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Viral Pneumonia Medication

  • Author: Zab Mosenifar, MD, FACP, FCCP; Chief Editor: Ryland P Byrd, Jr, MD  more...
 
Updated: Jul 11, 2016
 

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Few specific antiviral agents exist. Acyclovir (for varicella and herpes simplex pneumonia) is efficacious. Ganciclovir and immunoglobulin are used in immunocompromised patients with CMV pneumonia.

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Antiviral agents

Class Summary

Acute lower respiratory tract infection from viral etiologies can be treated with antiviral agents. These agents inhibit DNA synthesis and viral replication by competing with deoxyguanosine triphosphate for viral DNA polymerase.

Agents used include amantadine, rimantadine, zanamivir, oseltamivir, ribavirin, acyclovir, ganciclovir, and foscarnet are used. The influenza drugs may be used as either prophylactic or therapeutic agents. Hyperimmune globulin is used primarily for passive immunization in some viral illnesses.

Zanamivir (Relenza)

 

Zanamivir inhibits neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, the release of viruses from infected cells and viral spread are decreased. Zanamivir is effective against influenza types A and B. The drug is inhaled through the Diskhaler oral inhalation device. Circular foil discs containing 5-mg blisters of the drug are inserted into the supplied inhalation device.

Oseltamivir (Tamiflu)

 

Oseltamivir inhibits neuraminidase, which is a glycoprotein on the surface of influenza virus that destroys an infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, it decreases the release of viruses from infected cells and thus viral spread. Oseltamivir is effective for treatment of influenza A or B infection, although resistant strains of seasonal influenza and H1N1 have been reported. Start within 40 hours of symptom onset.

Peramivir (Rapivab)

 

Peramivir elicits antiviral activity by inhibiting influenza virus neuraminidase, an enzyme that releases viral particles from the plasma membrane of infected cells. It is indicated for the treatment of acute uncomplicated influenza in adults who have been symptomatic for no more than 2 days. It is administered as a single 600 mg IV dose infused over 15-30 minutes.

Ribavirin (Virazole)

 

Ribavirin inhibits viral replication by inhibiting DNA and RNA synthesis. It has shown in vitro antiviral properties against RSV, parainfluenza, hantavirus, measles, and many other.

Acyclovir (Zovirax)

 

Acyclovir inhibits activity of both HSV-1 and HSV-2. It has affinity for viral thymidine kinase and, once phosphorylated, causes DNA chain termination when acted on by DNA polymerase. Patients experience less pain and faster resolution of HSV or VZV lesions when used within 24-48 hours of rash onset. Early initiation of therapy is imperative.

Ganciclovir (Cytovene, Vitrasert)

 

Ganciclovir is a synthetic guanine derivative that is active against CMV, HSV, HHV-6, and HHV-8. It is an acyclic nucleoside analog of 2'-deoxyguanosine that inhibits replication of herpesviruses both in vitro and in vivo. levels of ganciclovir-triphosphate are as much as 100-fold greater in CMV-infected cells than in uninfected cells, possibly because of preferential phosphorylation of ganciclovir in virus-infected cells. An oral prodrug, valganciclovir, is now available.

Foscarnet (Foscavir)

 

Foscarnet is an organic analog of inorganic pyrophosphate that inhibits replication of known herpesviruses, including CMV, HSV-1, and HSV-2. It inhibits viral replication at pyrophosphate-binding sites on virus-specific DNA polymerases. Poor clinical response or persistent viral excretion during therapy may result from viral resistance. Patients who can tolerate foscarnet well may benefit from initiation of maintenance treatment at 120 mg/kg/d early in treatment. Individualize dosing based on renal function status.

Cidofovir (Vistide)

 

Cidofovir has demonstrated good in vitro activity against adenoviruses, including serotype 14. Cidofovir has shown some efficacy in treating adenovirus infection in immunocompromised patients, especially HSCT recipients.

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Monoclonal Antibodies

Class Summary

Humanized monoclonal antibodies such as palivizumab are useful in the prevention of lower respiratory tract disease caused by RSV in pediatric patients.

Palivizumab (Synagis)

 

Palivizumab is a humanized monoclonal antibody directed against the F (fusion) protein of RSV. Given monthly through the RSV season, it has been demonstrated to decrease the chances of RSV hospitalization in premature babies who are at increased risk for severe RSV-related illness.

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Immune Globulins

Class Summary

High-dose intravenous immunoglobulin has been used successfully in conjunction with ganciclovir for the treatment of CMV pneumonia.

Immune globulin IV (Gamimune, Gammagard, Sandoglobulin, Gammar-P)

 

Immune globulin IV neutralizes circulating myelin antibodies through anti-idiotypic antibodies. It down-regulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T cells and B cells; and augments suppressor T cells. The drug also blocks the complement cascade, promotes remyelination, and may increase CSF IgG levels (10%).

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Beta-Agonists

Class Summary

Many patients with viral pneumonia have bronchospasm, which is relieved or improved with the use of beta-agonist drugs.

Albuterol (Proventil)

 

Albuterol is a beta-agonist used to treat bronchospasm. It relaxes bronchial smooth muscle with its action on beta2-receptors. It has little effect on cardiac muscle contractility.

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Contributor Information and Disclosures
Author

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Arthur Jeng, MD Assistant Professor of Clinical Medicine, University of California at Los Angeles School of Medicine

Arthur Jeng, MD is a member of the following medical societies: Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgements

Shakeel Amanullah, MD Consulting Physician, Pulmonary, Critical Care, and Sleep Medicine, Lancaster General Hospital

Shakeel Amanullah, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

Dan V Dinescu, MD Fellow in Pulmonary Medicine, Department of Internal Medicine, Memorial Sloan Kettering Cancer Center

Dan V Dinescu, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Thoracic Society, Medical Society of the State of New York, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Kavita Garg, MD Professor, Department of Radiology, University of Colorado School of Medicine

Kavita Garg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Gloria J Kuhn, DO, PhD, FACEP Professor, Vice-Chair of Academic Affairs, Dept of Emergency Medicine, Wayne State University School of Medicine; Professor, Department of Internal Medicine, Section of Emergency Medicine, Michigan State University College of Osteopathic Medicine

Gloria J Kuhn, DO, PhD, FACEP is a member of the following medical societies: American Osteopathic Association

Disclosure: Nothing to disclose.

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Mark L Shapiro, MD Chief, Department of Radiology, Englewood Hospital and Medical Center

Mark L Shapiro, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America

Disclosure: Nothing to disclose.

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Satinder P Singh, MD, FCCP Professor of Radiology and Medicine, Chief of Cardiopulmonary Radiology, Director of Cardiac CT, Director of Combined Cardiopulmonary and Abdominal Radiology, Department of Radiology, University of Alabama at Birmingham School of Medicine

Disclosure: Nothing to disclose.

Eric J Stern, MD Professor of Radiology, Adjunct Professor of Medicine, Adjunct Professor of Medical Education and Biomedical Informatics, Adjunct Professor of Global Health, Vice-Chair, Academic Affairs, University of Washington School of Medicine

Eric J Stern, MD is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, European Society of Radiology, Radiological Society of North America, and Society of Thoracic Radiology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Head of Infectious Disease Fellowship Program, Orlando Regional Medical Center

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

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Pneumonia, viral: A 52-year-old woman developed fever, cough, and dyspnea. She also developed a rash that was prominent over the face and the trunk. The chest radiograph showed interstitial infiltrates, with suggestion of a micronodular process. The Tzanck smear results from the skin vesicle suggest varicella-zoster virus.
Pneumonia, viral: A 52-year-old woman developed fever, cough, and dyspnea. She also developed a rash that was prominent over the face and the trunk. The chest radiograph showed interstitial infiltrates, with suggestion of a micronodular process. The Tzanck smear results from the skin vesicle suggest varicella-zoster virus. She was treated with acyclovir; resolution of varicella-zoster virus infection occurred after 7 days of therapy.
Bilateral interstitial infiltrates in a 31-year-old patient with influenza pneumonia.
Right-middle-lobe infiltrate in a 2-month-old boy with pneumonia due to respiratory syncytial virus (RSV).
High-power Papanicolaou (Pap) stain showing a virus on a bronchial wash. Viruses in general show "smudgy" nuclei, may or may not show nuclear or cytoplasmic inclusions, and may demonstrate other features such as multinucleation or margination of chromatin to the periphery of the cell nucleus. Certain features are more indicative of one virus over another. This is an example of herpes virus (cells infected are located in the center right).
High-power Papanicolaou (Pap) stain of cytomegalovirus (center). This cell has a very large, dark intranuclear inclusion.
High-power hematoxin-and-eosin stain of giant cell pneumonia following measles. A multinucleated cell (center) contains eosinophilic intranuclear inclusions.
High-power hematoxin-and-eosin stain of numerous cells infected with the cytomegalovirus (large cells with enlarged nuclei containing dark-purple intranuclear inclusions surrounded by a clear halo).
High-power hematoxin-and-eosin stained herpes simplexvirus, characterized by "smudgy" degenerating nuclei. Some cells are multinucleated with margination of the chromatin to the periphery of the nuclei and molding of the nuclei to each other.
Table 1. Diagnostic Techniques Used for Viral Pneumonia
Virus Viral Culture Cytologic Evaluation Rapid Antigen Detection Gene Amplification
Influenza virus HAa, SVb   IFc, ELISAd RT-PCRe
Adenovirus CEf, SV Intranuclear inclusions IF, ELISA RT-PCR
Paramyxoviruses
Respiratory syncytial virus CE, SV Eosinophilic cytoplasmic inclusions IF, ELISA RT-PCR
Parainfluenza virus HA, SV Eosinophilic intranuclear inclusions IF, ELISA RT-PCR
Measles virus HA      
Herpes viruses
Herpes simplex virus CE, SV Cytoplasmic inclusions IF, ELISA PCR
Varicella-zoster virus CE Cytoplasmic inclusions IF RT-PCR
Cytomegalovirus CE, SV "Owl's eye" cells IF, ELISA RT-PCR
Hantavirus     Antibodies against FCVg FVC RNA by RT-PCR
a HA - Hemaglutination



b SV - Shell viral culture



c IF - Immunofluorescence



d ELISA - Enzyme-linked immunosorbent assay



eRT-PCR - Reverse transcriptase polymerase chain reaction



fCE - Cytopathogenic effects



gFCV - Four corners virus



Table 2. Treatment and Prevention of Common Causes of Viral Pneumonia
Virus Treatment Prevention
Influenza virus Oseltamivir



Peramivir



Zanamivir



Influenza vaccine



Chemoprophylaxis with:



Zanamivir



Oseltamivir



Respiratory syncytial virus Ribavirin RSV immunoglobulin



Palivizumab



Parainfluenza virus Ribavirin  
Herpes simplex virus Acyclovir  
Varicella-zoster virus Acyclovir Varicella-zoster immunoglobulin
Adenovirus Ribavirin  
Measles virus Ribavirin Intravenous immunoglobulin
Cytomegalovirus Ganciclovir



Foscarnet



Intravenous immunoglobulin
Table 3. Characteristics of Anti-Influenza Drugs
  Amantadine



(Symmetrel)



Rimantadine



(Flumadine)



Zanamivir



(Relenza)



Oseltamivir



(Tamiflu)



Mechanism of action M2 ion channel blockade inhibits HAa cleavage beta block RNA encoding, which reduces early viral replication. Viral NAb inhibition prevents sialic acid cleavage from HA beta virus gets trapped inside cells, and epithelial spread is blocked.
Spectrum Influenza A only Influenza A only Influenza A and B Influenza A and B
Oral bioavailability Good Good Poor Good
Protein binding, % 67 40 None Minimal
Half-life, h 12-18 24-36 2.5-5 1-3
Excretion Renal (not removed by hemodialysis)   Renal and gastrointestinal Renal
Drug interaction Synergistic CNS toxicity with antihistamines, anticholinergics, CNS stimulants Beta Plasma level: ASAc, acetaminophen None None
Renal clearance TMP-SMZd, triamterene, hydrochlorothiazide, quinine sulfate, quinidine Cimetidine None None
a HA - Hemagglutinin



b NA - Neuraminidase



c ASA - Acetylsalicylic acid



d TMP-SMZ - Trimethoprim and sulfamethoxazole



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