Pre-emptive treatment
Pre-emptive treatment involves monitoring the patient’s CMV viral load to detect viral replication before the patient develops symptoms, then starting early antiviral treatment to prevent progression to symptomatic CMV disease. See Cytomegalovirus (CMV) infection for treatment of symptomatic CMV disease.
Monitor the patient’s CMV DNA by nucleic acid amplification tests (NAAT) (eg polymerase chain reaction [PCR]) on peripheral whole blood or serum once- or twice-weekly from the time of engraftment. The threshold for starting pre-emptive treatment has not been established due to variability in diagnostic assays—consult local protocols or the transplant centre for interpretation of results.
The need for pre-emptive treatment is determined by the viral load or the rate of change in the viral load—consult local protocols. Take into account the risk of infection, the degree of immunosuppression and the type of transplant. Some centres start pre-emptive treatment if two consecutive CMV DNA NAAT (eg PCR) results are positive, regardless of the viral load.
For pre-emptive treatment of CMV, use:
valganciclovir 900 mg orally, 12-hourly; see below for duration of therapy. For dosage adjustment in adults with kidney impairment, see valganciclovir treatment dosage adjustment. cytomegalovirus, pre-emptive treatment (immunocompromised adult without HIV) valganciclovir valganciclovir valganciclovir
For allogeneic HSCT recipients with active GVHD of the gut, patients with severe diarrhoea, or those unable to tolerate oral therapy, use:
ganciclovir 5 mg/kg intravenously, 12-hourly. For dosage adjustment in adults with kidney impairment, see ganciclovir treatment dosage adjustment. Switch to oral valganciclovir (see dosage above) when possible; see below for duration of therapy. cytomegalovirus, pre-emptive treatment (immunocompromised adult without HIV) ganciclovir
Duration of therapy: measure CMV DNA weekly in whole blood. Stop treatment when one or two CMV DNA results are negative—consult local protocols. If the patient developed symptomatic CMV disease, secondary prophylaxis (maintenance therapy) may be required. If the patient did not develop symptomatic CMV disease, maintenance therapy is not usually required—seek expert advice or consult local protocols.
Continue CMV DNA monitoring for 100 days after the transplant, or for 180 days if there is significant ongoing GVHD or immunosuppression at day 100.