Risk Factors for Hypoxia, Mechanical Ventilation, and Mortality in Lung Transplant Recipients Hospitalized with Respiratory Syncytial Virus: A Multicenter International Cohort Study

Abstract Background Lung transplant (LT) recipients are at high risk for severe respiratory syncytial virus (RSV) infection, but predictors of worse outcomes remain poorly defined. Methods Retrospective multicenter cohort study of adult LT recipients hospitalized with PCR-confirmed RSV infection between January 2016 and December 2019. Clinical characteristics, treatments, and outcomes within 90 days were analyzed. Logistic regression was used to identify predictors of outcomes, while Cox proportional hazards models assessed risk factors for mortality. Results 155 LT recipients were included. Median age was 61 years, RSV occurred a median of 14 months post-transplant. Risk factors for hypoxic respiratory failure were baseline oxygen use [OR 4.8, (1.29–23.93)] and lower respiratory tract symptoms [OR 3.74, (1.49–10.18)]. Older age increased the risk of mechanical ventilation [OR 1.06, (1.02–1.12)], while oral ribavirin was associated with reduced risk [OR 0.34, (0.14–0.82)]; this association was attenuated when oral and inhaled ribavirin were combined into a single exposure variable [OR 0.77, (0.22–2.66)]; oral ribavirin was not associated with reduced 90-day mortality [HR 5.27, (0.68–40.83)]. Secondary bacterial or fungal infections occurred in 33.5%, associated with prior mechanical ventilation. Lung function declined significantly post-RSV infection, with nearly half experiencing >10% decrease in FEV1. Ninety-day all-cause mortality was 7.7%, with mechanical ventilation independently associated with death [HR 7.79, (2.47–24.60)]. Conclusions RSV infection in LT recipients is associated with high morbidity, graft function decline, and mortality. The association between older age and severe outcomes suggests the importance of preventive strategies in this high-risk population.