Decisions

• Promptly perform rapid diagnostic laboratory tests (sensitivity 88-89%, specificity 91-94%) or PCR testing on patients admitted with symptoms to facilitate early initiation of treatment when indicated. 7, 5
• Use nasopharyngeal swabs for respiratory disease and conjunctival swabs for ocular disease. 5

Common Pitfalls to Avoid

• Do not prescribe antibiotics for adenovirus infection in immunocompetent patients, as they provide no benefit and contribute to antimicrobial resistance. 4, 6
• Do not use topical corticosteroids for conjunctivitis without confirming the diagnosis is not herpes simplex virus, as corticosteroids can worsen HSV infections and lead to corneal scarring. 4, 6
• Do not underestimate the contagiousness of adenovirus—the virus survives for weeks on surfaces, requiring rigorous infection control measures. 4, 5
• Not all immunocompromised patients require antiviral treatment—reserve cidofovir for severe or disseminated disease given its nephrotoxicity. 7, 1, 2, 3
• Restrict healthcare personnel with acute upper respiratory tract infections from caring for high-risk patients (infants, immunocompromised, cardiac patients, premature infants). 7