How we treat cytomegalovirus in hematopoietic cell transplant recipients

Abstract

Cytomegalovirus (CMV) continues to cause major complications after hematopoietic cell transplantation (HCT). Over the past decade, most centers have adopted preemptive antiviral treatment or prophylaxis strategies to prevent CMV disease. Both strategies are effective but also have shortcomings with presently available drugs. Here, we review aspects of CMV treatment and prevention in HCT recipients, including currently used drugs and diagnostics, ways to optimize preemptive therapy strategies with quantitative polymerase chain reaction assays, the use of prophylaxis, management of CMV disease caused by wild-type or drug-resistant strains, and future strategies.

Figures

Figure 1

CMV viral load to start preemptive therapy (PET) used at the FHCRC in Seattle, WA, and the Karolinska Institute, Stockholm, Sweden.

Figure 2

CMV drug resistance. Development of drug resistance requires prolonged pre-exposure (usually weeks to months) to the antiviral drug and persistent reactivation in the presence of drug, which will ultimately lead to the selection of resistant strains.

Figure 3

CMV drug resistance mutation maps. CMV drug resistance mutation maps for the UL97 (A) and DNA polymerase (B) genes. Figure was obtained with permission from S. Chou.