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Zamora D, Xie H, Sadowska-Klasa A, Kampouri E, Biernacki MA, Ueda Oshima M, Duke E, Green ML, Kimball LE, Holmberg L, Waghmare A, Greninger AL, Jerome KR, Hill GR, Hill JA, Leisenring WM, Boeckh MJ. CMV reactivation during pretransplantation evaluation: a novel risk factor for posttransplantation CMV reactivation. Blood Adv 2024; 8:4568-4580. [PMID: 38924728 PMCID: PMC11399585 DOI: 10.1182/bloodadvances.2023012234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 05/29/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
ABSTRACT Cytomegalovirus (CMV) disease occurs occasionally before allogeneic hematopoietic cell transplantation (HCT) and is associated with poor post-HCT outcomes; however, the impact of pre-HCT CMV reactivation is unknown. Pre-HCT CMV reactivation was assessed in HCT candidates from the preemptive antiviral therapy (2007-2017) and letermovir prophylaxis (2018-2021) eras. CMV DNA polymerase chain reaction (PCR) surveillance was routinely performed during the pre-HCT workup period, and antiviral therapy was recommended according to risk of progression to CMV disease. Risk factors for pre-HCT CMV reactivation were characterized, and the associations of pre-HCT CMV reactivation with post-HCT outcomes were examined using logistic regression and Cox proportional hazard models, respectively. A total of 1694 patients were identified, and 11% had pre-HCT CMV reactivation 14 days (median; interquartile range [IQR], 6-23) before HCT. Lymphopenia (≤0.3 × 103/μL) was the strongest risk factor for pre-HCT CMV reactivation at multiple PCR levels. In the preemptive therapy era, patients with pre-HCT CMV reactivation had a significantly increased risk of CMV reactivation by day 100 as well as CMV disease and death by 1 year after HCT. Clearance of pre-HCT CMV reactivation was associated with a lower risk of post-HCT CMV reactivation. Similar associations with post-HCT CMV end points were observed in a cohort of patients receiving letermovir prophylaxis. Pre-HCT CMV reactivation can be routinely detected in high-risk HCT candidates and is a significant risk factor for post-HCT CMV reactivation and disease. Pre-HCT CMV DNA PCR surveillance is recommended in high-risk HCT candidates, and antiviral therapy may be indicated to prevent post-HCT CMV reactivation.
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Affiliation(s)
- Danniel Zamora
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Alicja Sadowska-Klasa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
- Department of Hematology and Transplantology, Medical University of Gdansk, Gdansk, Poland
| | - Eleftheria Kampouri
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Melinda A Biernacki
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Elizabeth Duke
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Margaret L Green
- Division of Allergy & Infectious Disease, University of Washington School of Medicine, Seattle, WA
| | - Louise E Kimball
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Leona Holmberg
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Alpana Waghmare
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Alexander L Greninger
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, WA
| | - Geoffrey R Hill
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Michael J Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA
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2
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Sadowska-Klasa A, Özkök S, Xie H, Leisenring W, Zamora D, Seo S, Sheldon J, Lee SJ, Jerome KR, Green ML, Boeckh M. Late cytomegalovirus disease after hematopoietic cell transplantation: significance of novel transplantation techniques. Blood Adv 2024; 8:3639-3651. [PMID: 38537062 DOI: 10.1182/bloodadvances.2023012175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/01/2024] [Indexed: 07/12/2024] Open
Abstract
ABSTRACT Preemptive therapy (PET) and letermovir prophylaxis are effective in preventing cytomegalovirus (CMV) disease within the first 100 days after allogeneic hematopoietic cell transplantation (HCT) but are associated with late-onset CMV disease. We retrospectively examined the clinical manifestations, risk factors, prevention algorithm, and outcome of late CMV disease in CMV seropositive day 100 survivors transplanted between 2001-2017 (PET cohort) and 2018-2021 (letermovir cohort). There were 203 episodes of late CMV disease among 2469 day 100 survivors, and the estimated cumulative incidence of first late CMV disease was 7.2% (95% confidence interval [CI], 6.2-8.3) with no difference between the PET (7.4%; 95% CI, 6.4-8.6) and the letermovir group (5.4%; 95% CI, 3.2-8.3). Thirty-seven patients (1.5%) had a second episode of CMV disease. In multivariable Cox regression models, posttransplant cyclophosphamide was associated with an increased risk of gastrointestinal CMV disease. CMV viremia or disease detected before day 100, corticosteroid treatment after day 100 at dose ≥1 mg/kg, acute and chronic graft-versus-host disease, lymphopenia, HLA-mismatched related donor status, were also associated with late CMV disease. HLA-mismatched donor status and late use of corticosteroids (≥1 mg/kg) were risk factors for late CMV disease recurrence. Late CMV disease occurred most frequently in a setting of prolonged low-level untreated viremia and was independently associated with death by 2 years after HCT. In summary, late CMV disease continues to occur in the present era. Improved prevention strategies for late CMV disease are needed.
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Affiliation(s)
- Alicja Sadowska-Klasa
- Fred Hutchinson Cancer Center, Seattle, WA
- Department of Hematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Hu Xie
- Fred Hutchinson Cancer Center, Seattle, WA
| | - Wendy Leisenring
- Fred Hutchinson Cancer Center, Seattle, WA
- University of Washington, Seattle, WA
| | | | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | | | - Stephanie J Lee
- Fred Hutchinson Cancer Center, Seattle, WA
- University of Washington, Seattle, WA
| | - Keith R Jerome
- Fred Hutchinson Cancer Center, Seattle, WA
- University of Washington, Seattle, WA
| | | | - Michael Boeckh
- Fred Hutchinson Cancer Center, Seattle, WA
- University of Washington, Seattle, WA
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3
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Yong MK, Slavin MA, Chemaly RF, Papanicolaou GA. CMV prevention strategies in allogeneic hematopoietic cell transplantation; the role of prophylaxis and pre-emptive monitoring in the era of letermovir. Transpl Infect Dis 2023; 25 Suppl 1:e14171. [PMID: 37864299 DOI: 10.1111/tid.14171] [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: 08/15/2023] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 10/22/2023]
Abstract
The preferred strategy for preventing CMV in at-risk populations in alloHCT has undergone a significant practice shift in recent years where the pendulum has swung from a pre-emptive approach to now offering letermovir prophylaxis to all CMV seropositive recipients. Letermovir prophylaxis has resulted in significant reductions in post-transplant clinically significant CMV infection (csCMVi) as well as other important outcomes such as CMV disease, resistant, and refractory CMV infections and nonrelapse mortality. However, prophylactic strategies are not without some limitations, namely delayed onset CMV infections, delayed CMV-specific T cell immune reconstitution, increased drug costs and limited data within pediatric populations. Thus, this review aims to provide an overview of prophylaxis and pre-emptive CMV preventative strategies, and how they are applicable in the current era of letermovir prophylaxis.
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Affiliation(s)
- Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Centre, Houston, Texas, USA
| | - Genovefa A Papanicolaou
- Department of Medicine, Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
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4
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Trirattanapikul A, Pasomsub E, Siriyotha S, Pattanaprateep O, Phuphuakrat A. Diagnostic stewardship to limit repeat plasma cytomegalovirus viral load testing. BMC Infect Dis 2023; 23:387. [PMID: 37296377 DOI: 10.1186/s12879-023-08355-0] [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: 12/08/2022] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Frequent serial monitoring of plasma cytomegalovirus (CMV) viral load caused unnecessary budgets for laboratory testing without changes in treatment. We aimed to implement diagnostic stewardship to limit CMV viral load testing at appropriate intervals. METHODS A quasi-experimental study was performed. To avoid unnecessary plasma CMV viral load testing, the inpatient electronic pop-up reminder was launched in 2021. In cases with plasma CMV viral load testing was ordered in intervals of less than five days, telephone interview and feedback were performed. Pre-post intervention data was compared in terms of clinical and monetary outcomes. The rate of plasma CMV viral load testing performed in intervals of less than five days was compared between 2021 and 2019 using the Poisson regression model. RESULTS After the protocol implementation, there was a significant decrease in the rate of plasma CMV viral load test orders in intervals of less than five days from 17.5% to 8.0% [incidence rate ratio 0.40, p < 0.001]. There was no statistically significant difference in the incidence of CMV DNAemia and CMV disease (p = 0.407 and 0.602, respectively). As a result, the hospital could save the costs of plasma CMV viral load testing per 1,000 patients performed with intervals of less than five days from 2,646,048.11 to 1,360,062.89 Thai Baht. CONCLUSIONS The diagnostic stewardship program is safe and helpful in reducing unnecessary plasma CMV viral load testing and costs.
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Affiliation(s)
- Akeatit Trirattanapikul
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Ekawat Pasomsub
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sukanya Siriyotha
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Angsana Phuphuakrat
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchathewi, Bangkok, 10400, Thailand.
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Lopedote P, Xue E, Chotivatanapong J, Pao EC, Wychera C, Dahlberg AE, Thur L, Roberts L, Baker K, Gooley TA, Hingorani S, Milano F. Acute kidney injury and chronic kidney disease in umbilical cord blood transplant recipients. Front Oncol 2023; 13:1186503. [PMID: 37260983 PMCID: PMC10229046 DOI: 10.3389/fonc.2023.1186503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
Introduction Acute kidney injury (AKI) is a frequent early complication post hematopoietic stem cell transplant (HSCT), associated with high morbidity and mortality. Cord blood transplant (CBT) recipients are potentially exposed to more nephrotoxic insults, compared to patients undergoing HSCT from other donor sources. We aimed to identify risk factors for AKI in patients undergoing CBT. We also aimed to identify the impact of AKI on chronic kidney disease (CKD) and survival outcomes by one-year post-CBT. Methods Adults and children who underwent a first CBT at our Institution were retrospectively evaluated. AKI was staged according to Kidney Disease Improving Global Outcomes (KDIGO) definitions. Cox regression models were used to estimate the association of demographic factors and post-CBT parameters with the cause-specific hazard of AKI. Results We identified 276 patients. Median age was 32 years, 28% (77/276) were children (<18 years) and 129 (47%) were white. A myeloablative conditioning regimen was administered to 243 patients (88%) and 248 (90%) received cyclosporine for GVHD prophylaxis. One-hundred and eighty-six patients (67%) developed AKI by day 60 post-transplant, with 72 (26%) developing severe AKI (stage 2 and 3). In a multivariable analysis, each increase in bilirubin level of 1 mg/dL was associated with a 23% increase in the risk of severe AKI (adjusted HR 1.23, 95% CI 1.13 - 1.34, p<.0001). Conversely, systemic steroid administration appeared to be protective of severe AKI (unadjusted HR 0.36, 95% CI 0.18 - 0.72, p=.004) in a univariate model . Two-hundred-forty-seven patients were evaluable at the one-year time point. Among those, 100 patients (40%) developed CKD one-year post-CBT. Severe AKI was associated with a higher hazard of non-relapse mortality (adjusted HR=3.26, 95% CI 1.65-6.45, p=.001) and overall mortality (adjusted HR=2.28, 95% CI 1.22-4.27, p=.01). Discussion AKI is a frequent complication after CBT and is associated with worse outcomes. Questions remain as to the mechanism of the protective role of steroids on kidney function in the setting of CBT.
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Affiliation(s)
- Paolo Lopedote
- Department of Medicine, St. Elizabeth’s Medical Center, Boston University, Boston, MA, United States
| | - Elisabetta Xue
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | - Julie Chotivatanapong
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Emily C. Pao
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Chiara Wychera
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Ann E. Dahlberg
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Laurel Thur
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Laura Roberts
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Kelsey Baker
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Ted A. Gooley
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Sangeeta Hingorani
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
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6
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Douglas G, Yong MK, Tio SY, Chau M, Prabahran A, Sasadeusz J, Slavin M, Ritchie D, Chee L. Effective CMV prophylaxis with high-dose valaciclovir in allogeneic hematopoietic stem-cell recipients at a high risk of CMV infection. Transpl Infect Dis 2023; 25:e13994. [PMID: 36413495 DOI: 10.1111/tid.13994] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/29/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection increases mortality and morbidity following allogeneic hematopoietic stem-cell transplantation (alloHSCT). Universal antiviral prophylaxis with letermovir is effective but unsubsidized in Australia. Valaciclovir demonstrates anti-CMV activity in high doses, but few current real-world studies explore its use as primary prophylaxis in high-risk patients post-alloHSCT. METHODS We performed a retrospective analysis of alloHSCT recipients at high risk of clinically significant CMV infection (cs-CMVi), defined as a plasma CMV DNA viral load of >400 IU/ml requiring preemptive therapy, or CMV disease. High-risk recipients were CMV seropositive and underwent T-cell depleted, haploidentical or umbilical cord stem-cell transplants. Consecutive patients transplanted from July 2018 to January 2020, treated with valaciclovir 2 g TDS from day +7 to +100 (HD-VALA), were compared to a historical cohort (July 2017-June 2018) who only received preemptive CMV therapy, and standard valaciclovir (SD-VALA) for varicella/herpes prophylaxis. We compared incidence of and time to cs-CMVi. RESULTS In the SD-VALA cohort (n = 27, median CMV follow-up duration 259 days), 23/27 (85%) developed cs-CMVi at a median of 39 days. For the HD-VALA cohort (n = 35, median CMV follow-up duration 216 days), 19/35 (54%) developed cs-CMVi, at a median of 68 days. Time to cs-CMVi was significantly longer in HD-VALA cohort (p < .0001). On multivariate analysis, HD VALA reduced the risk of cs-CMVi (HR 0.32, p = .0005). CONCLUSIONS In alloHSCT recipients at high risk for cs-CMVi, HD-VALA resulted in lower cumulative reactivation, and delayed reactivation, reducing requirement for preemptive CMV therapy in the early post-engraftment period.
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Affiliation(s)
- Genevieve Douglas
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia
| | - Michelle K Yong
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Australia.,National Centre for Infections in Cancer, Parkville, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Shio Yen Tio
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Australia.,National Centre for Infections in Cancer, Parkville, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Maggie Chau
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia.,Pharmacy Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Ashvind Prabahran
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia
| | - Joe Sasadeusz
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Australia
| | - Monica Slavin
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Australia.,National Centre for Infections in Cancer, Parkville, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - David Ritchie
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Lynette Chee
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
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7
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Hawks KG, Fegley A, Sabo RT, Roberts CH, Toor AA. High dose valacyclovir for cytomegalovirus prophylaxis following allogeneic hematopoietic cell transplantation. J Oncol Pharm Pract 2023; 29:130-137. [PMID: 34854771 DOI: 10.1177/10781552211060479] [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: 12/15/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) is one of the most common and clinically significant viral infections following allogeneic hematopoietic cell transplantation (HCT). Currently available options for CMV prophylaxis and treatment present challenges related to side effects and cost. METHODS In this retrospective medical record review, the incidence of clinically significant CMV infection (CMV disease or reactivation requiring preemptive treatment) following allogeneic HCT was compared in patients receiving valacyclovir 1 g three times daily versus acyclovir 400 mg every 12 h for viral prophylaxis. RESULTS Forty-five patients who received valacyclovir were matched based on propensity scoring to 35 patients who received acyclovir. All patients received reduced-intensity conditioning regimens containing anti-thymocyte globulin. Clinically significant CMV infection by day + 180 was lower in the valacyclovir group compared to the acyclovir group (18% vs. 57%, p = 0.0004). Patients receiving valacyclovir prophylaxis also had less severe infection evidenced by a reduction in CMV disease, lower peak CMV titers, delayed CMV reactivation, and less secondary neutropenia. CONCLUSION Prospective evaluation of valacyclovir 1 g three times daily for viral prophylaxis following allogeneic HCT is warranted. Due to valacyclovir's favorable toxicity profile and affordable cost, it has the potential to benefit patients on a broad scale as an option for CMV prophylaxis.
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Affiliation(s)
- Kelly G Hawks
- Department of Pharmacy Services, 6887Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Amanda Fegley
- Department of Pharmacy Services, 6887Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Roy T Sabo
- Department of Biostatistics, 6889Virginia Commonwealth University, Richmond, VA, USA
| | - Catherine H Roberts
- Department of Internal Medicine, Massey Cancer Center, 6887Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Amir A Toor
- Department of Internal Medicine, Massey Cancer Center, 6887Virginia Commonwealth University Health System, Richmond, VA, USA
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8
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Extended-duration letermovir prophylaxis for cytomegalovirus infection after cord blood transplantation in adults. Blood Adv 2022; 6:6291-6300. [PMID: 35802462 PMCID: PMC9806329 DOI: 10.1182/bloodadvances.2022008047] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/22/2022] [Accepted: 07/01/2022] [Indexed: 01/07/2023] Open
Abstract
Cord blood transplantation (CBT) can be complicated by a high incidence of clinically significant cytomegalovirus infection (csCMVi). We have investigated the efficacy of extended letermovir prophylaxis in seropositive adult CBT recipients. The aim was to continue prophylaxis for ≥6 months (insurance permitting). By day 100, the incidence of csCMVi was 0% in 28 patients who received letermovir prophylaxis. Moreover, of 24 patients alive at day 100, none had csCMVi by day 180, having continued prophylaxis for all (n = 20) or part (n = 4) of that period. Overall, 20 patients stopped letermovir at a median of 354 days (range, 119-455 days) posttransplant, with only 5 requiring 1 (n = 4) or 2 (n = 1) courses of valganciclovir (median total duration, 58 days; range, 12-67 days) for postprophylaxis viremia, with no subsequent csCMVi. There were no toxicities attributable to letermovir. Of the 62 historic control subjects who received acyclovir only, 51 developed csCMVi (median onset, 34 days; range, 5-74 days), for a day 100 incidence of 82% (95% confidence interval, 73-92). Seven patients developed proven/probable CMV disease, and 6 died before day 100 (3 with proven/probable CMV pneumonia). Forty-five patients required extended therapy during the first 6 months for 1 (n = 10), 2 (n = 14), or 3/persistent (n = 21) csCMVi, with 43 (84%) of 51 developing significant treatment toxicities. Letermovir is a highly effective, well-tolerated prophylaxis that mitigates CMV infection, CMV-related mortality, and antiviral therapy toxicities in CBT recipients. Our data support prophylaxis duration of at least 6 months after CBT.
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9
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Freyer CW, Carulli A, Gier S, Ganetsky A, Timlin C, Schuster M, Babushok D, Frey NV, Gill SI, Hexner EO, Luger SM, Mangan JK, Martin ME, McCurdy SR, Perl AE, Porter DL, Pratz K, Smith J, Stadtmauer EA, Loren AW. Letermovir vs. high-dose valacyclovir for cytomegalovirus prophylaxis following haploidentical or mismatched unrelated donor allogeneic hematopoietic cell transplantation receiving post-transplant cyclophosphamide. Leuk Lymphoma 2022; 63:1925-1933. [PMID: 35188052 DOI: 10.1080/10428194.2022.2042686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients undergoing haploidentical or mismatched unrelated donor (haplo/MMUD) allogeneic hematopoietic cell transplantation (alloHCT) receiving post-transplant cyclophosphamide (PTCy) are at high risk of cytomegalovirus (CMV) infection. Experience with letermovir (LET) in this population is limited. This single center retrospective cohort study compared CMV and transplant outcomes between LET and a historical control with high-dose valacyclovir (HDV) prophylaxis in adults undergoing haplo/MMUD alloHCT. Thirty-eight CMV seropositive patients were included, 19 in each arm. LET reduced the incidence of CMV infection (5% vs. 53%, RR 0.01, 95% CI 0.014-0.71, p = .001) and need for CMV treatment by day +100 (5% vs. 37%, RR 0.14, 95% CI 0.18-0.99, p = .017) compared to HDV. Median CMV event-free-survival was improved with LET (not reached vs. 80 days, HR 0.114, 95% CI 0.07-0.61, p = .004). These data support the efficacy of LET in alternative donor transplants.
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Affiliation(s)
- Craig W Freyer
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alison Carulli
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shannon Gier
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Alex Ganetsky
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen Timlin
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mindy Schuster
- Infectious Diseases Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Daria Babushok
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Noelle V Frey
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Saar I Gill
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Elizabeth O Hexner
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Selina M Luger
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - James K Mangan
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Mary Ellen Martin
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Shannon R McCurdy
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Alexander E Perl
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - David L Porter
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Keith Pratz
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Jacqueline Smith
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Edward A Stadtmauer
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Alison W Loren
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
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10
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Yong MK, Shigle TL, Kim YJ, Carpenter PA, Chemaly RF, Papanicolaou GA. American Society for Transplantation and Cellular Therapy Series: #4 - Cytomegalovirus treatment and management of resistant or refractory infections after hematopoietic cell transplantation. Transplant Cell Ther 2021; 27:957-967. [PMID: 34560310 DOI: 10.1016/j.jtct.2021.09.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 11/29/2022]
Abstract
The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy (ASTCT) partnered with its Transpl. Infect. Dis. Special Interest Group (TID-SIG) to update its 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A new approach was employed with the goal of better serving clinical providers by publishing each standalone topic in the infectious diseases series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious diseases and HCT content experts developed and answered FAQs. Topics were finalized with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. The fourth topic in the series focuses on the management and treatment of cytomegalovirus (CMV) resistant and refractory infections. The diagnosis, definitions of resistant and refractory CMV, risk factors, virological genotypes and treatment algorithms are reviewed.
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Affiliation(s)
- Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, 3000, Australia; Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne Victoria, 3050, Australia.
| | - Terri Lynn Shigle
- Division of Pharmacy, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Centre, Seattle, WA, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, & Employee Health, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Genovefa A Papanicolaou
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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11
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Hakki M, Aitken SL, Danziger-Isakov L, Michaels MG, Carpenter PA, Chemaly RF, Papanicolaou GA, Boeckh M, Marty FM. American Society for Transplantation and Cellular Therapy Series: #3-Prevention of Cytomegalovirus Infection and Disease After Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:707-719. [PMID: 34452721 DOI: 10.1016/j.jtct.2021.05.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 11/20/2022]
Abstract
The Practice Guidelines Committee of the American Society for Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to update its 2009 compendium-style infectious diseases guidelines for the care of hematopoietic cell transplant (HCT) recipients. A new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease and HCT content experts developed and answered FAQs. Topics were finalized with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. The third topic in the series focuses on the prevention of cytomegalovirus infection and disease in HCT recipients by reviewing prophylaxis and preemptive therapy approaches; key definitions, relevant risk factors, and diagnostic monitoring considerations are also reviewed.
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Affiliation(s)
- Morgan Hakki
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon.
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lara Danziger-Isakov
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Marian G Michaels
- Division of Pediatric Infectious Diseases, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and the University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Vaccine and Infectious Disease Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Francisco M Marty
- Division of Infectious Diseases, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
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12
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Delayed-onset cytomegalovirus infection is frequent after discontinuing letermovir in cord blood transplant recipients. Blood Adv 2021; 5:3113-3119. [PMID: 34402885 DOI: 10.1182/bloodadvances.2021004362] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/25/2021] [Indexed: 11/20/2022] Open
Abstract
Cytomegalovirus (CMV)-seropositive umbilical cord blood transplantation (CBT) recipients have a high incidence of CMV-associated complications. There are limited data regarding the efficacy of letermovir for preventing clinically significant CMV infection (CS-CMVi), and the impact of letermovir prophylaxis on delayed-onset CMV reactivation after letermovir discontinuation, in CBT recipients. We compared the cumulative incidence of CS-CMVi and CMV detection in 21 CMV-seropositive CBT recipients receiving letermovir prophylaxis with a historical cohort of 40 CBT recipients receiving high-dose valacyclovir prophylaxis. Letermovir was administered on day +1 up to day +98. The cumulative incidence of CS-CMVi was significantly lower by day 98 in the letermovir cohort (19% vs 65%). This difference was lost by 1 year due to a higher incidence of delayed-onset CMV reactivation in the letermovir cohort. No patients developed CMV disease in the letermovir cohort within the first 98 days compared with 2 cases (2.4%) in the high-dose valacyclovir cohort; 2 patients developed CMV enteritis after discontinuing letermovir. Median viral loads were similar in both cohorts. Thus, letermovir is effective at preventing CS-CMVi after CBT, but frequent delayed-onset infections after letermovir discontinuation mandate close monitoring and consideration for extended prophylaxis.
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13
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Olson AL, Politikos I, Brunstein C, Milano F, Barker J, Hill JA. Guidelines for Infection Prophylaxis, Monitoring and Therapy in Cord Blood Transplantation. Transplant Cell Ther 2021; 27:359-362. [PMID: 33965172 DOI: 10.1016/j.jtct.2021.01.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/14/2022]
Abstract
As an alternative stem cell source, cord blood (CB) has many advantages. However, delayed engraftment, lack of transferred immunity, and a significant incidence of acute graft-versus-host disease renders CB transplant (CBT) recipients at high risk of infectious complications. This guidance written by CBT and infectious disease experts outlines evidence-based recommendations for the prevention and treatment of opportunistic infections in adult patients undergoing CBT. Topics addressed include bacterial, fungal, viral, pneumocystis jirovcii and toxoplasmosis prophylaxis, suggested PCR monitoring for viruses, therapy for the most commonly encountered infections after CBT. We review key concepts including the recent important role of letermovir in the prevention of CMV reactivation. In instances where there is a paucity of data, practice recommendations are provided, including the duration of antimicrobial prophylaxis.
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Affiliation(s)
- Amanda L Olson
- The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | | | | | - Fillipo Milano
- The Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Juliet Barker
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua A Hill
- The Fred Hutchinson Cancer Research Center, Seattle, Washington
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14
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Reed DR, Petroni GR, West M, Jones C, Alfaraj A, Williams PG, DeGregory K, Grose K, Monson S, Varadarajan I, Volodin L, Donowitz GR, Kindwall-Keller TL, Ballen KK. Prophylactic pretransplant ganciclovir to reduce cytomegalovirus infection after hematopoietic stem cell transplantation. Hematol Oncol Stem Cell Ther 2021; 16:61-69. [PMID: 36634280 DOI: 10.1016/j.hemonc.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 03/22/2021] [Accepted: 05/24/2021] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE/BACKGROUND Cytomegalovirus (CMV) reactivation remains a serious complication after allogeneic hematopoietic cell transplantation (HCT) occurring in approximately 60-70% of CMV-seropositive HCT recipients. CMV reactivation leads to adverse outcomes including end-organ damage, graft-versus-host disease, and graft failure. METHODS Ganciclovir was administered pretransplant at 5 mg/kg twice daily intravenously from the start of conditioning to Day T-2 to CMV-seropositive patients receiving their first allogeneic HCT. CMV DNA was monitored weekly until at least Day 100 posttransplant. RESULTS A total of 109 consecutive patients were treated, median age 57 (range 20-73) years. Of these, 36 (33%) patients had a CMV reactivation within the first 105 days posttransplant with a median time of reactivation of 52.5 (range 36-104) days posttransplant. The cumulative incidence of CMV reactivation at Day 105 posttransplant was 33.1% (95% confidence interval: 24.4-42.0). One patient developed CMV disease. CONCLUSION The use of pretransplant ganciclovir was associated with low incidence of CMV reactivation and disease. These data suggest that pretransplant ganciclovir with preemptive therapy for viral reactivation may be a useful strategy to reduce CMV reactivation. Future prospective trials are needed to compare strategies for CMV prophylaxis.
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Affiliation(s)
- Daniel R Reed
- Section of Hematology and Oncology, Comprehensive Cancer Center of Wake Forest Baptist Health, Winston-Salem, NC, USA.
| | - Gina R Petroni
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Melissa West
- Department of Pharmacy, University of Virginia, Charlottesville, VA, USA
| | - Caroline Jones
- Department of Pharmacy, University of Virginia, Charlottesville, VA, USA
| | - Abeer Alfaraj
- BayHealth Hematology/Oncology Associates, Delaware, PA, USA
| | - Paige G Williams
- Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Kathlene DeGregory
- Department of Pharmacy, University of Virginia, Charlottesville, VA, USA
| | - Kyle Grose
- Department of Pharmacy, University of Kansas, Kansas City, KS, USA
| | - Sandra Monson
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Indumathy Varadarajan
- Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Leonid Volodin
- Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
| | - Gerald R Donowitz
- Department of Infectious Disease, University of Virginia, Charlottesville, VA, USA
| | | | - Karen K Ballen
- Division of Hematology and Oncology, University of Virginia, Charlottesville, VA, USA
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15
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Xue E, Xie H, Leisenring WM, Kimball LE, Goyal S, Chung L, Blazevic R, Maltez B, Edwards A, Dahlberg AE, Salit RB, Delaney C, Pergam SA, Boeckh M, Milano F, Hill JA. High Incidence of Herpes Zoster After Cord Blood Hematopoietic Cell Transplant Despite Longer Duration of Antiviral Prophylaxis. Clin Infect Dis 2021; 72:1350-1357. [PMID: 32150265 DOI: 10.1093/cid/ciaa222] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/03/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cord blood transplant (CBT) recipients have a high incidence of herpes zoster (HZ) in the context of short-term peritransplant antiviral prophylaxis. In 2009, international guidelines recommended HZ prophylaxis for at least 1 year after hematopoietic cell transplant. The impact of longer-term antiviral prophylaxis on HZ incidence after CBT is unknown. METHODS We retrospectively analyzed varicella zoster virus (VZV)-seropositive CBT recipients who were transplanted between 2006 and 2016. We abstracted HZ events and other variables for up to 5 years post-CBT. We calculated the cumulative incidence of HZ and used Cox proportional hazards regression to identify variables associated with HZ. RESULTS The study cohort consisted of 227 patients. Among 1-year survivors, 91% were still receiving prophylaxis, for a median duration of 20.6 months. HZ occurred in 44 patients (19%) at a median of 23.6 months. The cumulative incidence of HZ by 1 year after CBT was 1.8% (95% confidence interval [CI], .1%-4%), but increased to 26% (95% CI, 19%-33%) by 5 years. In a multivariable analysis, acute graft-vs-host disease was associated with increased risk, whereas antiviral prophylaxis was associated with reduced risk for HZ (adjusted hazard ratio, 0.19 [95% CI, .09-.4]). There was no association between CD4+ T-cell counts at 1 year post-CBT and subsequent risk for HZ. CONCLUSIONS We found a high incidence of HZ after CBT despite antiviral prophylaxis for > 1 year. Based on these findings, we suggest longer duration of prophylaxis for HZ after CBT. Compliance with antiviral prophylaxis, VZV-specific immune monitoring, and vaccination to mitigate HZ after CBT also require further study.
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Affiliation(s)
- Elisabetta Xue
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Hematology and Bone Marrow Transplant Unit, San Raffaele Scientific Institute, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Louise E Kimball
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sonia Goyal
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Lisa Chung
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Rachel Blazevic
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Byron Maltez
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Anna Edwards
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Ann E Dahlberg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Rachel B Salit
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Colleen Delaney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Nohla Therapeutics, Seattle, Washington, USA
| | - Steven A Pergam
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Joshua A Hill
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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16
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Yong MK, Gottlieb D, Lindsay J, Kok J, Rawlinson W, Slavin M, Ritchie D, Bajel A, Grigg A. New advances in the management of cytomegalovirus in allogeneic haemopoietic stem cell transplantation. Intern Med J 2021; 50:277-284. [PMID: 31403736 DOI: 10.1111/imj.14462] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 08/06/2019] [Accepted: 08/06/2019] [Indexed: 12/11/2022]
Abstract
Cytomegalovirus (CMV) viraemia continues to be a frequent complication in the post-haemopoietic stem cell transplantation period despite a low incidence of CMV end-organ disease. Several significant advances in the understanding and management of CMV infection have occurred in the last few years including improved diagnostics, monitoring of CMV immunity, availability of novel anti-CMV drugs, and emerging use of immunotherapies including CMV-specific T-cell infusions. In addition to reviewing these advances we also explore some of the more practical prescribing issues of the older and newer CMV drugs including cost, toxicity and drug interactions to help clinicians navigate this new era of CMV management.
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Affiliation(s)
- Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - David Gottlieb
- Department of Haematology and Bone Marrow Transplantation, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia.,Sydney Cellular Therapies Laboratory, Westmead Hospital, Sydney, New South Wales, Australia
| | - Julian Lindsay
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Pharmacy Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jen Kok
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Sydney, New South Wales, Australia
| | - William Rawlinson
- NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - David Ritchie
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ashish Bajel
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew Grigg
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Clinical Haematology and Olivia Newton John Cancer Research Institute, Austin Hospital, Melbourne, Victoria, Australia
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17
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Whited LK, Handy VW, Hosing C, Chow E. Incidence of viral and fungal complications after utilization of alternative donor sources in hematopoietic cell transplantation. Pharmacotherapy 2020; 40:773-787. [PMID: 32497299 DOI: 10.1002/phar.2433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) remains the only curable option for adult patients with hematologic malignancies. According to guidelines published by the American Society for Transplantation and Cellular Therapy, allogeneic HCT should be offered to all intermediate- and high-risk patients with acute leukemia. While matched-related donor (MRD) grafts continue to be the preferred stem cell source for allogeneic HCT, studies comparing MRD grafts to matched-unrelated donor (MUD) grafts showed comparable outcomes in patients with acute leukemia. Unfortunately, for those without a suitable matched-related graft, the probability of finding a suitable matched-unrelated donor varies significantly depending on racial and ethnic background. With allogeneic HCT procedures increasing year after year due to the increased availability of suitable donors, each of these alternative donor sources merits special clinical considerations, specifically with regard to infections. Infections remain a significant cause of morbidity and mortality after allogeneic transplant, especially in those receiving alternative donor grafts. Due to the high-risk nature associated with these donor grafts, it is important to understand the true risk of developing infectious complications. While there are a multitude of infections that have been described in patients post-allogeneic HCT, this review seeks to focus on the incidence of cytomegalovirus (CMV) and invasive fungal infections (IFI) in adult patients receiving alternative donor source transplantation for hematologic malignancies.
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Affiliation(s)
- Laura K Whited
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Victoria W Handy
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chitra Hosing
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eric Chow
- Janssen Scientific Affairs, LLC, Horsham, Pennsylvania, USA
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18
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Sharma P, Gakhar N, MacDonald J, Abidi MZ, Benamu E, Bajrovic V, Purev E, Haverkos BM, Tobin J, Kaiser J, Chase S, Miller M, Weinberg A, Gutman JA. Letermovir prophylaxis through day 100 post transplant is safe and effective compared with alternative CMV prophylaxis strategies following adult cord blood and haploidentical cord blood transplantation. Bone Marrow Transplant 2019; 55:780-786. [PMID: 31664185 DOI: 10.1038/s41409-019-0730-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/09/2019] [Accepted: 10/16/2019] [Indexed: 01/07/2023]
Abstract
We compared CMV outcomes of three prophylactic approaches used for CBT and haploidentical cord transplants from December 2009 through 2018: letermovir (n = 32) through day 100 post transplant, "valacyclovir day 100" (valacyclovir 2 g orally three times daily through day 100) (n = 60), and "valacyclovir hospital discharge" (valacyclovir 2 g orally three times daily through hospital discharge then acyclovir 800 mg twice daily) (n = 41). Through day 100, none in the letermovir group, six (10%) in the "valacyclovir day 100," and nine (22%) in the "valacyclovir hospital discharge" group required CMV directed treatment (p = 0.005 and 0.06 comparing letermovir to "valacyclovir hospital discharge" and "valacyclovir day 100"). Fewer patients in the letermovir group (n = 7, 22%) had any CMV reactivation versus the "valacyclovir day 100" group (n = 20, 33%) versus the "valacyclovir hospital discharge" group (n = 23, 57%) (p = 0.003 and 0.21 comparing letermovir to "valacyclovir hospital discharge" and "valacyclovir day 100"). Among patients not reactivating CMV before 100 days, reactivation rates between day 100 and 180 were higher in the letermovir and "valacyclovir day 100" groups than the "valacyclovir hospital discharge" group. Letermovir is safe and effective compared with alternative prophylaxis approaches following CBT through day 100. Reactivation and monitoring after day 100 remain potential concerns.
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Affiliation(s)
- Prashant Sharma
- Department of Medicine, University of Colorado, Denver, CO, USA
| | - Neel Gakhar
- Department of Medicine, University of Colorado, Denver, CO, USA
| | | | - Maheen Z Abidi
- Department of Medicine, University of Colorado, Denver, CO, USA.,Division of Infectious Disease, University of Colorado, Denver, CO, USA.,Division of Hematology, University of Colorado, Denver, CO, USA
| | - Esther Benamu
- Department of Medicine, University of Colorado, Denver, CO, USA.,Division of Infectious Disease, University of Colorado, Denver, CO, USA.,Division of Hematology, University of Colorado, Denver, CO, USA
| | - Valida Bajrovic
- Department of Medicine, University of Colorado, Denver, CO, USA.,Division of Infectious Disease, University of Colorado, Denver, CO, USA.,Division of Hematology, University of Colorado, Denver, CO, USA
| | - Enkhtsetseg Purev
- Department of Medicine, University of Colorado, Denver, CO, USA.,Division of Pharmacy, University of Colorado, Denver, CO, USA
| | - Bradley M Haverkos
- Department of Medicine, University of Colorado, Denver, CO, USA.,Division of Hematology, University of Colorado, Denver, CO, USA
| | - Jennifer Tobin
- Division of Pharmacy, University of Colorado, Denver, CO, USA
| | - Jeff Kaiser
- Division of Pharmacy, University of Colorado, Denver, CO, USA
| | - Stephanie Chase
- Division of Pharmacy, University of Colorado, Denver, CO, USA
| | - Matthew Miller
- Division of Pharmacy, University of Colorado, Denver, CO, USA
| | - Adriana Weinberg
- Department of Medicine, University of Colorado, Denver, CO, USA.,Division of Infectious Disease, University of Colorado, Denver, CO, USA.,Division of Hematology, University of Colorado, Denver, CO, USA
| | - Jonathan A Gutman
- Department of Medicine, University of Colorado, Denver, CO, USA. .,Division of Pharmacy, University of Colorado, Denver, CO, USA.
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19
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Dahlberg A, Milano F. Improved Survival after Cord Blood Transplantation: Single-Center Experience in Pediatric Patients Over a 2-Decade Period. Biol Blood Marrow Transplant 2019; 25:e117-e118. [PMID: 30771496 DOI: 10.1016/j.bbmt.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 02/07/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Ann Dahlberg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington, Seattle, Washington
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington, Seattle, Washington.
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20
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Abstract
PURPOSE OF REVIEW Cytomegalovirus infection (CMVi) has been the troll of allogeneic hematopoietic cell transplantation (allo-HCT). Over the last 4 decades various approaches have been adopted to minimize the burden from CMVi. There has been major advancement in the management of CMVi in HCT within the last few years that is poised to change the approaches employed in preventing and managing CMVi. This review will summarize recent advances and potential future development in the management of CMV in HCT. RECENT FINDING The major development has been the approval of letermovir for the prevention of CMVi in allo-HCT recipients. Also, with the potential availability of tests that can determine host CMV immunity a risk adapted approach to CMV prevention may become a possibility. SUMMARY The landscape of CMV prevention is about to change with the approval of a new anti-CMV antiviral that is safe and effective. However, the prophylaxis may lead to late onset CMVi in the context of ongoing risk factors after stopping prophylaxis and measures to counter this shifting epidemiology will need further research; such as extending the prophylaxis in high-risk patients vs. immunotherapy with vaccination and T-cell therapy.
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21
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Diamond DJ, LaRosa C, Chiuppesi F, Contreras H, Dadwal S, Wussow F, Bautista S, Nakamura R, Zaia JA. A fifty-year odyssey: prospects for a cytomegalovirus vaccine in transplant and congenital infection. Expert Rev Vaccines 2018; 17:889-911. [PMID: 30246580 PMCID: PMC6343505 DOI: 10.1080/14760584.2018.1526085] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/17/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION It has been almost fifty years since the Towne strain was used by Plotkin and collaborators as the first vaccine candidate for cytomegalovirus (CMV). While that approach showed partial efficacy, there have been a multitude of challenges to improve on the promise of a CMV vaccine. Efforts have been dichotomized into a therapeutic vaccine for patients with CMV-infected allografts, either stem cells or solid organ, and a prophylactic vaccine for congenital infection. AREAS COVERED This review will evaluate research prospects for a therapeutic vaccine for transplant recipients that recognizes CMV utilizing primarily T cell responses. Similarly, we will provide an extensive discussion on attempts to develop a vaccine to prevent the manifestations of congenital infection, based on eliciting a humoral anti-CMV protective response. The review will also describe newer developments that have upended the efforts toward such a vaccine through the discovery of a second pathway of CMV infection that utilizes an alternative receptor for entry using a series of antigens that have been determined to be important for prevention of infection. EXPERT COMMENTARY There is a concerted effort to unify separate therapeutic and prophylactic vaccine strategies into a single delivery agent that would be effective for both transplant-related and congenital infection.
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Affiliation(s)
- Don J. Diamond
- Department of Experimental Therapeutics, Beckman Research
Institute of City of Hope, Duarte, CA
| | - Corinna LaRosa
- Department of Experimental Therapeutics, Beckman Research
Institute of City of Hope, Duarte, CA
| | - Flavia Chiuppesi
- Department of Experimental Therapeutics, Beckman Research
Institute of City of Hope, Duarte, CA
| | - Heidi Contreras
- Department of Experimental Therapeutics, Beckman Research
Institute of City of Hope, Duarte, CA
| | - Sanjeet Dadwal
- Department of Medical Specialties, City of Hope National
Medical Center, Duarte, CA
| | - Felix Wussow
- Department of Experimental Therapeutics, Beckman Research
Institute of City of Hope, Duarte, CA
| | - Supriya Bautista
- Department of Experimental Therapeutics, Beckman Research
Institute of City of Hope, Duarte, CA
| | - Ryotaro Nakamura
- Department of Hematology & Hematopoetic Cell
Transplantation, City of Hope National Medical Center, Duarte, CA
| | - John A. Zaia
- Center for Gene Therapy, Hematological Malignancy and Stem
Cell Transplantation Institute, City of Hope, Duarte, CA
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