Ribavirin for respiratory syncytial virus infection.

Over the winter of 1988, 10 infants with congenital heart disease were treated for severe bronchiolitis at Guy's Hospital. All required respiratory support of greater than 50% oxygen in a headbox, and seven required assisted ventilation. Seven patients were positive for respiratory syncytial virus, and seven received nebulised ribavirin for three to five days. There were four deaths, all infants with pre-existing pulmonary hypertension (see table). Despite the early use of nebulised ribavirin, supervised by Brittania Pharmaceuticals Ltd, some patients continued to deteriorate. Only three patients showed some improvement after ribavirin use. No patient improved when ribavirin was first used after ventilation had commenced. Indeed one child had an unexplained cardiorespiratory collapse on the ventilator shortly after starting ribavirin. We documented no other possible side effects. We wish to emphasise the severity in Britain of respiratory syncytial virus bronchiolitis in infants with congenital heart disease. The high mortality in the presence of pulmonary hypertension confirms earlier American reports.1 Our clinical impression was that ribavirin, started very early in the disease 'may' prevent some infants progressing to respiratory failure. The outcome was never one of dramatic clinical improvement. The resource implications of widespread early use of ribavirin in all mildly symptomatic infants are very great however (approximately £600 for a three day course). We therefore strongly support the call for randomised controlled trials of ribavirin in bronchiolitic infants with cardiopulmonary disease.2