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. 2009 Sep 9;15(10):1143–1238. doi: 10.1016/j.bbmt.2009.06.019

Pathogen: Cytomegalovirus

Indication First Choice Alternatives

  • Preemptive Therapy (< 100 days post-HCT)

  • •

    Administer to all allogeneic HCT recipients (all ages) with evidence of CMV infection in blood by antigenemia, PCR for CMV DNA or detection of CMV mRNA

  • •

    CMV seropositive autologous HCT recipients (all ages) at high risk (TBI, recent fludarabine or 2-chlorodeoxyadenosine) when CMV antigenemia is ≥5 cell/slide (or any level for recipients of CD34+ selected grafts) [245]

  • Note: Continue screening for CMV reactivation and re-treat if screening tests become positive after discontinuation of therapy (BI)

  • Ganciclovir, 5mg/kg/dose, intravenously (i.v.)

  • Allogeneic HCT(all ages):

  • Induction: Twice daily for 7-14 days.

  • Maintenance: Daily if CMV is still detetable and declining and continue until the indicator test is negative

  • Note: Minimum total induction and maintenance treatment is 2 weeks when 14 days of twice daily is used and 3 weeks when a 7-day induction course is used (AI)

  • Autologous HCT (all ages):

  • Induction: Twice daily for 7 days

  • Maintenance: Continue daily until the indicator test is negative but a minimum of 2 weeks (BII)

  • Note: CMV detection methods should be negative when therapy is stopped

  • Note: Criteria for duration of induction and maintenance doses are the same as those listed for Ganciclovir

  • Foscarnet, i.v. (AI)

  • Induction: 60 mg/kg twice daily

  • Maintenance: 90 mg/kg daily

  • Valganciclovir (oral)

  • (persons >40 kg with good oral intake) (BII)

  • Induction: 900 mg twice daily

  • Maintenance: 900 mg daily

  • Cidofovir, i.v. (CII)

  • Induction: 5 mg/kg per week for 2 doses

  • Maintenance: 5 mg/kg every other week

  • (prehydration and probenecid needed as per package insert)

  • Prophylactic Therapy (engraftment to day 100 post- HCT, ie, Phase II)

  • •

    Allogeneic HCT recipients (all ages)

  • Ganciclovir, 5mg/kg/dose, i.v.

  • Induction: Twice daily for 5-7 days;

  • Maintenance: Daily until day 100 after HCT (AI)

  • Foscarnet, 60 mg/kg

  • i.v. twice daily for 7 days, followed by 90-120 mg/kg i.v. once daily until day 100 after HCT (CIII)

  • Acyclovir, (in combination with screening for CMV reactivation): 500 mg/m2 i.v. 3 times per day; or 800 mg orally 4 times daily (≥40 kg); or 600 mg/m2 orally 4 times daily (<40 kg) (CI)

  • Valacyclovir:

  • in combination with screening for CMV reactivation: 2 g 3-4 times per day (≥40 kg) (CI)

  • Preemptive Therapy (>100 days post-HCT) for:

  • •

    Allogeneic HCT recipients (all ages)

  • •

    All patients receiving steroids for GVHD

  • •

    All patients who received CMV therapy <100 days after HCT

  • when:

  • a) antigenemia is ≥5 cells/slide; or b) the patient has had ≥2

  • consecutively positive viremia or polymerase chain reaction tests

  • Ganciclovir, 5 mg/kg/dose, i.v.

  • Induction: Twice daily for 7-14 days

  • Maintenance: Daily for 1-2 weeks or until the indicator test is negative (BIII)

  • Or

  • Valganciclovir (persons .≥40 kg with good oral intake)

  • Induction: 900 mg orally twice daily for 7-14 days;

  • Maintenance: 900 mg orally daily for 1-2 weeks until indicator test is negative (BIII)

  • Note: Minimum treatment course is 14 days regardless of drug used

  • Foscarnet, 60 mg/kg

  • i.v. every 12 hours for 14 days; continue treatment at 90 mg/kg/day daily for 7-4 days or until the indicator test is negative (AI)

GVHD indicates graft-versus-host disease; HCT, hematopoietic cell transplantation; PCR, polymerase chain reaction; CMV, cytomegalovirus; TBI, total body irradiation.

Notes: Patients who do not tolerate standard doses of ganciclovir should be treated with foscarnet.

Ganciclovir and foscarnet doses should be reduced in patients with renal impairment. Prehydration is required for foscarnet and cidofovir administration.