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Piñana JL, Giménez E, Vázquez L, Marcos MÁ, Guerreiro M, Duarte R, Pérez A, de Miguel C, Espigado I, González-Vicent M, Suarez-Lledó M, García-Cadenas I, Martino R, Cedillo A, Rovira M, de la Cámara R, Navarro D, Solano C. Update on Cytomegalovirus Infection Management in Allogeneic Hematopoietic Stem Cell Transplant Recipients. A Consensus Document of the Spanish Group for Hematopoietic Transplantation and Cell Therapy (GETH-TC). Mediterr J Hematol Infect Dis 2024; 16:e2024065. [PMID: 39258183 PMCID: PMC11385272 DOI: 10.4084/mjhid.2024.065] [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: 06/10/2024] [Accepted: 08/02/2024] [Indexed: 09/12/2024] Open
Abstract
Background Cytomegalovirus (CMV) infection is a common complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT) and in patients receiving novel hematological therapies. Its impact on morbidity and mortality necessitates effective management strategies. Despite recent advances in diagnostics and treatment, unresolved questions persist regarding monitoring and treatment, prompting the need for updated recommendations. Methods A consensus was reached among a panel of experts selected for their expertise in CMV research and clinical practice. Key clinical areas and questions were identified based on previous surveys and literature reviews. Recommendations were formulated through consensus and graded using established guidelines. Results Recommendations were provided for virological monitoring, including the timing and frequency of CMV DNAemia surveillance, especially during letermovir (LMV) prophylaxis. We evaluated the role of CMV DNA load quantification in diagnosing CMV disease, particularly pneumonia and gastrointestinal involvement, along with the utility of specific CMV immune monitoring in identifying at-risk patients. Strategies for tailoring LMV prophylaxis, managing breakthrough DNAemia, and implementing secondary prophylaxis in refractory cases were outlined. Additionally, criteria for initiating early antiviral treatment based on viral load dynamics were discussed. Conclusion The consensus provides updated recommendations for managing CMV infection in hematological patients, focusing on unresolved issues in monitoring, prophylaxis, treatment, and resistance. These recommendations aim to guide clinical practice and improve outcomes in this high-risk population. Further research is warranted to validate these recommendations and address ongoing challenges in CMV management with emerging antiviral combinations, particularly in pediatric populations.
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Affiliation(s)
- José Luis Piñana
- Hematology Service, Hospital Clinico Universitario, INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Estela Giménez
- Microbiology Service, Hospital Clinico Universitario, INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Lourdes Vázquez
- Hematology Department, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
| | | | - Manuel Guerreiro
- Hematology Service, Hospital Universitario y Politécnico La Fe. Health Research, Valencia, Spain
| | - Rafael Duarte
- Hematology Service, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Ariadna Pérez
- Hematology Service, Hospital Clinico Universitario, INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Carlos de Miguel
- Hematology Service, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Ildefonso Espigado
- Hematology Service, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - María Suarez-Lledó
- BMT Unit, Haematology Department, Institute of Haematology and Oncology, IDIBAPS, Hospital Clinic, University of Barcelona, Barcelona, Spain. Josep Carreras Leukaemia Research Foundation
| | | | - Rodrigo Martino
- Hematology Service. Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Angel Cedillo
- Spanish Hematopoietic Stem Cell Transplantation and Cell Therapy Group (GETH-TC) Secretary, Madrid, Spain
| | - Monserrat Rovira
- BMT Unit, Haematology Department, Institute of Haematology and Oncology, IDIBAPS, Hospital Clinic, University of Barcelona, Barcelona, Spain. Josep Carreras Leukaemia Research Foundation
| | | | - David Navarro
- Hematology Department, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
- Department of Microbiology School of Medicine, University of Valencia, Valencia, Spain
| | - Carlos Solano
- Hematology Service, Hospital Clinico Universitario, INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
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Kampouri E, Little JS, Crocchiolo R, Hill JA. Human herpesvirus-6, HHV-8 and parvovirus B19 after allogeneic hematopoietic cell transplant: the lesser-known viral complications. Curr Opin Infect Dis 2024; 37:245-253. [PMID: 38726832 DOI: 10.1097/qco.0000000000001020] [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: 06/28/2024]
Abstract
PURPOSE OF REVIEW Viral infections continue to burden allogeneic hematopoietic cell transplant (HCT) recipients. We review the epidemiology, diagnosis, and management of human herpesvirus (HHV)-6, HHV-8 and parvovirus B19 following HCT. RECENT FINDINGS Advances in HCT practices significantly improved outcomes but impact viral epidemiology: post-transplant cyclophosphamide for graft-versus-host disease prevention increases HHV-6 reactivation risk while the impact of letermovir for CMV prophylaxis - and resulting decrease in broad-spectrum antivirals - is more complex. Beyond the well established HHV-6 encephalitis, recent evidence implicates HHV-6 in pneumonitis. Novel less toxic therapeutic approaches (brincidofovir, virus-specific T-cells) may enable preventive strategies in the future. HHV-8 is the causal agent of Kaposi's sarcoma, which is only sporadically reported after HCT, but other manifestations are possible and not well elucidated. Parvovirus B19 can cause severe disease post-HCT, frequently manifesting with anemia, but can also be easily overlooked due to lack of routine screening and ambiguity of manifestations. SUMMARY Studies should establish the contemporary epidemiology of HHV-6, and other more insidious viruses, such as HHV-8 and parvovirus B19 following HCT and should encompass novel cellular therapies. Standardized and readily available diagnostic methods are key to elucidate epidemiology and optimize preventive and therapeutic strategies to mitigate the burden of infection.
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Affiliation(s)
- Eleftheria Kampouri
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jessica S Little
- Dana-Farber Cancer Institute
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Roberto Crocchiolo
- Servizio di Immunoematologia e Medicina Trasfusionale, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Joshua A Hill
- Vaccine and Infectious Disease Division
- Clinical Research Division, Fred Hutchinson Cancer Center
- Department of Medicine, University of Washington, Seattle, Washington, USA
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3
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Hopff SM, Wingen-Heimann SM, Classen AY, Blau IW, Bug G, Hebermehl C, Kraus S, Penack O, Rettig AR, Schmitt T, Steinbrunn T, Teschner D, Vehreschild MJGT, Wehr C, Vehreschild JJ. Real-world experience with letermovir for cytomegalovirus-prophylaxis after allogeneic hematopoietic cell transplantation: A multi-centre observational study. J Infect 2024; 89:106220. [PMID: 38960103 DOI: 10.1016/j.jinf.2024.106220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/27/2024] [Accepted: 06/27/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVES Efficacy and safety of letermovir as prophylaxis for clinically significant cytomegalovirus infections (csCVMi) was evaluated in randomised controlled trials while most of the real-world studies are single-centre experiences. METHODS We performed a retrospective, multi-centre case-control study at six German university hospitals to evaluate clinical experiences in patients receiving CMV prophylaxis with letermovir (n = 200) compared to controls without CMV prophylaxis (n = 200) during a 48-week follow-up period after allogeneic hematopoietic cell transplantation (aHCT). RESULTS The incidence of csCMVi after aHCT was significantly reduced in the letermovir (34%, n = 68) compared to the control group (56%, n = 112; p < 0.001). Letermovir as CMV prophylaxis (OR 0.362) was found to be the only independent variable associated with the prevention of csCMVi. Patients receiving letermovir showed significantly better survival compared to the control group (HR = 1.735, 95% CI: 1.111-2.712; p = 0.014). Of all csCMVi, 46% (n = 31) occurred after discontinuation of letermovir prophylaxis. Severe neutropenia (<500 neutrophils/µL) on the day of the stem cell infusion was the only independent variable for an increased risk of csCMVi after the end of letermovir prophylaxis. CONCLUSIONS Our study highlights the preventive effects of letermovir on csCMVi after aHCT. A substantial proportion of patients developed a csCMVi after discontinuation of letermovir. In particular, patients with severe neutropenia require specific attention after drug discontinuation.
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Affiliation(s)
- Sina M Hopff
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Centre for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany.
| | - Sebastian M Wingen-Heimann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Germany; University of Applied Sciences for Economics and Management (FOM), Cologne, Germany
| | - Annika Y Classen
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Centre for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Igor-Wolfgang Blau
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Gesine Bug
- Goethe University Frankfurt, University Hospital, Department of Medicine 2, Frankfurt am Main, Germany
| | - Corinna Hebermehl
- University Medical Centre of the Johannes Gutenberg University Mainz, Department of Hematology and Medical Oncology, Mainz, Germany
| | - Sabrina Kraus
- University Hospital of Würzburg, Department of Internal Medicine II, Würzburg, Germany
| | - Olaf Penack
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andrés R Rettig
- Department of Medicine I/ Hematology, Oncology and Stem Cell Transplantation, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Timo Schmitt
- University Medical Centre of the Johannes Gutenberg University Mainz, Department of Hematology and Medical Oncology, Mainz, Germany
| | - Torsten Steinbrunn
- University Hospital of Würzburg, Department of Internal Medicine II, Würzburg, Germany; Dana-Farber Cancer Institute, Department of Medical Oncology, Harvard Medical School, Boston, MA, USA
| | - Daniel Teschner
- University Medical Centre of the Johannes Gutenberg University Mainz, Department of Hematology and Medical Oncology, Mainz, Germany; University Hospital of Würzburg, Department of Internal Medicine II, Würzburg, Germany
| | - Maria J G T Vehreschild
- Goethe University Frankfurt, University Hospital Frankfurt, Department of Internal Medicine, Infectious Diseases, Frankfurt am Main, Germany
| | - Claudia Wehr
- Department of Medicine I/ Hematology, Oncology and Stem Cell Transplantation, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - J Janne Vehreschild
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Goethe University Frankfurt, University Hospital, Department of Medicine 2, Frankfurt am Main, Germany
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4
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La Rosa C, Park Y, Yang D, Zhou Q, Kaltcheva T, Karras N, Cheng J, Sun W, Diamond DJ, Pawlowska A. Cytomegalovirus Triplex vaccine in pediatric hematopoietic stem cell transplant patients at high risk for cytomegalovirus complications: evaluation of vaccine safety, immunogenicity and impact on viremia requiring antivirals. Haematologica 2024; 109:2303-2308. [PMID: 38426277 PMCID: PMC11215362 DOI: 10.3324/haematol.2023.284256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 02/23/2024] [Indexed: 03/02/2024] Open
Affiliation(s)
- Corinna La Rosa
- Department of Hematology and Hematopoietic Cell Transplantation.
| | - Yoonsuh Park
- Department of Hematology and Hematopoietic Cell Transplantation
| | - Dongyun Yang
- Department of Hematology and Hematopoietic Cell Transplantation
| | - Qiao Zhou
- Department of Hematology and Hematopoietic Cell Transplantation
| | | | - Nicole Karras
- Department of Pediatrics, City of Hope National Medical Center, Duarte, CA
| | - Jerry Cheng
- Department of Pediatrics, City of Hope National Medical Center, Duarte, CA
| | - Weili Sun
- The Janssen Pharmaceutical Companies of Johnson and Johnson, Los Angeles, CA
| | - Don J Diamond
- Department of Hematology and Hematopoietic Cell Transplantation
| | - Anna Pawlowska
- Department of Pediatrics, City of Hope National Medical Center, Duarte, CA
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Sassine J, Siegrist EA, Shafat TF, Chemaly RF. Advances and prospect in herpesviruses infections after haematopoietic cell transplantation: closer to the finish line? Clin Microbiol Infect 2024:S1198-743X(24)00300-8. [PMID: 38945270 DOI: 10.1016/j.cmi.2024.06.020] [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: 04/20/2024] [Revised: 06/18/2024] [Accepted: 06/23/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Herpesviruses represent common and significant infectious complications after allogeneic haematopoietic cell transplantation (HCT). In the last decade, major advances in the prevention and treatment of these infections were accomplished. OBJECTIVES The aim of this paper is to review the recent advances in the prophylaxis and treatment of herpesvirus infections after allogeneic HCT, to assess the persisting challenges, and to offer future directions for the prevention and management of these infections. SOURCES We searched PubMed for relevant literature regarding specific herpesviruses complicating allogeneic HCT through March 2024. CONTENT The largest advances in this past decade were witnessed for cytomegalovirus (CMV) with the advent of letermovir for primary prophylaxis and the development of maribavir as an option for refractory and/or resistant CMV infections in transplant recipients. For varicella zoster virus, prevention of reactivation with the recombinant zoster vaccine offers an additional prophylactic intervention. Pritelivir is being explored for the treatment of drug-resistant or refractory Herpes simplex virus infections. Although rituximab is now an established option for preemptive therapy for Epstein-Barr virus, Human Herpesvirus-6 remains the most elusive virus of the herpesvirus family, with a lack of evidence supporting the benefit of any agent for prophylaxis or for optimal preemptive therapy. IMPLICATIONS Although considerable advances have been achieved for the treatment and prevention of herpes virus infections, most notably with CMV, the coming years should hold additional opportunities to tame the beast in these herpesviruses postallogeneic HCT, with the advent of new antivirals, cell-mediated immunity testing, and cytotoxic T lymphocytes infusions.
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Affiliation(s)
- Joseph Sassine
- Infectious Diseases Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | | | - Tali Fainguelernt Shafat
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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6
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Febres-Aldana A, Khawaja F, Morado-Aramburo O, Shigle TL, Rondon G, Sassine J, Spallone A, Srinivasan K, Ramdial J, Alousi A, Champlin R, Chen G, Daher M, Rezvani K, Ariza-Heredia EJ, Shpall EJ, Chemaly RF. Mortality in recipients of allogeneic haematopoietic cell transplantation in the era of cytomegalovirus primary prophylaxis: a single-centre retrospective experience. Clin Microbiol Infect 2024; 30:803-809. [PMID: 38460821 DOI: 10.1016/j.cmi.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 02/26/2024] [Accepted: 03/03/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVES Allogeneic haematopoietic cell transplant (allo-HCT) recipients who are cytomegalovirus (CMV)-seronegative have better post-transplant outcomes than CMV-seropositive recipients. Letermovir (LTV) is approved for CMV primary prophylaxis in adults who are CMV-seropositive after allo-HCT, and its use is associated with improved long-term post-transplant outcomes. We analysed whether LTV has affected the relationship between CMV serostatus and post-transplant outcomes. METHODS We conducted a retrospective single-centre cohort study of allo-HCT recipients, stratified according to donor (D) and recipient (R). CMV serostatus and the use of LTV: D-/R-, R+/LTV-, and R+/LTV+. Outcomes measured were all-cause and non-relapse mortality, clinically significant CMV infection, graft-versus-host disease, and relapse up to week 48 after allo-HCT. The D-/R- group served as the reference for comparisons in univariate, competing risk regression, and cumulative incidence functions. RESULTS The analysis included 1071 consecutive allo-HCT recipients: 131 D-/R-, 557 R+/LTV-, and 383 R+/LTV+. All-cause mortality by day 100 was 6.1% for the D-/R- group, compared with 14.0% (p 0.024) and 7.8% (p 0.7) for the R+/LTV- and R+/LTV + groups, respectively. Non-relapse mortality by day 100 was 11.0%, 6.8% and 3.8% for R+/LTV-, R+/LTV+, and D-/R- groups, respectively, without significant difference. When including relapse as a competing event, the hazard ratio for non-relapse mortality was 1.83 (95% CI: 1.12-2.99, p 0.017) for R+/LTV- compared with D-/R- and 1.05 (95% CI 0.62-1.77, p 0.85) for R+/LTV + compared with D-/R-. DISCUSSION CMV primary prophylaxis with LTV abrogated the mortality gap based on CMV serostatus, a protective effect that persisted after discontinuation of primary prophylaxis.
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Affiliation(s)
- Anthony Febres-Aldana
- Department of Infectious Diseases, Infection Control & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Medicine, Division of Infectious Disease, Moffitt Cancer Center, Tampa, FL, USA
| | - Fareed Khawaja
- Department of Infectious Diseases, Infection Control & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Oscar Morado-Aramburo
- Department of Infectious Diseases, Infection Control & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Terri Lynn Shigle
- Division of Pharmacy, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Sassine
- Infectious Diseases Section, Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Amy Spallone
- Department of Infectious Diseases, Infection Control & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Krithika Srinivasan
- Department of Infectious Diseases, Infection Control & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeremy Ramdial
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - George Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - May Daher
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katayoun Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ella J Ariza-Heredia
- Department of Infectious Diseases, Infection Control & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Song E. Case Report: Approaches for managing resistant cytomegalovirus in pediatric allogeneic hematopoietic cell transplantation recipients. Front Pediatr 2024; 12:1394006. [PMID: 38884102 PMCID: PMC11177687 DOI: 10.3389/fped.2024.1394006] [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: 02/29/2024] [Accepted: 03/26/2024] [Indexed: 06/18/2024] Open
Abstract
The instructional case is a pediatric haploidentical TCRαβ+/CD19+ depleted allogeneic hematopoietic cell transplantation recipient who developed early onset CMV infection, which was complicated by resistant CMV (both UL97 and UL54) and successfully managed with maribavir and haploidentical CMV-specific T lymphocytes. Novel approaches to resistant CMV infection are reviewed and effective utilization of recent advances in diagnosis and management of resistant CMV in pediatric HCT are highlighted.
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Affiliation(s)
- Eunkyung Song
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States
- Division of Infectious Diseases & Host Defense, Nationwide Children's Hospital, Columbus, OH, United States
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8
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Cochran WV, Dioverti MV, Langlee J, Barker LN, Shedeck A, Toman LP, Avery RK. Approaches and Challenges in the Current Management of Cytomegalovirus in Transplant Recipients: Highlighting the Role of Advanced Practice Providers (Nurse Practitioners and Physician Assistants). Ann Transplant 2024; 29:e941185. [PMID: 38650316 PMCID: PMC11055468 DOI: 10.12659/aot.941185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 01/22/2024] [Indexed: 04/25/2024] Open
Abstract
Cytomegalovirus (CMV) infection is associated with increased morbidity and mortality in hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients, with traditional anti-CMV therapies limited by their associated toxicities and the development of resistance. Clinical providers are often faced with challenging and complicated CMV infections that require multiple courses of antiviral therapies. Increasingly, advanced practice providers (APPs) are playing an important role in the day-to-day management of transplant recipients with CMV infection, including resistant/refractory CMV and other complex CMV syndromes. Here, we provide an overview of current preventative and treatment strategies for CMV infection in HCT and SOT recipients, highlighting the challenging aspects of current management and the potential utility of newer antiviral agents. This article also focuses on how a multidisciplinary team, orchestrated by APPs, can improve CMV-associated patient outcomes. Protocols using antiviral agents for the prevention or treatment of CMV infections require carefully designed and meticulously implemented strategies to ensure the best clinical outcomes for patients. APPs, who have increasingly become the frontline providers of outpatient care for transplant recipients, are ideally positioned to design and carry out these protocols.
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Affiliation(s)
- Willa V. Cochran
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Julie Langlee
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Audra Shedeck
- Sidney Kimmel Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lindsey P. Toman
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Robin K. Avery
- Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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9
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Kampouri E, Ibrahimi SS, Xie H, Wong ER, Hecht JB, Sekhon MK, Vo A, Stevens-Ayers TL, Green DJ, Gauthier J, Maloney DG, Perez A, Jerome KR, Leisenring WM, Boeckh MJ, Hill JA. Cytomegalovirus (CMV) Reactivation and CMV-Specific Cell-Mediated Immunity After Chimeric Antigen Receptor T-Cell Therapy. Clin Infect Dis 2024; 78:1022-1032. [PMID: 37975819 PMCID: PMC11006113 DOI: 10.1093/cid/ciad708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/03/2023] [Accepted: 11/16/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The epidemiology of cytomegalovirus (CMV) after chimeric antigen receptor-modified T-cell immunotherapy (CARTx) is poorly understood owing to a lack of routine surveillance. METHODS We prospectively enrolled 72 adult CMV-seropositive CD19-, CD20-, or BCMA-targeted CARTx recipients and tested plasma samples for CMV before and weekly up to 12 weeks after CARTx. We assessed CMV-specific cell-mediated immunity (CMV-CMI) before and 2 and 4 weeks after CARTx, using an interferon γ release assay to quantify T-cell responses to IE-1 and pp65. We tested pre-CARTx samples to calculate a risk score for cytopenias and infection (CAR-HEMATOTOX). We used Cox regression to evaluate CMV risk factors and evaluated the predictive performance of CMV-CMI for CMV reactivation in receiver operator characteristic curves. RESULTS CMV was detected in 1 patient (1.4%) before and in 18 (25%) after CARTx, for a cumulative incidence of 27% (95% confidence interval, 16.8-38.2). The median CMV viral load (interquartile range) was 127 (interquartile range, 61-276) IU/mL, with no end-organ disease observed; 5 patients received preemptive therapy based on clinical results. CMV-CMI values reached a nadir 2 weeks after infusion and recovered to baseline levels by week 4. In adjusted models, BCMA-CARTx (vs CD19/CD20) and corticosteroid use for >3 days were significantly associated with CMV reactivation, and possible associations were detected for lower week 2 CMV-CMI and more prior antitumor regimens. The cumulative incidence of CMV reactivation almost doubled when stratified by BCMA-CARTx target and use of corticosteroids for >3 days (46% and 49%, respectively). CONCLUSIONS CMV testing could be considered between 2 and 6 weeks in high-risk CARTx recipients.
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Affiliation(s)
- Eleftheria Kampouri
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Sarah S Ibrahimi
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Elizabeth R Wong
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Jessica B Hecht
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Mandeep K Sekhon
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Alythia Vo
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Terry L Stevens-Ayers
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Damian J Green
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jordan Gauthier
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ailyn Perez
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Michael J Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
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10
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Ohmoto A, Fuji S. Letermovir for cytomegalovirus infection in allogeneic hematopoietic stem-cell transplantation: tips and notes for effective use in clinical practice. Expert Rev Anti Infect Ther 2024; 22:169-178. [PMID: 38404258 DOI: 10.1080/14787210.2024.2322439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/20/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection remains a major complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). While conventional antiviral agents such as ganciclovir can be used for CMV prophylaxis, toxicities such as myelosuppression are a major concern. AREA COVERED This work aimed to summarize the latest information and practical issues regarding a new anti-CMV agent, letermovir (LET). EXPERT OPINION LET inhibits CMV replication by binding to components of the DNA terminase complex. A phase 3 trial in allo-HSCT recipients showed a reduced incidence of clinically significant CMV infection in the LET group. In 2017, this agent was first approved for CMV prophylaxis in adult CMV-seropositive allo-HSCT recipients in the United States, and is now used worldwide. While LET has an excellent toxicity profile, there are issues to be aware of, such as interactions with other drug classes (e.g. immunosuppressants and antifungals) and reactivation of CMV infection following LET cessation. While LET is the current standard of care for CMV prophylaxis, there are no established protocols for preemptive treatment of asymptomatic CMV viremia or for treatment of developed CMV disease. Further research is needed to maximize the benefits of LET, including the discovery of biomarkers.
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Affiliation(s)
- Akihiro Ohmoto
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shigeo Fuji
- Department of Hematology, Osaka International Cancer Institute, Osaka, Japan
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11
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Kampouri E, Handley G, Hill JA. Human Herpes Virus-6 (HHV-6) Reactivation after Hematopoietic Cell Transplant and Chimeric Antigen Receptor (CAR)- T Cell Therapy: A Shifting Landscape. Viruses 2024; 16:498. [PMID: 38675841 PMCID: PMC11054085 DOI: 10.3390/v16040498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/04/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024] Open
Abstract
HHV-6B reactivation affects approximately half of all allogeneic hematopoietic cell transplant (HCT) recipients. HHV-6B is the most frequent infectious cause of encephalitis following HCT and is associated with pleiotropic manifestations in this setting, including graft-versus-host disease, myelosuppression, pneumonitis, and CMV reactivation, although the causal link is not always clear. When the virus inserts its genome in chromosomes of germ cells, the chromosomally integrated form (ciHHV6) is inherited by offspring. The condition of ciHHV6 is characterized by the persistent detection of HHV-6 DNA, often confounding diagnosis of reactivation and disease-this has also been associated with adverse outcomes. Recent changes in clinical practice in the field of cellular therapies, including a wider use of post-HCT cyclophosphamide, the advent of letermovir for CMV prophylaxis, and the rapid expansion of novel cellular therapies require contemporary epidemiological studies to determine the pathogenic role and spectrum of disease of HHV-6B in the current era. Research into the epidemiology and clinical significance of HHV-6B in chimeric antigen receptor T cell (CAR-T cell) therapy recipients is in its infancy. No controlled trials have determined the optimal treatment for HHV-6B. Treatment is reserved for end-organ disease, and the choice of antiviral agent is influenced by expected toxicities. Virus-specific T cells may provide a novel, less toxic therapeutic modality but is more logistically challenging. Preventive strategies are hindered by the high toxicity of current antivirals. Ongoing study is needed to keep up with the evolving epidemiology and impact of HHV-6 in diverse and expanding immunocompromised patient populations.
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Affiliation(s)
- Eleftheria Kampouri
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Guy Handley
- Department of Medicine, Division of Infectious Disease and International Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA;
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Joshua A. Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA;
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA 98109, USA
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
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12
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Toya T, Mizuno K, Sakurai M, Kato J, Mori T, Doki N, Masuda S, Aotsuka N, Tsukamoto S, Sakaida E, Nakajima Y, Fujisawa S, Machida S, Aoyama Y, Yokoyama H, Shono K, Hatta Y, Usuki K, Kataoka K, Kanda Y. Differential clinical impact of letermovir prophylaxis according to graft sources: a KSGCT multicenter retrospective analysis. Blood Adv 2024; 8:1084-1093. [PMID: 38330190 PMCID: PMC10907401 DOI: 10.1182/bloodadvances.2023010735] [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: 05/24/2023] [Revised: 10/30/2023] [Accepted: 11/21/2023] [Indexed: 02/10/2024] Open
Abstract
ABSTRACT Clinically significant cytomegalovirus infection (csCMVi) is frequently observed after allogeneic hematopoietic stem cell transplantation (HSCT) and prophylaxis with letermovir is commonly adopted. However, the clinical benefit of letermovir prophylaxis according to graft sources has not been sufficiently elucidated. We retrospectively analyzed 2194 recipients of HSCT who were CMV-seropositive (236 with letermovir prophylaxis and 1958 without prophylaxis against CMV). csCMVi was significantly less frequent in patients with letermovir prophylaxis than in those without (23.7% vs 58.7% at 100 days after HSCT, P < .001) and the same trend was seen when recipients of bone marrow (BM), peripheral blood stem cell (PBSC), or cord blood (CB) transplantation were separately analyzed. In recipients of BM, nonrelapse mortality (NRM) was significantly lower in the letermovir group at 6 months after HSCT (5.0% vs 14.9%, P = .018), and the same trend was observed in recipients of PBSCs (14.7% vs 24.8%, P = .062); however, there was no statistical significance at 1 year (BM, 21.1% vs 30.4%, P = .67; PBSCs, 21.2% vs 30.4%, P = .096). In contrast, NRM was comparable between recipients of CB with and without letermovir prophylaxis throughout the clinical course (6 months, 23.6% vs 24.3%, P =.92; 1 year, 29.3% vs 31.0%, P = .77), which was confirmed by multivariate analyses. In conclusion, the impact of letermovir prophylaxis on NRM and csCMVi should be separately considered according to graft sources.
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Affiliation(s)
- Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kota Mizuno
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masatoshi Sakurai
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jun Kato
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Shinichi Masuda
- Department of Hematology and Oncology, Japanese Red Cross Narita Hospital, Chiba, Japan
| | - Nobuyuki Aotsuka
- Department of Hematology and Oncology, Japanese Red Cross Narita Hospital, Chiba, Japan
| | | | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Yuki Nakajima
- Department of Hematology, Yokohama City University Medical Center, Yokohama, Japan
| | - Shin Fujisawa
- Department of Hematology, Yokohama City University Medical Center, Yokohama, Japan
| | - Shinichiro Machida
- Department of Hematology and Oncology, Tokai University Hospital, Isehara, Japan
| | - Yasuyuki Aoyama
- Department of Hematology and Oncology, Tokai University Hospital, Isehara, Japan
| | - Hiroki Yokoyama
- Division of Clinical Oncology/Hematology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Katsuhiro Shono
- Department of Hematology, Aoba Municipal Hospital, Chiba, Japan
| | - Yoshihiro Hatta
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Keisuke Kataoka
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
- Division of Molecular Oncology, National Cancer Center Research Institute, Tokyo, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
- Division of Hematology, Jichi Medical University, Tochigi, Japan
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13
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Włodarczyk M, Wieczorkiewicz-Kabut A, Białas K, Koclęga A, Noster I, Zielińska P, Helbig G. Real-Life Data on the Efficacy and Safety of Letermovir for Primary Prophylaxis of Cytomegalovirus in Allogeneic Hematopoietic Stem Cell Recipients: A Single-Center Analysis. Turk J Haematol 2024; 41:9-15. [PMID: 38345092 PMCID: PMC10918401 DOI: 10.4274/tjh.galenos.2024.2024.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 02/11/2024] [Indexed: 03/05/2024] Open
Abstract
Objective Cytomegalovirus (CMV) reactivation is a life-threatening complication after allogeneic hematopoietic stem cell transplantation (HSCT). Introduction of letermovir (LMV) seems to improve post-transplant outcomes, but delayed-onset CMV reactivation still remains a challenge. In this study, we report on our first experience with LMV prophylaxis in 93 CMV-seropositive adult patients receiving HSCT in our center. Materials and Methods We retrospectively analyzed the data of 93 adult CMV-seropositive recipients receiving LMV as CMV prophylaxis after HSCT for hematological malignancies between 2019 and 2023. The starting LMV dose was 480 mg daily, reduced to 240 mg daily for those receiving cyclosporin A co-administration. CMV DNA in the blood was measured by real-time polymerase chain reaction weekly for the first 2 months after transplantation, then every other week until the end of immunosuppressive treatment. LMV was continued to day +100 or to CMV reactivation. Results The median recipient age at the time of transplant was 51 (range: 20-71) years. All patients received grafts from peripheral blood, mostly for acute myeloid leukemia (60%). The median time from transplantation to LMV initiation was 3 (range: 0-24) days. While 55% of patients were transplanted from matched related donors, 32% had unrelated donors and 13% underwent haploidentical HSCT. Four patients (4%) had CMV “blips” while on LMV, but the drug was continued and repeated assays were negative. Only 2 patients (2%) experienced CMV reactivation while on LMV, on days 48 and 34 after HSCT, respectively. Seven patients (7%) developed late-onset CMV reactivation after a median of 124 days after HSCT (range: 118-152 days) and they were successfully treated with ganciclovir. CMV disease was not observed. Grade III-IV acute graft-versus-host disease occurred in 6 patients (6%) during LMV treatment. LMV treatment was free of side effects. Conclusion LMV prophylaxis was effective in preventing CMV reactivation with a favorable safety profile. CMV reactivation occurred mostly after LMV discontinuation; thus, extending the duration of prophylaxis beyond 100 days could be beneficial.
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Affiliation(s)
- Martyna Włodarczyk
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Agata Wieczorkiewicz-Kabut
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Krzysztof Białas
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Anna Koclęga
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Izabela Noster
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Patrycja Zielińska
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Grzegorz Helbig
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
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14
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Pang I, Chen P, Trinh GV, Remberger M, Novitzky-Basso I, Gerbitz A, Kim DD, Kumar R, Lam W, Law AD, Lipton JH, Viswabandya A, Pasic I, Mattsson J, Michelis FV. Letermovir prophylaxis for cytomegalovirus reactivation in allogeneic hematopoietic cell transplant recipients: Single center Canadian data. Eur J Haematol 2024; 112:301-309. [PMID: 37830403 DOI: 10.1111/ejh.14117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) is associated with morbidity and mortality following allogeneic hematopoietic cell transplantation (alloHCT). Letermovir is a novel antiviral agent that prevents CMV reactivation in alloHCT patients, with limited data regarding influence on post-alloHCT outcomes. METHODS We retrospectively examined 273 alloHCT recipients, 158 in the non-letermovir cohort (NLC), and 115 in the cohort using letermovir prophylaxis (LC). Patients that received letermovir were CMV-seropositive and met criteria for high risk of CMV reactivation. RESULTS Median start of letermovir was 21 days post-alloHCT, median duration of prophylaxis was 86 days. Letermovir prophylaxis demonstrated a statistically significant reduction in first CMV reactivation (at 200 days post 63.9% in the NLC vs. 35.7% in the LC; p < .001). On univariate analysis at 1 year, overall survival (OS) for NLC was 79.6% and 79.5% for LC (p = .54). Non relapse mortality (NRM) at 1 year for NLC was 12% and 12.3% for LC (p = .69). Cumulative incidence of relapse (CIR) at 1 year was 13.9% for NLC versus 17.1 for the LC (p = .27). On multivariable analysis, there was no significant difference between the two cohorts for OS, NRM, and CIR. CONCLUSIONS Letermovir prophylaxis started at day +21 post-alloHCT reduced CMV reactivation, with no impact on posttransplant outcomes.
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Affiliation(s)
- Ian Pang
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Peggy Chen
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Gertrude V Trinh
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Mats Remberger
- Department of Medical Sciences, Uppsala University and KFUE, Uppsala University Hospital, Uppsala, Sweden
| | - Igor Novitzky-Basso
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Armin Gerbitz
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Dennis D Kim
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Rajat Kumar
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Wilson Lam
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Arjun D Law
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Jeffrey H Lipton
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Auro Viswabandya
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Ivan Pasic
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Jonas Mattsson
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - Fotios V Michelis
- Hans Messner Allogeneic Transplant Program, Princess Margaret Cancer Centre, Toronto, Canada
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15
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Lin A, Brown S, Chinapen S, Lee YJ, Seo SK, Ponce DM, Shahid Z, Giralt S, Papanicolaou GA, Perales MA, Shaffer BC. Patterns of CMV infection after letermovir withdrawal in recipients of posttransplant cyclophosphamide-based transplant. Blood Adv 2023; 7:7153-7160. [PMID: 37906513 PMCID: PMC10698256 DOI: 10.1182/bloodadvances.2023010966] [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: 06/13/2023] [Revised: 10/05/2023] [Accepted: 10/20/2023] [Indexed: 11/02/2023] Open
Abstract
Reactivation of latent cytomegalovirus (CMV) is increased in recipients of allogeneic hematopoietic cell transplantation (allo-HCT) with seropositive CMV using posttransplant cyclophosphamide (PT-Cy)-based graft-versus-host disease (GVHD) prophylaxis. Letermovir, a novel DNA terminase complex inhibitor, reduces the incidence of clinically significant CMV infection (csCMVi) in this population; however, parameters that predict csCMVi after letermovir withdrawal are not well described. Here, we examined clinical and immunological parameters in 294 recipients of PT-Cy-based allo-HCT, including 157 patients with CMV, of whom 80 completed letermovir prophylaxis without csCMVi and subsequently stopped letermovir. In this population, the median duration of letermovir exposure was 203 days (interquartile range [IQR], 160-250 days). After letermovir withdrawal, the 90-day cumulative incidence of csCMVi was 23.0% (95% confidence interval, 14.3-32.8). There were no episodes of CMV end-organ disease. Hypogammaglobulinemia before letermovir discontinuation was predictive of csCMVi (hazard ratio, 0.33; 95% confidence interval, 0.12-0.93; P = .03), whereas T-cell and B-cell reconstitution before letermovir withdrawal were not predictive of csCMVi. Higher numbers of natural killer cells were found before letermovir withdrawal in patients who experienced csCMVi (median, 202 vs 160; P = .03). In recipients with seropositive CMV, CD3+CD4-CD8+ T-cell reconstitution was faster in patients with CMV regardless of letermovir exposure. Taken together, these data suggest that csCMVi after letermovir withdrawal was frequent in patients treated with PT-Cy, despite prolonged exposure. Strategies to boost CMV-specific adaptive immunity in patients with persistent hypogammaglobulinemia is a logical pathway to reduce csCMVi after letermovir withdrawal.
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Affiliation(s)
- Andrew Lin
- Adult BMT Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Samantha Brown
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Stephanie Chinapen
- Adult BMT Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yeon Joo Lee
- Infectious Diseases Service, Division of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Internal Medicine, Weill Cornell Medical School, New York, NY
| | - Susan K. Seo
- Infectious Diseases Service, Division of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Internal Medicine, Weill Cornell Medical School, New York, NY
| | - Doris M. Ponce
- Adult BMT Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Internal Medicine, Weill Cornell Medical School, New York, NY
| | - Zainab Shahid
- Infectious Diseases Service, Division of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Internal Medicine, Weill Cornell Medical School, New York, NY
| | - Sergio Giralt
- Adult BMT Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Internal Medicine, Weill Cornell Medical School, New York, NY
| | - Genovefa A. Papanicolaou
- Infectious Diseases Service, Division of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Internal Medicine, Weill Cornell Medical School, New York, NY
| | - Miguel-Angel Perales
- Adult BMT Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Internal Medicine, Weill Cornell Medical School, New York, NY
| | - Brian C. Shaffer
- Adult BMT Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Internal Medicine, Weill Cornell Medical School, New York, NY
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16
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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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17
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Kampouri E, Zamora D, Kiem ES, Liu W, Ibrahimi S, Blazevic RL, Lovas EA, Kimball LE, Huang ML, Jerome KR, Ueda Oshima M, Mielcarek M, Zerr DM, Boeckh MJ, Krantz EM, Hill JA. Human herpesvirus-6 reactivation and disease after allogeneic haematopoietic cell transplantation in the era of letermovir for cytomegalovirus prophylaxis. Clin Microbiol Infect 2023; 29:1450.e1-1450.e7. [PMID: 37532126 PMCID: PMC10828110 DOI: 10.1016/j.cmi.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/12/2023] [Accepted: 07/27/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVES Letermovir for cytomegalovirus (CMV) prophylaxis in allogeneic haematopoietic cell transplant (HCT) recipients has decreased anti-CMV therapy use. Contrary to letermovir, anti-CMV antivirals are also active against human herpesvirus-6 (HHV-6). We assessed changes in HHV-6 epidemiology in the post-letermovir era. METHODS We conducted a retrospective cohort study of CMV-seropositive allogeneic HCT recipients comparing time periods before and after routine use of prophylactic letermovir. HHV-6 testing was at the discretion of clinicians. We computed the cumulative incidence of broad-spectrum antiviral initiation (foscarnet, (val)ganciclovir, and/or cidofovir), HHV-6 testing, and HHV-6 detection in blood and cerebrospinal fluid within 100 days after HCT. We used Cox proportional-hazards models with stabilized inverse probability of treatment weights to compare outcomes between cohorts balanced for baseline factors. RESULTS We analysed 738 patients, 376 in the pre-letermovir and 362 in the post-letermovir cohort. Broad-spectrum antiviral initiation incidence decreased from 65% (95% CI, 60-70%) pre-letermovir to 21% (95% CI, 17-25%) post-letermovir. The cumulative incidence of HHV-6 testing (17% [95% CI, 13-21%] pre-letermovir versus 13% [95% CI, 10-16%] post-letermovir), detection (3% [95% CI, 1-5%] in both cohorts), and HHV-6 encephalitis (0.5% [95% CI, 0.1-1.8%] pre-letermovir and 0.6% [95% CI, 0.1-1.9%] post-letermovir) were similar between cohorts. First HHV-6 detection occurred at a median of 37 days (interquartile range, 18-58) in the pre-letermovir cohort and 27 (interquartile range, 25-34) in the post-letermovir cohort. In a weighted model, there was no association between the pre-versus post-letermovir cohort and HHV-6 detection (adjusted hazard ratio, 1.08; 95% CI, 0.44-2.62). DISCUSSION Despite a large decrease in broad-spectrum antivirals after the introduction of letermovir prophylaxis in CMV-seropositive allogeneic HCT recipients, there was no evidence for increased clinically detected HHV-6 reactivation and disease.
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Affiliation(s)
- Eleftheria Kampouri
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Danniel Zamora
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Erika S Kiem
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Winnie Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Sarah Ibrahimi
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Rachel L Blazevic
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Erika A Lovas
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Louise E Kimball
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Meei-Li Huang
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Keith R Jerome
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Masumi Ueda Oshima
- Department of Medicine, University of Washington, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Marco Mielcarek
- Department of Medicine, University of Washington, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Danielle M Zerr
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Michael J Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Elizabeth M Krantz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
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18
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Orofino G, Xue E, Doglio M, Noviello M, Tassi E, Cristante M, Acerbis A, Clerici D, Farina F, Campodonico E, Bruno A, Piemontese S, Mastaglio S, Diral E, Milani R, Ruggeri A, Corti C, Vago L, Bonini C, Peccatori J, Ciceri F, Lupo Stanghellini MT, Greco R. Dynamics of polyclonal immuno-reconstitution after allogeneic transplant with post-transplant cyclophosphamide and letermovir. Bone Marrow Transplant 2023; 58:1104-1111. [PMID: 37468541 DOI: 10.1038/s41409-023-02046-9] [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: 04/04/2023] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 07/21/2023]
Abstract
Cytomegalovirus (CMV) reactivations are strong stimulators of immune-reconstitution (IR) in hematopoietic stem cell transplantation (HSCT) recipients. Herein, we analyzed 317 CMV-seropositive consecutive patients (n = 109 letermovir, LTV; n = 208 no-LTV), undergoing HSCT with post-transplant cyclophosphamide (PTCy) and calcineurin inhibitor- (CNI) free graft-versus-host-disease (GvHD) prophylaxis. At day+90, median CD19+/mm3 was higher in LTV-cohort: 5.5 [0;439] versus 2 [0;294], p = 0.008; median CD3+/mm3 counts were lower in LTV-cohort, with no differences in CD4+, CD8+ and NK-cells. At day+180 median CD3+, CD4+ and CD8+/mm3 values were comparable between groups. Higher CD19+/mm3 counts were observed in LTV-cohort: 62 [0; 2983] versus 42 [0; 863]. Significantly higher median NK/mm3 values were seen in LTV-cohort: 225.5 [0;763] versus 163.5 [0;1181], p = 0.0003. The impact of LTV on B-cell IR at 3 months and NK-cell levels at 6 months was retained in multivariate analysis (p < 0.01), whereas the effect on T-cells was not confirmed. Moreover, we confirmed a significant reduction of clinically-relevant CMV, and moderate-to- severe chronic GvHD in LTV-cohort. Overall, in our study the use of LTV was associated with a slight improvement of B-cell and NK-cells reconstitution, with only minor impact on T-cell subsets, giving new insights on polyclonal IR for HSCT recipients in the LTV era.
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Affiliation(s)
- Giorgio Orofino
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
| | - Elisabetta Xue
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Matteo Doglio
- Experimental Hematology Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Maddalena Noviello
- Experimental Hematology Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Cell Therapy Immunomonitoring Laboratory (MITiCi), Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Hospital, Milano, Italy
| | - Elena Tassi
- Experimental Hematology Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Cell Therapy Immunomonitoring Laboratory (MITiCi), Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Hospital, Milano, Italy
| | | | - Andrea Acerbis
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
| | - Daniela Clerici
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Francesca Farina
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Edoardo Campodonico
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
| | - Alessandro Bruno
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
| | - Simona Piemontese
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Sara Mastaglio
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Elisa Diral
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Raffaella Milani
- Immunohematology and Transfusion Medicine Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Annalisa Ruggeri
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Consuelo Corti
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Luca Vago
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology IRCCS San Raffaele Hospital, Milano, Italy
| | - Chiara Bonini
- Università Vita-Salute San Raffaele, Milano, Italy
- Experimental Hematology Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Cell Therapy Immunomonitoring Laboratory (MITiCi), Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Hospital, Milano, Italy
| | - Jacopo Peccatori
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Fabio Ciceri
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy.
- Università Vita-Salute San Raffaele, Milano, Italy.
| | | | - Raffaella Greco
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy.
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19
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Sepassi A, Saunders IM, Bounthavong M, Taplitz RA, Logan C, Watanabe JH. Effectiveness of letermovir for cytomegalovirus prophylaxis in allogeneic hematopoietic stem cell transplant recipients: A global systematic review. J Am Pharm Assoc (2003) 2023; 63:1138-1149. [PMID: 37207713 DOI: 10.1016/j.japh.2023.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/30/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE(S) Letermovir (LET), a novel antiviral, has largely supplanted more traditional preemptive therapy (PET) for cytomegalovirus (CMV) prophylaxis in allogeneic hematopoietic stem cell transplant (allo-HCT) patients. Use of LET demonstrated efficacy against placebo in phase III randomized controlled trials, but is considerably more expensive than PET. This review aimed to evaluate the real-world effectiveness of LET in preventing clinically significant CMV infection (csCMVi) for allo-HCT recipients and related outcomes. DESIGN A systematic literature review was performed using an a priori protocol using PubMed, Scopus, and ClinicalTrials.gov from January 2010 to October 2021. SETTING AND PARTICIPANTS Studies were included if they met the following criteria: LET compared with PET, CMV-related outcomes, patients aged 18 years or older, and English language-only articles. Descriptive statistics were used to summarize study characteristics and outcomes. OUTCOME MEASURES CMV viremia, csCMVi, CMV end-organ disease, graft-versus-host-disease, all-cause mortality. RESULTS A total of 233 abstracts were screened, with 30 included in this review. Randomized trials demonstrated efficacy of LET prophylaxis in preventing csCMVi. Observational studies demonstrated varying degrees of effectiveness of LET prophylaxis compared with use of PET alone. All studies with a comparator group resulted in lower rates of csCMVi for patients using LET. Included studies varied widely by CMV viral load threshold cutoff and CMV test units, limiting synthesis of results owing to high heterogeneity. CONCLUSION LET reduces risk of csCMVi, but lack of standardized clinical definitions on how to evaluate csCMVi and related outcomes largely prevent synthesis of results. Clinicians must consider this limitation in the context of evaluating the effectiveness of LET to other antiviral therapies, especially for patients at risk of late-onset CMV. Future studies should focus on prospective data collection through registries and concordance of diagnostic definitions to mitigate study heterogeneity.
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20
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Dadwal SS, Papanicolaou GA, Boeckh M. How I prevent viral reactivation in high-risk patients. Blood 2023; 141:2062-2074. [PMID: 36493341 PMCID: PMC10163320 DOI: 10.1182/blood.2021014676] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/10/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
Preventing viral infections at an early stage is a key strategy for successfully improving transplant outcomes. Preemptive therapy and prophylaxis with antiviral agents have been successfully used to prevent clinically significant viral infections in hematopoietic cell transplant recipients. Major progress has been made over the past decades in preventing viral infections through a better understanding of the biology and risk factors, as well as the introduction of novel antiviral agents and advances in immunotherapy. High-quality evidence exists for the effective prevention of herpes simplex virus, varicella-zoster virus, and cytomegalovirus infection and disease. Few data are available on the effective prevention of human herpesvirus 6, Epstein-Barr virus, adenovirus, and BK virus infections. To highlight the spectrum of clinical practice, here we review high-risk situations that we handle with a high degree of uniformity and cases that feature differences in approaches, reflecting distinct hematopoietic cell transplant practices, such as ex vivo T-cell depletion.
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Affiliation(s)
- Sanjeet S. Dadwal
- Division of Infectious Disease, Department of Medicine, City of Hope National Medical Center, Duarte, CA
| | - Genovefa A. Papanicolaou
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY
| | - Michael Boeckh
- Vaccine and Infectious and Clinical Research Divisions, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
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21
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Perchetti GA, Biernacki MA, Xie H, Castor J, Joncas-Schronce L, Ueda Oshima M, Kim Y, Jerome KR, Sandmaier BM, Martin PJ, Boeckh M, Greninger AL, Zamora D. Cytomegalovirus breakthrough and resistance during letermovir prophylaxis. Bone Marrow Transplant 2023; 58:430-436. [PMID: 36693927 DOI: 10.1038/s41409-023-01920-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
Letermovir is a relatively new antiviral for prophylaxis against cytomegalovirus (CMV) after allogeneic hematopoietic cell transplantation (HCT). CMV-seropositive HCT recipients who received letermovir prophylaxis from 2018 to 2020 at our center were evaluated for letermovir resistance and breakthrough CMV reactivation. Two-hundred twenty-six letermovir recipients were identified and 7/15 (47%) with CMV DNAemia ≥200 IU/mL were successfully genotyped for UL56 resistance. A single C325Y resistance mutation was identified in an umbilical cord blood recipient. Ninety-five (42%), 43 (19%), and 15 (7%) patients had breakthrough CMV at any level, ≥150 IU/mL, and ≥500 IU/mL, respectively. Risk factors for breakthrough CMV reactivation at each viral threshold were examined. Cumulative steroid exposure was the strongest risk factor for CMV at all evaluated viral thresholds. Graft-versus-host disease prophylaxis with post-transplantation cyclophosphamide (aHR 2.34, 95% CI 1.28-4.28, p = 0.001) or calcineurin inhibitors plus mycophenolate (aHR 2.24, 95% CI 1.30-3.86, p = 0.004) were also associated with an increased risk of CMV reactivation at any level. De novo letermovir resistance is rare and can be successfully treated using other antivirals. Letermovir effectively prevents clinically significant CMV, however, subclinical CMV reactivation occurs frequently at our center.
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Affiliation(s)
- Garrett A Perchetti
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Melinda A Biernacki
- Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jared Castor
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Laurel Joncas-Schronce
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Masumi Ueda Oshima
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Medical Oncology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
| | - YoungJun Kim
- Department of Pathology, University of Virginia, School of Medicine, Charlottesville, VA, USA
| | - Keith R Jerome
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Brenda M Sandmaier
- Division of Medical Oncology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Paul J Martin
- Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Alexander L Greninger
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Danniel Zamora
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA.
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22
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Callens R, Colman S, Delie A, Schauwvlieghe A, Lodewyck T, Selleslag D, Reynders M, Kerre T, Padalko E. Immunological monitoring after allogeneic stem cell transplantation: T-SPOT.CMV and QuantiFERON-CMV, are they the same? Transplant Cell Ther 2023:S2666-6367(23)01177-6. [PMID: 36963722 DOI: 10.1016/j.jtct.2023.03.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/14/2023] [Accepted: 03/15/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND CMV-reactivation and -disease is still a major concern after allogeneic stem cell transplantation [allo-HSCT], despite prophylactic and pre-emptive strategies. In recent years, immunologic monitoring using CMV-IGRA has gained interest to better risk stratify immunocompromised patients or to guide prophylactic therapies. CMV-IGRA can quantify CMV cell-mediated immunity by measuring the interferon-gamma that is released by CD4+ and CD8+ T-lymphocytes in the presence of CMV-antigens. However, the two most widely used CMV-IGRAs, T-SPOT.CMV and QuantiFERON-CMV, have not yet been compared in the setting of an allo-HSCT. OBJECTIVE To perform a method comparison between the T-SPOT.CMV and QuantiFERON-CMV 28 and 100 days after allo-HSCT, and to assess predictive values of both tests for CMV-reactivation. STUDY DESIGN In a bicentric prospective trial, 27 patients were included. Samples were taken on day +28 and day +100 after allo-HSCT. Patients' clinical information was collected up to 270 days after the transplant. Method comparison was performed using Cohen's kappa. RESULTS On day +28 (n=26) after allo-HSCT T-SPOT.CMV gave three positive test results, and QuantiFERON-CMV only two. On day +100 (n=24) T-SPOT.CMV gave seven positive test results, and QuantiFERON-CMV nine. One discordant result was obtained at day +28 (n=26), while six results were discordant at day +100 (n=24). Method comparison showed a strong agreement on day +28 (κ = 0.780 [95% CI: 0.366-1.000]), but only a moderate agreement on day +100 (κ = 0.442 [95% CI: 0.070-0.814]) and on pooled data from both time points (κ = 0.578 [95% CI: 0.300-0.856]). Four clinically significant CMV infections, (CS-CMVi) were observed, all occurring after discontinuation of letermovir-prophylaxis. None of those four patients had a positive result with either test at day +100 (or day +28). Negative predictive values (NPV) and sensitivity are therefore very high at 100% (for both tests, for NPV and sensitivity, measured at day +100). At day+100, positive predictive values (PPV) and specificity were considerably lower (T-SPOT.CMV: PPV 23.5% and specificity 35% - QuantiFERON-CMV: PPV 26.7% and specificity 45%). CONCLUSION T-SPOT.CMV and QuantiFERON-CMV only have a moderate agreement (at day +100) after allo-HSCT. Although these IGRAs are very promising, as shown by their very high negative predictive values for protection against CS-CMVi, they are not interchangeable. Future research should stipulate which IGRA was used, and future guidelines should preferably be assay-specific. As the QuantiFERON-CMV to date still lacks a large validation study after allo-HSCT, the moderate agreement with the T-SPOT.CMV poses a significant hurdle in the routine implementation of this test.
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Affiliation(s)
- Rutger Callens
- Department of Hematology, Ghent University Hospital, Ghent, Belgium; Department of Hematology, AZ Delta, Roeselare, Belgium
| | - Sofie Colman
- Department of Laboratory Medicine, O.L.V. van Lourdes Hospital, Waregem, Belgium
| | - Anke Delie
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | | | - Tom Lodewyck
- Department of Hematology, AZ Sint-Jan Hospital, Bruges, Belgium
| | | | - Marijke Reynders
- Department of Laboratory Medicine, AZ Sint-Jan Hospital, Bruges, Belgium
| | - Tessa Kerre
- Department of Hematology, Ghent University Hospital, Ghent, Belgium; Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Elizaveta Padalko
- Department of Medical Microbiology, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Ghent University, Ghent, Belgium.
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23
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Giménez E, Guerreiro M, Torres I, Aguilar C, Albert E, Hernández-Boluda JC, Hernani R, Pérez A, Amat P, Piñana JL, Montoro J, Solano C, Navarro D. Features of cytomegalovirus DNAemia and virus-specific T-cell responses in allogeneic hematopoietic stem-cell transplant recipients during prophylaxis with letermovir. Transpl Infect Dis 2023; 25:e14021. [PMID: 36748748 DOI: 10.1111/tid.14021] [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: 11/11/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is scarce information on the natural kinetics of cytomegalovirus (CMV) DNAemia and dynamics of CMV-specific T-cell reconstitution in allogeneic hematopoietic transplant recipients (allo-HSCT) undergoing letermovir (LMV) prophylaxis. METHODS Twelve adult CMV-seropositive high-risk recipients (median age, 53 years; 9 males/3 females) undergoing LMV prophylaxis and 13 non-LMV allo-HSCT controls (median age, 58 years; 7 males/6 females) were included. CMV DNAemia in plasma was monitored by real-time polymerase chain reaction. Preemptive antiviral therapy (PET) was administered upon detection of ≥1500 IU/ml. CMV-specific interferon-gamma (IFN-γ)-producing CD8+ and CD4+ T cells were enumerated by flow cytometry around days +30, +60, and +90 after allo-HSCT. Ex vivo experiments assessing of the potential effect of LMV on CMV-specific T-cell expansion in a single CMV-seropositive donor were also conducted. RESULTS Five LMV patients (41.6%) developed CMV DNAemia that cleared spontaneously. Four patients (33.3%) developed CMV DNAemia after LMV cessation, of which two required PET. Nine non-LMV patients (69.2%) developed CMV DNAemia (five required PET). The percentage of LMV and non-LMV patients exhibiting detectable CMV-specific T-cell responses was comparable (7/10 vs. 10/13; p = .71). Nevertheless, median CMV-specific CD4+ and CD8+ T-cell counts were lower in LMV patients by days +60 (p = .006 and .02, respectively) and +90 (p = .08 and .02). Ex vivo, CMV-specific CD8+ T cells expanded to the same level either in the presence (19.8%) or in the absence of LMV (20.6%). CONCLUSIONS In our series, episodes of CMV DNAemia in LMV patients cleared spontaneously. A diminished degree of CMV-specific T-cell reconstitution in LMV patients compared to non-LMV patients was observed.
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Affiliation(s)
- Estela Giménez
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Guerreiro
- Hematology Service, Hospital Universitario y Politécnico "La Fe", Valencia, Spain
| | - Ignacio Torres
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Cristobal Aguilar
- Hematology Service, Hospital Universitario y Politécnico "La Fe", Valencia, Spain
| | - Eliseo Albert
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Juan Carlos Hernández-Boluda
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Rafael Hernani
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Ariadna Pérez
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Paula Amat
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - José Luis Piñana
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Juan Montoro
- Hematology Service, Hospital Universitario y Politécnico "La Fe", Valencia, Spain
| | - Carlos Solano
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.,Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
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24
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New trends in the management of cytomegalovirus infection after allogeneic hematopoietic cell transplantation: a survey of the Infectious Diseases Working Pary of EBMT. Bone Marrow Transplant 2023; 58:203-208. [PMID: 36396949 PMCID: PMC9672643 DOI: 10.1038/s41409-022-01863-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/19/2022] [Accepted: 10/24/2022] [Indexed: 11/18/2022]
Abstract
The management of cytomegalovirus (CMV) infection was assessed with a survey performed in 2020 by the Infectious Diseases Working Party of European Society for Blood and Marrow Transplantation (EBMT). One-hundred-eighty of the 579 EBMT centres (31%) responded. CMV monitoring with quantitative PCR for CMV-DNAemia was used by 97% of centres while the duration of monitoring was variable according to the patient immune recovery and the ongoing immunosuppressive therapy. CMV prophylaxis for high-risk patients was used in 101 (56%) of centres: letermovir in 62 centres (61%), aciclovir/valaciclovir in 19 centres (19%), ganciclovir/valganciclovir in 17 centres (17%), foscarnet in 3 (3%). The most used trigger for pre-emptive therapy was a threshold of >103 copies/ml or >103 IU/ml. Ganciclovir/valganciclovir confirmed the preferred first line treatment both for pre-emptive and CMV disease therapy. CMV-cytotoxic T-cells were used mainly in the setting of relapsing/refractory CMV disease. Forty-eight centres reported CMV refractory/resistant infection due to mutated CMV strain.This survey showed that letermovir prophylaxis is adopted by more than half of centres using a prophylaxis approach for CMV infection. How letermovir prophylaxis will modify other important pillars of daily CMV management, such as frequency of CMV-DNAemia monitoring and preemptive therapy, remain a matter of investigation.
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25
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Khawaja F, Spallone A, Kotton CN, Chemaly RF. Cytomegalovirus infection in transplant recipients: newly approved additions to our armamentarium. Clin Microbiol Infect 2023; 29:44-50. [PMID: 35843567 DOI: 10.1016/j.cmi.2022.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/01/2022] [Accepted: 07/02/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND The burden that cytomegalovirus (CMV) portends for haematopoietic and solid-organ transplant recipients cannot be understated. Valganciclovir and ganciclovir have successfully been used for prevention and treatment of CMV infections, although with serious side effects such as leucopenia and some development of resistance. Until recently, available therapies for ganciclovir-resistant CMV have significant toxicities. Although advances have been made in the field, the unmet medical needs for effective and well-tolerated therapies are significant. OBJECTIVES This review aims to summarise the current and emerging CMV antiviral drugs and discusses future perspectives in the field. SOURCES We searched for relevant articles with pertinent keywords: "Cytomegalovirus OR CMV", "Transplant" and "Antiviral". Articles published after 2019 were given preference. Articles were reviewed by the authors for relevance and impact to the subject of interest. CONTENT We outline in this review current advances in prophylaxis of CMV infection with letermovir, breakthrough CMV infections while on or after prophylaxis, the development of resistant and refractory CMV infections, and the newly approved anti-CMV agent, maribavir, in haematopoietic and solid-organ transplant recipients. IMPLICATIONS Prevention of CMV infections after transplant has improved greatly over the past few years. Despite major advancements, breakthrough CMV infections and development of refractory and resistant CMV infections remain major complications post transplantation. We highlight emerging therapeutics that tolerably and effectively prevent and treat CMV infections, especially refractory and resistant cases.
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Affiliation(s)
- Fareed Khawaja
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy Spallone
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Camille N Kotton
- Transplant Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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26
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Liu LW, Yn A, Gao F, Olson M, Crain M, Abboud R, Westervelt P, Abboud C, Vij R, Stockerl-Goldstein K, Pusic I, Cashen AF, Schroeder MA. Letermovir discontinuation at D+100 after Allogeneic Stem Cell Transplant is associated with increased CMV-related mortality. Transplant Cell Ther 2022; 28:510.e1-510.e9. [DOI: 10.1016/j.jtct.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 11/12/2022]
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