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Chung MC, Chen CH, Chang SS, Lee CY, Tian YC, Wu MY, Wang HH, Yu CC, Chen TW, Kao CC, Hsu CY, Chiang YJ, Wu MJ, Chen YT, Wu MS. Prevention and management of cytomegalovirus infection and disease in kidney transplant: A consensus statement of the Transplantation Society of Taiwan. J Formos Med Assoc 2024:S0929-6646(24)00245-6. [PMID: 38777672 DOI: 10.1016/j.jfma.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/24/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
Kidney transplant recipients have an increased risk of cytomegalovirus (CMV) infection and disease. A strategy for mitigating the risk of CMV infection in kidney transplant recipients has not yet been established in Taiwan. The Transplantation Society of Taiwan aimed to develop a consensus by expert opinion on the prevention and management of CMV infection. Based on the results of Consensus Conference, we suggested low-dose valganciclovir prophylaxis (450 mg once daily) for kidney transplant recipients. The prophylaxis duration was ≥6 months for high-risk (D+/R-) patients and 3 months for moderate-risk (R+) patients. Even for low-risk (D-/R-) patients, prophylaxis for at least 3 months is recommended because of the high seroprevalence of CMV in Taiwan. CMV prophylaxis was suggested after anti-thymocyte globulin treatment but not after methylprednisolone pulse therapy. Routine surveillance after prophylaxis, secondary prophylaxis after CMV disease treatment, and mTOR inhibitors for primary CMV prophylaxis were not recommended. Letermovir and marabavir are emerging CMV agents used for prophylaxis and refractory CMV disease. CMV immunoglobulins have been used to treat refractory CMV disease in Taiwan. We hope this consensus will help professionals manage patients with CMV in Taiwan to improve the quality of care.
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Affiliation(s)
- Mu-Chi Chung
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Hsu Chen
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Ph.D. Program in Tissue Engineering and Regenerative Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; Department of Life Science, Tunghai University, Taichung, Taiwan
| | - Shen-Shin Chang
- Division of Transplantation, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Yuan Lee
- Department of Surgery, National Taiwan University Hospital, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center and Department of Nephrology Linkou Chang Aging Memorial Hospital, Taiwan
| | - Mei-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan; Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
| | - Hsu-Han Wang
- Department of Urology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Cheng Yu
- Division of Urology, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Teng-Wei Chen
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Chang Kao
- Division of Urology, Department of Surgery, Tri-service General Hospital, National Defense Medical, Taiwan
| | - Chih-Yang Hsu
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Taiwan
| | - Yang-Jen Chiang
- Department of Urology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Ju Wu
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taiwan; Division of Nephrology, Department of Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yen-Ta Chen
- Division of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mai-Szu Wu
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan; TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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2
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Stewart AG, Kotton CN. What's New: Updates on Cytomegalovirus in Solid Organ Transplantation. Transplantation 2024; 108:884-897. [PMID: 37899366 DOI: 10.1097/tp.0000000000004855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Cytomegalovirus (CMV) is one of the most common infections occurring after solid organ transplantation. This high burden of disease, which incurs sizeable morbidity, may be worsening with the proportion of high-risk D+/R- solid organ transplantation recipients increasing in some regions globally. Cohort studies continue to support either universal prophylaxis or preemptive therapy as effective prevention strategies. Letermovir prophylaxis was noninferior to valganciclovir in adult high-risk D+/R- kidney transplant recipients with fewer drug-related adverse events in a recent clinical trial and has now been approved for such use in some regions. Maribavir preemptive therapy failed to demonstrate noninferiority when compared with valganciclovir in hematopoietic stem cell transplant recipients but looked promising for safety. Donor matching could be useful in prevention CMV disease with a survival advantage demonstrated in seronegative recipients waiting up to 30 mo for a seronegative kidney. Immune-guided prophylaxis resulted in fewer CMV infection episodes in lung transplant recipients when compared with fixed-duration prophylaxis in a recent clinical trial. For treatment of refractory or resistant CMV infection, maribavir was more efficacious and better tolerated when compared with investigator-initiated therapy in its registration trial for this condition. Further research regarding best treatment and prophylaxis of resistant or refractory CMV infection is needed to reflect best clinical practice choices. Optimal use of immune globulin or CMV-specific T cells for prevention or treatment of CMV disease remains undefined. Standardized definitions for the design of CMV clinical trials have been developed. In this review, we highlight recent updates in the field from data published since 2018.
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Affiliation(s)
- Adam G Stewart
- Centre for Clinical Research, Faculty of Medicine, University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, QLD, Australia
| | - Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Hardinger KL, Brennan DC. Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches. Ann Pharmacother 2024:10600280241237534. [PMID: 38501850 DOI: 10.1177/10600280241237534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
OBJECTIVE The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation. DATA SOURCES A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation. STUDY SELECTION AND DATA EXTRACTION Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded. DATA SYNTHESIS After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV. CONCLUSIONS Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.
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Affiliation(s)
- Karen L Hardinger
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel C Brennan
- Johns Hopkins Comprehensive Transplant Center, Baltimore, MD, USA
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Yeh PJ, Wu RC, Tsou YK, Chen CM, Chiu CT, Chen CC, Lai MW, Pan YB, Le PH. Comparative Analysis of Cytomegalovirus Gastrointestinal Disease in Immunocompetent and Immunocompromised Patients. Viruses 2024; 16:452. [PMID: 38543817 PMCID: PMC10974964 DOI: 10.3390/v16030452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) gastrointestinal (GI) diseases impact both immunocompromised and immunocompetent individuals, yet comprehensive studies highlighting the differences between these groups are lacking. METHODS In this retrospective study (January 2000 to July 2022) of 401 patients with confirmed CMV GI diseases, we categorized them based on immunological status and compared manifestations, treatments, outcomes, and prognostic factors. RESULTS The immunocompromised patients (n = 193) showed older age, severe illnesses, and higher comorbidity rates. GI bleeding, the predominant manifestation, occurred more in the immunocompetent group (92.6% vs. 63.6%, p = 0.009). Despite longer antiviral therapy, the immunocompromised patients had higher in-hospital (32.2% vs. 18.9%, p = 0.034) and overall mortality rates (91.1% vs. 43.4%, p < 0.001). The independent factors influencing in-hospital mortality in the immunocompromised patients included GI bleeding (OR 5.782, 95% CI 1.257-26.599, p = 0.024) and antiviral therapy ≥ 14 days (OR 0.232, 95% CI 0.059-0.911, p = 0.036). In the immunocompetent patients, age (OR 1.08, 95% CI 1.006-1.159, p = 0.032), GI bleeding (OR 10.036, 95% CI 1.183-85.133, p = 0.035), and time to diagnosis (OR 1.029, 95% CI 1.004-1.055, p = 0.021) were significant prognostic factors, with the age and diagnosis time cut-offs for survival being 70 years and 31.5 days, respectively. CONCLUSIONS GI bleeding is the most common manifestation and prognostic factor in both groups. Early diagnosis and effective antiviral therapy can significantly reduce in-hospital mortality.
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Affiliation(s)
- Pai-Jui Yeh
- Department of Pediatric Gastroenterology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (P.-J.Y.); (C.-C.C.); (M.-W.L.)
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Ren-Chin Wu
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Department of Anatomic Pathology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yung-Kuan Tsou
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
| | - Chien-Ming Chen
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Department of Medical Imaging and Interventions, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Cheng-Tang Chiu
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan 333, Taiwan
| | - Chien-Chang Chen
- Department of Pediatric Gastroenterology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (P.-J.Y.); (C.-C.C.); (M.-W.L.)
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ming-Wei Lai
- Department of Pediatric Gastroenterology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (P.-J.Y.); (C.-C.C.); (M.-W.L.)
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
| | - Yu-Bin Pan
- Biostatistical Section, Clinical Trial Center, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 333, Taiwan;
| | - Puo-Hsien Le
- Inflammatory Bowel Disease Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (R.-C.W.); (C.-M.C.); (C.-T.C.)
- Chang Gung Microbiota Therapy Center, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
- Taiwan Association of the Study of Small Intestinal Disease, Taoyuan 333, Taiwan
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Thomas SJ, Ouellette CP. Viral meningoencephalitis in pediatric solid organ or hematopoietic cell transplant recipients: a diagnostic and therapeutic approach. Front Pediatr 2024; 12:1259088. [PMID: 38410764 PMCID: PMC10895047 DOI: 10.3389/fped.2024.1259088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024] Open
Abstract
Neurologic complications, both infectious and non-infectious, are frequent among hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients. Up to 46% of HCT and 50% of SOT recipients experience a neurological complication, including cerebrovascular accidents, drug toxicities, as well as infections. Defects in innate, adaptive, and humoral immune function among transplant recipients predispose to opportunistic infections, including central nervous system (CNS) disease. CNS infections remain uncommon overall amongst HCT and SOT recipients, compromising approximately 1% of total cases among adult patients. Given the relatively lower number of pediatric transplant recipients, the incidence of CNS disease amongst in this population remains unknown. Although infections comprise a small percentage of the neurological complications that occur post-transplant, the associated morbidity and mortality in an immunosuppressed state makes it imperative to promptly evaluate and aggressively treat a pediatric transplant patient with suspicion for viral meningoencephalitis. This manuscript guides the reader through a broad infectious and non-infectious diagnostic differential in a transplant recipient presenting with altered mentation and fever and thereafter, elaborates on diagnostics and management of viral meningoencephalitis. Hypothetical SOT and HCT patient cases have also been constructed to illustrate the diagnostic and management process in select viral etiologies. Given the unique risk for various opportunistic viral infections resulting in CNS disease among transplant recipients, the manuscript will provide a contemporary review of the epidemiology, risk factors, diagnosis, and management of viral meningoencephalitis in these patients.
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Affiliation(s)
- Sanya J. Thomas
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
| | - Christopher P. Ouellette
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
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Alsanea MS, Al-Qahtani AA, Almaghrabi RS, AlAbdulkareem MA, Alahideb BM, Obeid D, Alsuwairi FA, Alhamlan FS. Diagnosis of Human Cytomegalovirus Drug Resistance Mutations in Solid Organ Transplant Recipients-A Review. Diagnostics (Basel) 2024; 14:203. [PMID: 38248079 PMCID: PMC10814084 DOI: 10.3390/diagnostics14020203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/11/2023] [Accepted: 06/21/2023] [Indexed: 01/23/2024] Open
Abstract
Human cytomegalovirus (HCMV) infection may be asymptomatic in healthy individuals but can cause severe complications in immunocompromised patients, including transplant recipients. Breakthrough and drug-resistant HCMV infections in such patients are major concerns. Clinicians are first challenged to accurately diagnose HCMV infection and then to identify the most effective antiviral drug and determine when to initiate therapy, alter drug dosage, or switch medication. This review critically examines HCMV diagnostics approaches, particularly for immunocompromised patients, and the development of genotypic techniques to rapidly diagnose drug resistance mutations. The current standard method to identify prevalent and well-known resistance mutations involves polymerase chain reaction amplification of UL97, UL54, and UL56 gene regions, followed by Sanger sequencing. This method can confirm clinical suspicion of drug resistance as well as determine the level of drug resistance and range of cross-resistance with other drugs. Despite the effectiveness of this approach, there remains an urgent need for more rapid and point-of-care HCMV diagnosis, allowing for timely lifesaving intervention.
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Affiliation(s)
- Madain S. Alsanea
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
| | - Ahmed A. Al-Qahtani
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Reem S. Almaghrabi
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia;
| | - Maha A. AlAbdulkareem
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
| | - Basma M. Alahideb
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
| | - Dalia Obeid
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia;
| | - Feda A. Alsuwairi
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
| | - Fatimah S. Alhamlan
- Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (M.S.A.); (A.A.A.-Q.); (M.A.A.); (B.M.A.); (D.O.); (F.A.A.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia
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Tsai H, Bartash R, Burack D, Swaminathan N, So M. Bring it on again: antimicrobial stewardship in transplant infectious diseases: updates and new challenges. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e3. [PMID: 38234416 PMCID: PMC10789986 DOI: 10.1017/ash.2023.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 01/19/2024]
Abstract
Advancement in solid organ transplantation and hematopoietic stem cell transplant continues to improve the health outcomes of patients and widens the number of eligible patients who can benefit from the medical progress. Preserving the effectiveness of antimicrobials remains crucial, as otherwise transplant surgeries would be unsafe due to surgical site infections, and the risk of sepsis with neutropenia would preclude stem cell transplant. In this review, we provide updates on three previously discussed stewardship challenges: febrile neutropenia, Clostridioides difficile infection, and asymptomatic bacteriuria. We also offer insight into four new stewardship challenges: the applicability of the "shorter is better" paradigm shift to antimicrobial duration; antibiotic allergy delabeling and desensitization; colonization with multidrug-resistant gram-negative organisms; and management of cytomegalovirus infections. Specifically, data are accumulating for "shorter is better" and antibiotic allergy delabeling in transplant patients, following successes in the general population. Unique to transplant patients are the impact of multidrug-resistant organism colonization on clinical decision-making of antibiotic prophylaxis in transplant procedure and the need for antiviral stewardship in cytomegalovirus. We highlighted the expansion of antimicrobial stewardship interventions as potential solutions for these challenges, as well as gaps in knowledge and opportunities for further research.
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Affiliation(s)
- Helen Tsai
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Burack
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Neeraja Swaminathan
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
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8
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Roberts MB, Kotton CN. Letermovir Prophylaxis After Kidney Transplantation: Another Tool but Not a Revolution Yet. Transplantation 2024; 108:7-9. [PMID: 38098156 DOI: 10.1097/tp.0000000000004809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Matthew B Roberts
- Infectious Diseases Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Camille N Kotton
- Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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von Hoerschelmann E, Münch J, Gao L, Lücht C, Naik MG, Schmidt D, Pitzinger P, Michel D, Avaniadi P, Schrezenmeier E, Choi M, Halleck F, Budde K. Letermovir Rescue Therapy in Kidney Transplant Recipients with Refractory/Resistant CMV Disease. J Clin Med 2023; 13:100. [PMID: 38202107 PMCID: PMC10780128 DOI: 10.3390/jcm13010100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/12/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
(1) Background: CMV infections remain a problem after kidney transplantation, particularly if patients are refractory or resistant (r/r) to treatment with valganciclovir (VGCV) or ganciclovir (GCV). (2) Methods: In a single-center retrospective study, kidney transplant recipients (KTR) receiving letermovir (LTV) as rescue therapy for VGCV-/GCV-r/r CMV disease were analyzed regarding CMV history, immunosuppression, and outcomes. (3) Results: Of 201 KTR treated for CMV between 2017 and 2022, 8 patients received LTV following treatment failure with VGCV/GCV. All patients received CMV prophylaxis with VGCV according to the center's protocol, and 7/8 patients had a high-risk (D+/R-) CMV constellation. In seven of eight cases, rising CMV levels occurred during prophylaxis. In seven of eight patients, a mutation in UL97 associated with a decreased response to VGCV/GCV was detected. In four of eight patients, LTV resulted in CMV clearance after 24 ± 10 weeks (16-39 weeks), two of eight patients stabilized at viral loads <2000 cop/mL (6-20 weeks), and two of eight patients developed LTV resistance (range 8-10 weeks). (4) Conclusion: LTV, which is currently evaluated for CMV prophylaxis in kidney transplantation, also shows promising results for the treatment of patients with VGCV/GCV resistance despite the risk of developing LTV resistance. Additional studies are needed to further define its role in the treatment of patients with CMV resistance.
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Affiliation(s)
- Ellen von Hoerschelmann
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Johannes Münch
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Linde Gao
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Christian Lücht
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Marcel G. Naik
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Danilo Schmidt
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Paul Pitzinger
- Institute of Virology, Charité Universitätsmedizin Berlin, Labor Berlin-Charité-Vivantes GmbH, 10117 Berlin, Germany
| | - Detlef Michel
- Institute of Virology, Universitätsklinikum Ulm, 89081 Ulm, Germany
| | - Parthenopi Avaniadi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Eva Schrezenmeier
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Mira Choi
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Fabian Halleck
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
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10
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Chai Y, Zhang E, Cai Z, Xu D, Zhu C, Sun B. Isolation, synthesis and identification of degraded impurities in Letermovir. J Pharm Biomed Anal 2023; 236:115691. [PMID: 37703644 DOI: 10.1016/j.jpba.2023.115691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/23/2023] [Accepted: 08/31/2023] [Indexed: 09/15/2023]
Abstract
Letermovir is a cytomegalovirus inhibitor for cytomegalovirus infection a hematopoietic-cell transplantation. In the degradation test of Letermovir, five new impurities were detected at levels of ND ∼ 2.21 % (by oxide, thermal or photolytic). These impurities were synthesized directly, characterized and identified by HRMS NMR spectra and X-ray crystallography. Then co-injected with commercial products to confirm their retention times in HPLC. The possible formation pathways and synthetic methods of these impurities were discussed in details. Furthermore, the toxicological properties of impurities were evaluated by ACD/Percepta 14.52.0 (Build 3525) software.
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Affiliation(s)
- Yuzhu Chai
- School of Chemistry and Chemical Engineering, Southeast University, Nanjing 211189, PR China; Nanjing Chia-Tai Tianqing Pharmaceutical Company, Nanjing 210046, PR China
| | - Erlong Zhang
- Nanjing Chia-Tai Tianqing Pharmaceutical Company, Nanjing 210046, PR China
| | - Zhuoer Cai
- School of Chemistry and Chemical Engineering, Southeast University, Nanjing 211189, PR China
| | - Dan Xu
- Nanjing Chia-Tai Tianqing Pharmaceutical Company, Nanjing 210046, PR China
| | - Chunxia Zhu
- Nanjing Chia-Tai Tianqing Pharmaceutical Company, Nanjing 210046, PR China
| | - Baiwang Sun
- School of Chemistry and Chemical Engineering, Southeast University, Nanjing 211189, PR China.
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11
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Walti CS, Khanna N, Avery RK, Helanterä I. New Treatment Options for Refractory/Resistant CMV Infection. Transpl Int 2023; 36:11785. [PMID: 37901297 PMCID: PMC10600348 DOI: 10.3389/ti.2023.11785] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023]
Abstract
Despite advances in monitoring and treatment, cytomegalovirus (CMV) infections remain one of the most common complications after solid organ transplantation (SOT). CMV infection may fail to respond to standard first- and second-line antiviral therapies with or without the presence of antiviral resistance to these therapies. This failure to respond after 14 days of appropriate treatment is referred to as "resistant/refractory CMV." Limited data on refractory CMV without antiviral resistance are available. Reported rates of resistant CMV are up to 18% in SOT recipients treated for CMV. Therapeutic options for treating these infections are limited due to the toxicity of the agent used or transplant-related complications. This is often the challenge with conventional agents such as ganciclovir, foscarnet and cidofovir. Recent introduction of new CMV agents including maribavir and letermovir as well as the use of adoptive T cell therapy may improve the outcome of these difficult-to-treat infections in SOT recipients. In this expert review, we focus on new treatment options for resistant/refractory CMV infection and disease in SOT recipients, with an emphasis on maribavir, letermovir, and adoptive T cell therapy.
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Affiliation(s)
- Carla Simone Walti
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Biomedicine and Clinical Research, University and University Hospital of Basel, Basel, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Biomedicine and Clinical Research, University and University Hospital of Basel, Basel, Switzerland
| | - Robin K. Avery
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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12
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Breitkopf R, Treml B, Bukumiric Z, Innerhofer N, Fodor M, Radovanovic Spurnic A, Rajsic S. Cytomegalovirus Disease as a Risk Factor for Invasive Fungal Infections in Liver Transplant Recipients under Targeted Antiviral and Antimycotic Prophylaxis. J Clin Med 2023; 12:5198. [PMID: 37629240 PMCID: PMC10455861 DOI: 10.3390/jcm12165198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/27/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
Cytomegalovirus (CMV) infection is the most common opportunistic infection that occurs following orthotopic liver transplantation (OLT). In addition to the direct infection-related symptoms, it also triggers an immunological response that may contribute to adverse clinical outcomes. CMV disease has been described as a predictor of invasive fungal infections (IFIs) but its role under an antiviral prophylaxis regimen is unclear. METHODS We retrospectively analyzed the medical records of 214 adult liver transplant recipients (LTRs). Universal antiviral prophylaxis was utilized in recipients with CMV mismatch; intermediate- and low-risk patients received pre-emptive treatment. RESULTS Six percent of patients developed CMV disease independent of their serostatus. The occurrence of CMV disease was associated with elevated virus load and increased incidence of leucopenia and IFIs. Furthermore, CMV disease was associated with higher one-year mortality and increased relapse rates within the first year of OLT. CONCLUSIONS CMV disease causes significant morbidity and mortality in LTRs, directly affecting transplant outcomes. Due to the increased risk of IFIs, antifungal prophylaxis for CMV disease may be appropriate. Postoperative CMV monitoring should be considered after massive transfusion, even in low-risk serostatus constellations. In case of biliary complications, biliary CMV monitoring may be appropriate in the case of CMV-DNA blood-negative patients.
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Affiliation(s)
- Robert Breitkopf
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria (N.I.)
| | - Benedikt Treml
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria (N.I.)
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Nicole Innerhofer
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria (N.I.)
| | - Margot Fodor
- Department of Visceral, Transplantation and Thoracic Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria;
| | | | - Sasa Rajsic
- Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria (N.I.)
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13
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Raglow Z, Kaul DR. A New Antiviral Option for Cytomegalovirus Prevention After Kidney Transplant. JAMA 2023; 330:27-29. [PMID: 37279971 DOI: 10.1001/jama.2023.9100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Zoe Raglow
- Division of Infectious Disease, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Daniel R Kaul
- Division of Infectious Disease, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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14
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Kleiboeker SB. Prevalence of cytomegalovirus antiviral drug resistance in transplant recipients. Antiviral Res 2023; 215:105623. [PMID: 37150409 DOI: 10.1016/j.antiviral.2023.105623] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/30/2023] [Accepted: 05/04/2023] [Indexed: 05/09/2023]
Abstract
Cytomegalovirus (CMV) is a significant human pathogen, especially for immunocompromised patients, often treated with one or more antiviral drugs. Although the prevalence of resistance is low, the impact of drug resistant CMV infections on patient outcomes is high and genotypic testing is recommended when resistance is suspected. To assess the prevalence of CMV drug resistance mutations among samples submitted for genotypic testing, 2750 patient sample results were analyzed. Testing was performed by sequencing for ganciclovir (GCV), cidofovir (CDV), foscarnet (FOS), maribavir (MBV) and/or letermovir (LMV) resistance conferring mutations. Of the 2750 patient samples, 826 (30.04%) had resistance to one or more anti-CMV drug. Resistance mutations were most common in UL97, with 27.64% and 9.96% of samples having GCV and MBV mutations, respectively. Resistance mutations in UL54 were less common, with 6.11%, 5.98% and 1.76% of samples having GCV, CDV and FOS mutations, respectively. For LMV, resistance mutations in UL56 were present in 7.17% of samples, with mutations at codon 325 representing 80.95% of the observed LMV resistance mutations. Resistance to two drugs was identified in 215 samples and to 3 or more drugs in 35 samples. While a high prevalence of CMV resistance mutations was identified, this must be taken in the context of healthcare providers submitting samples from patients with suspected resistant CMV strains. For these patients, rapid monitoring for resistance allows treatment modifications based on objective results rather than empiric drug selection, which is particularly relevant given the presence of mutations conferring resistance to more than one drug.
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Affiliation(s)
- Steven B Kleiboeker
- Eurofins Viracor Clinical Diagnostics, 18000 West 99th Street, Lenexa, KS, 66219, USA.
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15
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IgG4-Related Oesophageal Disease with Cytomegalovirus Infection: A Case Report. J Pers Med 2023; 13:jpm13030493. [PMID: 36983676 PMCID: PMC10059879 DOI: 10.3390/jpm13030493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 03/12/2023] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a fibrous inflammatory process related to immunomodulation. The involvement of the pancreato-biliary tract, retroperitoneum/aorta, head and neck, and salivary glands are the most frequently observed disease phenotypes, differing in their epidemiological features, serological findings, and prognostic outcomes. IgG4-RD was combined with oesophageal ulcers, and the patients were infected with cytomegalovirus at the time of the examination. This constituted a huge challenge in the diagnosis and treatment of oesophageal ulcers. We report the case of a 53-year-old male who experienced nausea, vomiting, and anaemia recurrently for many years. According to his medical records, an upper gastrointestinal endoscopy revealed an oesophageal ulcer, and he had had numerous hospital visits for anaemia but with no definitive diagnosis, and he had responded poorly to therapy. However, with persistent symptoms, he came to our hospital and, according to the results of the upper gastrointestinal endoscopy, a serum IgG4 test, and histopathological and immunohistochemical staining, he was finally diagnosed with IgG4-related oesophageal disease combined with a cytomegalovirus infection. We hope that through this case, we can learn more about IgG4-RD and, at the same time, give clinicians a better understanding of IgG4-RD combined with oesophageal ulceration, a new understanding of cytomegalovirus infections, and improved clinical knowledge.
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