Clinical strategies for the management of cytomegalovirus infection and disease in allogeneic bone marrow transplant

Abstract

Summary:agents have been employed in an attempt to prevent the development of CMV infection and disease where either donor or recipient are seropositive. Four clinical strategies are proposed for the management of CMV disease: prophylaxis, suppression, preThere are four therapeutic approaches which can be used. These are: emptive therapy and treatment. The degree of risk of developing CMV disease and the safety profile of the Prophylaxis: Antiviral agents are administered to all BMT presently available drugs need to be considered when deciding on the most appropriate approach. We conrecipients at risk of developing CMV disease. Therapy is started prior to any detection of CMV. clude that a prophylactic strategy employing a drug with a safe toxicity profile followed by pre-emptive Suppression: Antiviral agents are administered to BMT recipients when CMV is detected from peripheral sites such treatment with an effective antiviral drug for failure of prophylaxis gives the best outcome in allogeneic HLA as in the urine or throat washings, but prior to the development of any clinical symptoms of CMV disease. matched bone marrow transplant recipients.

Infectious complications within the first year after nonmyeloablative allogeneic peripheral blood stem cell transplantation

“…The rate of asymptomatic CMV viremia may have been underestimated, since weekly CMV DNA detection in blood was performed only after the 10th patient was enrolled in this protocol. There is currently insufficient evidence to recommend a prophylaxis strategy vs a pre-emptive monitoring strategy in these patients, 18,19 but this high rate of CMV viremia suggests that one of these two strategies should be employed. The lower incidence of invasive CMV disease compared with past literature in unprophylaxed alloBMT recipients suggests that the biology and timetable of occurrence of infection in this nonmyeloablative group may be somewhat different from recipients of 'conventional' alloBMT.…”

Dose-adjusted preemptive therapy for cytomegalovirus disease based on real-time polymerase chain reaction after allogeneic hematopoietic stem cell transplantation

“…1 The mortality of CMV diseases, particularly CMV pneumonitis, remains high even after the introduction of combined therapy with ganciclovir and immunoglobulin. 2,3 Several studies have shown that the prophylactic use of ganciclovir successfully prevented CMV diseases, but survival benefit of this approach has not been clearly demonstrated because of its toxicities, particularly neutropenia. [4][5][6] In addition, the prophylactic use of ganciclovir has been associated with increased incidence of late CMV diseases.…”

Qualitative Plasma PCR Assay (AMPLICOR CMV Test) versus pp65 Antigenemia Assay for Monitoring Cytomegalovirus Viremia and Guiding Preemptive Ganciclovir Therapy in Allogeneic Stem Cell Transplantation

“…Nineteen of the 28 patients with CMV viremia received AG-guided preemptive ganciclovir therapy; had the positivity of the plasma PCR assay triggered the initiation of preemptive therapy, 9 additional patients would have been unnecessarily treated since none of them developed CMV end-stage organ disease. Although the AMPLICOR CMV assay is more sensitive than AG, the latter appears to be more suitable both for guiding the initiation of preemptive therapy and for monitoring a patient's response to antiviral therapy.Cytomegalovirus (CMV) infection remains a significant cause of morbidity and mortality in allogeneic stem cell or bone marrow transplant recipients (23,24). The prevention of CMV end-stage organ disease is therefore a major goal in the clinical management of these patients.…”

“…Cytomegalovirus (CMV) infection remains a significant cause of morbidity and mortality in allogeneic stem cell or bone marrow transplant recipients (23,24). The prevention of CMV end-stage organ disease is therefore a major goal in the clinical management of these patients.…”