What is the recommended management of adenovirus infection in children and young adults, including supportive care for immunocompetent patients and antiviral therapy for severe disease or immunocompromised individuals?

Management of Adenovirus Infection

For immunocompetent patients with adenovirus infection, supportive care is the standard of care, while severely ill immunocompromised patients with pneumonia, hepatitis, disseminated infection, or severe gastroenteritis should receive cidofovir antiviral therapy. 1, 2

Immunocompetent Patients: Supportive Care Only

Symptomatic Management

• Provide symptomatic relief with artificial tears for conjunctivitis, cold compresses, and oral analgesics for pain management 1
• Maintain adequate hydration, particularly in patients with gastrointestinal manifestations 1
• For fever >38.5°C, administer ibuprofen 0.2g orally every 4-6 hours as needed (maximum 4 times in 24 hours); temperatures below 38°C may be beneficial for antiviral immune response 2
• Do NOT prescribe antibiotics for adenovirus infection in immunocompetent patients—they provide no benefit and contribute to antimicrobial resistance 1

Infection Control Measures

• Educate patients that adenovirus is highly contagious and can survive for weeks on surfaces 1
• Advise minimizing contact with others for 10-14 days from symptom onset 1
• In healthcare settings, implement standard, contact, and droplet precautions with rigorous hand hygiene using soap and water or alcohol-based hand rubs 1
• Wear gloves when entering patient rooms, gowns when soiling with respiratory secretions is anticipated, and surgical masks with eye protection when within 3 feet of infected patients 1
• Place patients in private rooms when possible or cohort with other adenovirus-infected patients 1
• Disinfect surfaces with EPA-registered hospital disinfectants or sodium hypochlorite (1:10 dilution of household bleach) 1

Special Ophthalmologic Considerations

• 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 1
• Monitor for increased intraocular pressure and cataract formation when using corticosteroids 1
• Taper slowly to the minimum effective dose, recognizing that corticosteroids may prolong viral shedding 1
• Do NOT use topical corticosteroids without confirming the diagnosis is not herpes simplex virus, as corticosteroids can worsen HSV infections and lead to corneal scarring 1
• Debride membranes in membranous conjunctivitis to prevent corneal epithelial abrasions or permanent cicatricial changes 1

Immunocompromised Patients: Antiviral Therapy

Indications for Cidofovir

Cidofovir is the drug of choice for severely ill immunocompromised patients with adenovirus-associated disease including pneumonia, hepatitis, disseminated infection, or severe gastroenteritis 1, 3, 4, 5

Dosing Regimens

• 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 1
• Monitor closely for nephrotoxicity, which is the primary limiting adverse effect of cidofovir 1
• Not all immunocompromised patients require antiviral treatment—reserve cidofovir for severe or disseminated disease given its nephrotoxicity 1

Supportive Care for Severe Pneumonia

• Provide oxygen therapy titrated to maintain adequate saturation, starting at 5 L/min and adjusting to target oxygen levels 2
• Escalate respiratory support based on severity: nasal catheter → mask oxygen → high-flow nasal oxygen (HFNO) → non-invasive ventilation (NIV) → invasive mechanical ventilation 2
• For moderate-to-severe ARDS (PaO₂/FiO₂ < 150), implement protective lung ventilation with higher PEEP and prone positioning for >12 hours daily 2
• Consider ECMO for refractory hypoxemia unresponsive to conventional mechanical ventilation 2

Monitoring and Nutritional Support

• Continuously monitor vital signs (heart rate, oxygen saturation, respiratory rate, blood pressure) 2
• Perform regular laboratory monitoring including complete blood count, CRP, PCT, organ function tests, coagulation studies, and arterial blood gases 2
• Obtain serial chest imaging to assess disease progression 2
• For patients with nutrition risk scores <3: provide protein-rich foods with energy intake of 25-30 kcal/(kg·d) and protein 1.5 g/(kg·d) 2
• For patients with nutrition risk scores ≥3: initiate early nutritional support with increased protein intake (≥18g protein per oral supplement, 2-3 times daily) 2

Management of Secondary Bacterial Infections

• Maintain high suspicion for bacterial superinfection but avoid blind or inappropriate use of antibiotics 2
• Perform bacteriological surveillance and administer antibiotics only when secondary bacterial infection is suspected or documented 2
• For mild cases with suspected bacterial co-infection: use antibiotics effective against community-acquired pneumonia (amoxicillin, azithromycin, or fluoroquinolones) 2
• For severe cases: initiate empirical broad-spectrum antibacterial coverage for all possible pathogens, then de-escalate once causative bacteria are identified 2

Corticosteroid Use in Severe Disease

• Corticosteroid use should be approached with extreme caution and reserved only for patients with rapid disease progression or severe illness 2
• If used, administer methylprednisolone 40-80 mg daily (not exceeding 2 mg/kg daily) for short periods (3-5 days) 2
• Be aware that corticosteroids may improve clinical symptoms and accelerate lung lesion absorption but do not shorten hospital stay, and higher corticosteroid exposure is associated with increased risk of severe disease in some viral pneumonias 2

Diagnostic Approach

• 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 1
• Use nasopharyngeal swabs for respiratory disease and conjunctival swabs for ocular disease 1

Key Clinical Pitfalls to Avoid

• Do not underestimate the contagiousness of adenovirus—the virus survives for weeks on surfaces, requiring rigorous infection control measures 1
• Restrict healthcare personnel with acute upper respiratory tract infections from caring for high-risk patients (infants, immunocompromised, cardiac patients, premature infants) 1
• Fatality rates for untreated severe adenovirus pneumonia or disseminated disease in immunocompromised patients may exceed 50%, making early recognition and treatment critical 3, 4, 5