Treatment: Cytomegalovirus Infections

• When possible, seronegative donors should be used for seronegative transplant recipients.
• Ganciclovir (5 mg/kg IV bid for 14-21 days followed by 5 mg/kg IV qd) or valganciclovir (the oral prodrug of ganciclovir; 900 mg PO bid for 14-21 days followed by 900 mg PO qd) produces response rates of 70-90% among HIV-infected pts with CMV retinitis or colitis.
  • - In severe infections, ganciclovir is often combined with CMV immune globulin.
  • - Neutropenia is an adverse reaction to ganciclovir treatment that may require administration of colony-stimulating factors.
  • - Prophylactic or suppressive treatment can be given to high-risk transplant recipients (those who are seropositive before transplantation or culture positive without symptoms afterward).
  • - Resistance to ganciclovir is common among pts treated for >3 months and is usually related to mutations in the CMV UL97 gene.
  • - For CMV retinitis, ganciclovir can be administered via a slow-release pellet sutured into the eye, but this intervention does not provide treatment for the contralateral eye or for systemic disease.
• Foscarnet (180 mg/kg qd divided into 2 or 3 doses for 2 weeks, followed by 90-120 mg/kg IV qd) inhibits CMV DNA polymerase and is active against most ganciclovir-resistant CMV isolates. The primary adverse events include electrolyte disturbances and renal dysfunction.
• Cidofovir (5 mg/kg IV per week for 2 weeks followed by 3-5 mg/kg IV every 2 weeks) is a nucleotide analogue that is also effective against ganciclovir-resistant CMV; however, it can cause severe nephrotoxicity by proximal tubular cell injury. The use of saline hydration and probenecid reduces this adverse effect.
• CMV immune or hyperimmune globulin may reduce the risk of CMV disease in seronegative renal transplant recipients and prevent congenital CMV infection in infants born to women with primary CMV infection during pregnancy.