CMV after hematopoietic stem cell transplantation

From IDWiki

Background

Microbiology

Epidemiology

  • Reactivates in 60 to 70% of CMV-seropositive patients and primary infection affects 20 to 30% of seronegative recipients who have seropositive donors
Donor Recipient Risk
± + 60-70%
+ 20-30%
5%

Clinical Manifestations

  • With monitoring and preemptive therapy, CMV pneumonitis has decreased to 5% of seropositive allogeneic recipients
  • Pneumonitis (63%)
  • Enteritis (26%)
  • Retinitis (5%)
  • Increased risk of rejection

Management

Prophylaxis

  • Now commonly done with letermovir, started within 28 days of transplantation

Preemptive Therapy

  • Most frequently managed with weekly viral loads and preemptive treatment (PET) at a lab-specific threshold
  • Antiviral treatment follows a model of induction therapy for 14 days; if it has declined by at least 1 log, then step down to lower-dose maintenance therapy until viremia resolves fully; otherwise, continue induction dosing
    • Induction therapy
      • Ganciclovir 5 mg/kg q12h
      • If concerns about resistance or bone marrow suppression, foscarnet 90 mg/kg IV q12h
    • Maintenance therapy
      • Valganciclovir 900 mg po daily
      • If concerns about oral absorption, continue ganciclovir 5 mg/kg IV q24h
      • If concerns about resistance or bone marrow suppression, foscarnet 90 mg/kg IV q24h
  • Use CMV safe (leukoreduced or filtered) blood products if the recipient is CMV seronegative
Serostatus Blood products Duration of PET
D-/R- CMV safe weeks 2 to 12
D+/R- CMV safe weeks 2 to 12
autologous R- CMV safe weeks 2 to 5
D±/R+ CMV untested weeks 2 to 12, then q2-4wk until week 26
autologous R+ CMV untested weeks 2 to 5

CMV Disease

  • Treatment is with ganciclovir induction for 14 to 21 days with IVIG 500 mg/kg every other day, followed by maintenance ganciclovir for at least 3 to 4 weeks
  • May need to continue maintenance for longer if patient has GVHD, enteritis with deep ulcerations, or retinitis