Antivirals Do Not Fully Mitigate the Risk of CMV2

The standard antivirals selected to combat CMV infection, whether as monotherapy or in combination with a CMV intravenous immunoglobulin (CMV-IGIV), are ganciclovir or valganciclovir.3 

Antiviral drugs are unable to prevent free virus particles from infecting healthy cells2 

  • Although antiviral drugs block viral replication within the host cell, they cannot destroy intracellular or extracellular viruses, which may result in a rebound effect when antiviral therapy is discontinued4 
  • A limitation of antivirals is that they may be withdrawn due to poor antiviral activity or toxicity2,4 

In Adult SOT Recipients 

Standard of Care Guidelines Recommend CMV Prevention Approaches According to the Specific Organ

Organ Serostatus Risk level Recommended Alternative
All D–/R– Low Monitoring for clinical symptoms; consider antiviral prophylaxis against other herpes infections  Preemptive therapy
(if higher risk, ie, 
significant transfusions) 
Kidney D+/R– High 6 months of GCV/VGCV OR preemptive therapy 
R+ Intermediate 3 months of VGCV OR preemptive therapy 
Liver D+/R– High 3-6 months of VGCV (VGCV not FDA approved in liver) 
OR preemptive therapy 
R+ Intermediate 3 months of VGCV (VGCV not FDA approved in liver) 
OR preemptive therapy 
Pancreas D+/R– High 3-6 months of VGCV Preemptive therapy
R+ Intermediate 3 months of VGCV OR preemptive therapy 
Islet D+/R– Intermediate 3 months of VGCV Preemptive therapy
R+ Intermediate 3 months of VGCV (VGCV not FDA approved in liver) 
OR preemptive therapy 
Heart D+/R– High 3-6 months of GCV/VGCV  – Preemptive therapy 
– Some experts add CMV Ig to prophylaxis 
R+ Intermediate 3 months of GCV/VGCV OR preemptive therapy 
Lung D+/R– High 6-12 months of GCV/VGCV 
– Some experts add CMV Ig to prophylaxis 
Preemptive therapy
R+ Intermediate Minimum 6 months of GCV/VGCV 
Intestinal, composite tissue D+/R– High Minimum 6 months GCV/VGCV +/– surveillance after prophylaxis  – Preemptive therapy 
– Some experts add CMV Ig 
R+ High 3-6 months GCV/VGCV +/– surveillance after prophylaxis 

References: 1. Haidar G, Boeckh M, Singh N. Cytomegalovirus infection in solid organ and hematopoietic cell transplantation: state of the evidence. J Infect Dis. 2020;221(Suppl 1):S23-S31. 2. Majewska A, Młynarczyk-Bonikowska B, Malejczyk M, Majewski S, Młynarczyk G. Possibilities of prevention and treatment of human cytomegalovirus infections including new drugs and compounds with potential application. Advancements Microbiol. 2019:58(3):291-299. 3. Kotton CN, Kumar D, Caliendo AM. The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation. Transplantation. 2018;102(6):900-931. 4. Acosta E, Bowlin T, Brooks J, et al. Advances in the development of therapeutics for cytomegalovirus infections. J Infect Dis. 2020;221(Suppl 1):S32-S44. 5. Grossi PA, Mohacsi P, Szabolcs Z, Potena L. Cytomegalovirus immunoglobulin after thoracic transplantation: an overview. Transplantation. 2016;100(Suppl 3):S1-S4.   

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