Prevention of CMV is crucial to avoid both direct and indirect effects and optimize transplant outcomes.

VGCV has been extremely effective in CMV prevention, although the side effect of leukopenia is common; a recent phase III trial comparing letermovir with VGCV shows similar efficacy with reduced myelotoxicity in those who received letermovir.

In solid-organ-transplant patients, patients experiencing neutropenia are at increased risk of acute rejection.

Resistant/refractory (R/R) CMV generally occurs relatively rarely but conveys significant morbidity and mortality. Careful diagnosis is important; whenever possible, sequencing should be done to confirm resistance mutations.

Standard treatment of R/R CMV had significant toxicity. Maribavir provides better efficacy and less toxicity.