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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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Galaverna F, Baccelli F, Zama D, Tridello G, Masetti R, Soncini E, Mura R, Barzaghi F, Colombini A, Prunotto G, D'Amico MR, Calore E, Biffi A, Perruccio K, Gasperini P, Oltolini C, Quagliarella F, Giacomazzi A, Pagliara D, Locatelli F, Cesaro S. Letermovir for Cytomegalovirus infection in pediatric patients undergoing allogenic hematopoietic stem cell transplantation: a real-life study by the Infectious Diseases Working Group of Italian Association of Pediatric Hematology-Oncology (AIEOP). Bone Marrow Transplant 2024; 59:505-512. [PMID: 38272999 DOI: 10.1038/s41409-024-02209-2] [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: 09/29/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
Letermovir prophylaxis revolutionized the approach to Cytomegalovirus infection in adult hematopoietic stem cell transplant (HCT), while data in pediatric setting are still lacking. We retrospectively analyzed 87 HCT children transplanted in 11 AIEOP centers receiving letermovir as off-label indication between January 2020 and November 2022. Letermovir was used as primary, secondary prophylaxis or CMV treatment in 39, 26 and 22 cases, respectively; no discontinuation due to toxicity was reported. Median duration was 100 days (14-256) for primary and 96 days (8-271) for secondary prophylaxis, respectively. None of the patients experienced CMV-clinically significant reactivation during Letermovir primary prophylaxis; one patient developed breakthrough infection during secondary prophylaxis, and 10 and 1 patient experienced asymptomatic CMV-reactivation and CMV-primary infection after drug discontinuation, respectively. Median duration of letermovir in CMV treatment was 40 days (7-134), with 4/22 patients suffering CMV-pneumonia, with an overall response rate of 86.4%. With a median follow-up of 10.7 months (8.2-11.8), estimated 1-year overall survival was 86%; no CMV-related deaths were reported in prophylaxis groups. This is the largest report on Letermovir use in pediatric HCT; real-life data confirm an excellent toxicity profile, with high efficacy as CMV prophylaxis; results in CMV-infection treatment should be investigated in larger, prospective trials.
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Affiliation(s)
- Federica Galaverna
- Department of Pediatric Oncology, Hematology, Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy.
| | - Francesco Baccelli
- Department of Medical and surgical sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Daniele Zama
- Department of Medical and surgical sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gloria Tridello
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Riccardo Masetti
- Department of Medical and surgical sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elena Soncini
- Pediatric Oncohematology and Bone marrow transplant Unit, ASST Spedali Civili, Brescia, Italy
| | - Rossella Mura
- Pediatric Hematology Oncology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Federica Barzaghi
- Pediatric Immunohematology Unit and bone marrow transplant Unit, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Antonella Colombini
- Department of Pediatrics, Fondazione MBBM - Ospedale San Gerardo, Monza, Italy
| | - Giulia Prunotto
- Department of Pediatrics, Fondazione MBBM - Ospedale San Gerardo, Monza, Italy
| | - Maria Rosaria D'Amico
- Unità Operativa di Trapianto di Cellule Staminali Ematopoietiche e Terapie Cellulari, AORN Santobono-Pausilipon, Napoli, Italy
| | - Elisabetta Calore
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Alessandra Biffi
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Katia Perruccio
- Pediatric Oncology Hematology, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - Pietro Gasperini
- Department of Pediatrics, Azienda Unità Sanitaria Locale di Rimini, Rimini, Italy
| | - Chiara Oltolini
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Francesco Quagliarella
- Department of Pediatric Oncology, Hematology, Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Alice Giacomazzi
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Daria Pagliara
- Department of Pediatric Oncology, Hematology, Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Franco Locatelli
- Department of Pediatric Oncology, Hematology, Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
- Catholic University of the Sacred Heart, Roma, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Valencia Deray KG, Danziger-Isakov LA, Downes KJ. Current and Emerging Antiviral Agents in the Prevention and Treatment of Cytomegalovirus in Pediatric Transplant Recipients. J Pediatric Infect Dis Soc 2024; 13:S14-S21. [PMID: 38417084 PMCID: PMC10901473 DOI: 10.1093/jpids/piad059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/16/2023] [Indexed: 03/01/2024]
Abstract
Despite current prophylaxis regimens, cytomegalovirus (CMV) is common in hematopoietic cell transplantation (HCT) and solid organ transplantation (SOT) and remains a significant cause of morbidity and mortality. Newer antiviral medications are reshaping the landscape for prevention and treatment of CMV DNAemia, infection, and disease. Letermovir is approved for CMV prevention in adult HCT patients and is attractive due to the absence of marrow suppression seen with ganciclovir/valganciclovir. Letermovir should not be routinely used for CMV treatment due to its low threshold for resistance. Maribavir is approved for the treatment of refractory or resistant CMV disease in HCT and SOT recipients ≥12 years of age, though it has no current role in CMV prevention. More research is needed to fully elucidate the roles, efficacy, and safety of these newer agents in prevention and treatment of CMV in pediatric transplant recipients.
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Affiliation(s)
- Kristen G Valencia Deray
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Lara A Danziger-Isakov
- Division of Infectious Disease, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kevin J Downes
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Zhang Y, Chen X, Zhou M, Zhang Y, Chen C, Zhou R, Li Y, Yang F, Xu S, Wang C, Zhou W, Deng T, Pan S, Mo W, Wang S. Letermovir Effectively Prevents Cytomegalovirus Infection in Patients with Aplastic Anemia After Hematopoietic Stem Cell Transplantation: A Real-World Retrospective Cohort Study. Infect Dis Ther 2024; 13:345-359. [PMID: 38265628 PMCID: PMC10904706 DOI: 10.1007/s40121-024-00917-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION In this single-center retrospective cohort study, we investigated the efficacy of letermovir in preventing Cytomegalovirus (CMV) infection in patients with aplastic anemia (AA) who have undergone allogeneic hematopoietic stem cell transplantation (allo-HSCT). METHODS Based on whether or not letermovir was used for preventing CMV infection, the patients were categorized into two groups: letermovir and control groups. The overall survival (OS) rate and cumulative incidence of CMV infection during the first 100 days after allo-HSCT were evaluated. The study included 21 matched pairs of patients, identified through propensity score matching analysis, to compare CMV infection rates, treatment efficacy, and regression. RESULTS The incidence of CMV infection within 100 days after transplantation was significantly lower in the letermovir group than in the control group (26.5 vs. 77.4%, respectively; P < 0.001), among a total of 87 patients who underwent the transplant. In the matched cohort of 21 patients with AA, the letermovir group also showed a significantly reduced cumulative incidence of CMV infection (14.3 vs. 90.5% in the control group; P < 0.001). Compared to the control group, patients with CMV infection in the letermovir group had lower CMV-DNA load and a shorter clearance time. However, there was no significant difference in OS between both groups (P = 0.34). CONCLUSIONS Letermovir effectively prevents CMV infection in allo-HSCT recipients with AA and demonstrates a high safety profile.
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Affiliation(s)
- Yuling Zhang
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Xiaowei Chen
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Ming Zhou
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Yuping Zhang
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Cunte Chen
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Ruiqing Zhou
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Yumiao Li
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Fangfang Yang
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Shilin Xu
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Caixia Wang
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Wei Zhou
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Tingfen Deng
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Shiyi Pan
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Wenjian Mo
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China.
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, 510180, Guangdong, China.
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Pai VB, Tansmore J, Song E. Pharmacokinetic analysis driven letermovir dosing in pediatric hematopoietic cell transplantation patients with resistant CMV disease. Pediatr Transplant 2024; 28:e14580. [PMID: 37466088 DOI: 10.1111/petr.14580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/04/2023] [Accepted: 07/07/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Reactivation of cytomegalovirus (CMV) in CMV-seropositive patients after haploidentical T-cell receptor αβ+ /CD19+ depleted hematopoietic cell transplant (HCT) is common. Due to delayed CMV-specific immune reconstitution, patients may require prolonged antiviral therapy, including secondary prophylaxis (SP). We present our clinical experience with the off-label use of letermovir for SP in a severely immunocompromised 2-year-old toddler with refractory pre-B-cell ALL and bilateral retinitis caused by resistant CMV (A594V UL97 mutation) following a haploidentical TCRαβ+ /CD19+ depleted HCT. METHODS The patient underwent measurement of two separate sets of letermovir serum concentrations, drawn at pre-dose, 1 and 4 h (and 8 h during the second therapeutic drug monitoring) post-dose. Pharmacokinetic parameters, including AUC0-24 were calculated, and dose adjustment was performed based on the drug level. RESULTS While receiving oral letermovir 240 mg once daily without cyclosporine, the observed AUC0-24 was high (75 815 ng h/mL) with a Cmin of 209 ng/mL. The dose was reduced by 25% to 180 mg once daily. Despite the dose reduction, both AUC0-24 and Cmin values further increased to 119 095 ng h/L and 959 ng/mL, respectively. The patient continued oral letermovir 180 mg once daily for about 3 months, with adequate viral suppression (CMV viral load in plasma <150 IU/mL) and no recurrent CMV end-organ disease or adverse events. CONCLUSIONS Given limited options for anti-CMV therapy in young children with resistant CMV, letermovir could be considered as an alternative antiviral for SP. Further studies are warranted to evaluate the pharmacokinetics of letermovir in pediatric allogeneic HCT recipients.
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Affiliation(s)
- Vinita B Pai
- Nationwide Children's Hospital, Columbus, Ohio, USA
- College of Pharmacy, The Ohio State University, Columbus, Ohio, USA
| | | | - Eunkyung Song
- Nationwide Children's Hospital, Columbus, Ohio, USA
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
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6
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Li WW, Zhang YM, Shen MZ, Mo XD. Efficacy and safety of letermovir prophylaxis for cytomegalovirus infection after hematopoietic stem cell transplantation. BLOOD SCIENCE 2024; 6:e00178. [PMID: 38213825 PMCID: PMC10781138 DOI: 10.1097/bs9.0000000000000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/22/2023] [Indexed: 01/13/2024] Open
Abstract
Letermovir is a specific inhibitor of cytomegalovirus (CMV) terminase complex. Several studies have reported that letermovir can effectively prevent CMV activation after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We aimed to identify the efficacy and safety of letermovir prophylaxis for CMV infection after allo-HSCT with a systemic review and meta-analysis. A literature search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. PubMed and Embase databases were searched. A total of 28 studies were included. The incidence of CMV activation at 14 weeks after HSCT was 0.10 (95% confidence interval [CI], 0.06-0.18), which was 0.10 (95% CI, 0.04-0.21) and 0% in adult and children (2 studies were included and both of them were 0%). In addition, the incidence of CMV activation at 14 weeks after allo-HSCT was 0.11 (95% CI, 0.06-0.21) and 0.07 (only 1 study included), respectively, in retrospective and prospective studies. The incidence of CMV activation at 100 and 200 days after HSCT was 0.23 (95% CI, 0.16-0.33) and 0.49 (95% CI, 0.32-0.67), respectively. The incidence of CMV disease at 14 weeks and at 6 months after HSCT was 0.01 (95% CI, 0.01-0.02) and 0.03 (95% CI, 0.01-0.09), respectively. Thus, our systemic review and meta-analysis suggested that letermovir prophylaxis was safe and effective for CMV activation after allo-HSCT.
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Affiliation(s)
- Wen-Wen Li
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Department of Hematology, Qingdao Women and Children’s Hospital, Qingdao, China
| | - Yong-Mei Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Department of Hematology, Shijiazhuang People’s Hospital, Shijiazhuang, China
| | - Meng-Zhu Shen
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Dong Mo
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies (2019RU029), Chinese Academy of Medical Sciences, Beijing, China
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César T, Le MP, Klifa R, Castelle M, Fournier B, Lévy R, Chbihi M, Courteille V, Moshous D, Blanche S, Alligon M, Leruez-Ville M, Peytavin G, Frange P, Neven B. Letermovir for CMV Prophylaxis in Very High-Risk Pediatric Hematopoietic Stem Cell Transplantation Recipients for Inborn Errors of Immunity. J Clin Immunol 2023; 44:6. [PMID: 38117473 DOI: 10.1007/s10875-023-01617-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/06/2023] [Indexed: 12/21/2023]
Abstract
The burden of CMV infection and disease is important in pediatric hematopoietic stem cell transplantation (HSCT), notably in the subgroup of patients with inborn errors of immunity (IEIs). Letermovir (LMV) is now a standard of care for CMV prophylaxis in adult sero-positive (R+) recipients, but is not yet labeled for children. Published pediatric studies are still scarce. We report a monocentric real-life use of LMV in 36 HSCT pediatric recipients with IEIs considered at high-risk of CMV infection including 14 patients between 2 and 12 months of age. A homogenous dosage proportional to the body surface area was used. Pharmacokinetic (PK) was performed in 8 patients with a median of 6 years of age (range 0,6;15). The cumulative incidence of clinically significant CMV infections (CS-CMVi) and the overall survival of patients under LMV were compared to a very similar historical cohort under (val)aciclovir prophylaxis. LMV tolerance was good. As compared to the historical cohort, the incidence of CS-CMVi was significantly lower in LMV group (5 out of 36 transplants (13.9%) versus 28 of the 62 HSCT (45.2%)) (p = 0.002). Plasma LMV exposures did not significantly differ with those reported in adult patients. In this high-risk pediatric HSCT cohort transplanted for IEIs, CMV prophylaxis with LMV at a homogenous dosage was well tolerated and effective in preventing CS-CMVi compared with a historical cohort.
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Affiliation(s)
- Thibaut César
- Pediatric Hematology-Immunology and Rheumatology Department, Assistance Publique Hôpitaux de Paris (APHP), Necker University Hospital, Paris, France
| | - Minh P Le
- Pharmacology Department, APHP, Bichat Hospital, Paris, France
- INSERM UMR_S 1144, Paris, France
| | - Roman Klifa
- Pediatric Hematology-Immunology and Rheumatology Department, Assistance Publique Hôpitaux de Paris (APHP), Necker University Hospital, Paris, France
- Université Paris Cité, Paris, France
| | - Martin Castelle
- Pediatric Hematology-Immunology and Rheumatology Department, Assistance Publique Hôpitaux de Paris (APHP), Necker University Hospital, Paris, France
| | - Benjamin Fournier
- Pediatric Hematology-Immunology and Rheumatology Department, Assistance Publique Hôpitaux de Paris (APHP), Necker University Hospital, Paris, France
- Université Paris Cité, Paris, France
- Laboratory of Lymphocyte Activation and Susceptibility to EBV Infection, INSERM UMR1163, Institut Imagine, Paris, France
| | - Romain Lévy
- Pediatric Hematology-Immunology and Rheumatology Department, Assistance Publique Hôpitaux de Paris (APHP), Necker University Hospital, Paris, France
- Université Paris Cité, Paris, France
- Laboratory of Human Genetics of Infectious Diseases, Inserm UMR 1163, Imagine Institute, Paris, France
| | - Marwa Chbihi
- Pediatric Hematology-Immunology and Rheumatology Department, Assistance Publique Hôpitaux de Paris (APHP), Necker University Hospital, Paris, France
- Université Paris Cité, Paris, France
| | - Virginie Courteille
- French reference center for primary immune deficiencies (CEREDIH), Necker University Hospital, APHP, Paris, France
| | - Despina Moshous
- Pediatric Hematology-Immunology and Rheumatology Department, Assistance Publique Hôpitaux de Paris (APHP), Necker University Hospital, Paris, France
- Université Paris Cité, Paris, France
- French reference center for primary immune deficiencies (CEREDIH), Necker University Hospital, APHP, Paris, France
- Laboratory of Genome Dynamics in the Immune System, Imagine Institute, INSERM UMR 1163, Paris, France
| | - Stéphane Blanche
- Pediatric Hematology-Immunology and Rheumatology Department, Assistance Publique Hôpitaux de Paris (APHP), Necker University Hospital, Paris, France
- Université Paris Cité, Paris, France
| | - Mickaël Alligon
- French reference center for primary immune deficiencies (CEREDIH), Necker University Hospital, APHP, Paris, France
| | - Marianne Leruez-Ville
- Laboratory of Clinical Microbiology, APHP, Necker University Hospital, & Université Paris Cité, Paris, 7328 FETUS, URP, France
| | - Gilles Peytavin
- Pharmacology Department, APHP, Bichat Hospital, Paris, France
- IAME, INSERM UMR 1137, Paris, France
| | - Pierre Frange
- Laboratory of Clinical Microbiology, APHP, Necker University Hospital, & Université Paris Cité, Paris, 7328 FETUS, URP, France
| | - Bénédicte Neven
- Pediatric Hematology-Immunology and Rheumatology Department, Assistance Publique Hôpitaux de Paris (APHP), Necker University Hospital, Paris, France.
- Université Paris Cité, Paris, France.
- Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Imagine Institute, INSERM UMR- S_1163, Paris, France.
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8
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Styczynski J. Comment on: Letermovir for Cytomegalovirus prophylaxis in pediatric hematopoietic cell transplantation. Pediatr Blood Cancer 2023; 70:e30692. [PMID: 37740577 DOI: 10.1002/pbc.30692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/12/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
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9
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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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10
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Chen TT, David AP, Barthelmess EK, MacBrayne CE. Letermovir for Cytomegalovirus prophylaxis in pediatric hematopoietic stem cell transplantation. Pediatr Blood Cancer 2023; 70:e30608. [PMID: 37548491 DOI: 10.1002/pbc.30608] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/26/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Letermovir (LTV), an antiviral with exclusive activity against Cytomegalovirus (CMV), is approved for prophylaxis of CMV infection and disease in adult hematopoietic cell transplant (HCT) patients. The use of LTV in the pediatric HCT population is off-label, and has limited literature to support its use. PROCEDURE This was a single-center, retrospective, matched (1:1 LTV:non-LTV) cohort study of allogeneic HCT recipients transplanted at Children's Hospital Colorado from 2015 to 2022. The primary endpoint was clinically significant CMV DNAemia (defined as a CMV viral load >1000 copies/mL or any CMV DNAemia leading to preemptive treatment) through 6 months post transplant. Secondary outcomes included time to clinically significant CMV DNAemia, drug adverse effects, and dose adjustments of concomitant cyclosporine and voriconazole (known drug interactions). RESULTS We compared 41 patients who received LTV prophylaxis to 41 patients who received no CMV prophylaxis. There was less clinically significant CMV DNAemia through D+180 in the LTV group (9.8% vs. 17.0%, p = .33). Overall, LTV was well tolerated, and 87.8% of patients experienced no adverse effects related to the drug. There was no observed pattern in LTV effect on cyclosporine serum concentrations, but LTV was associated with decreased voriconazole trough levels. CONCLUSIONS In this retrospective study, the use of LTV prophylaxis in pediatric stem cell patients was associated with reduced clinically significant CMV DNAemia through D+180.
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Affiliation(s)
- Teaghan T Chen
- Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Alexandria P David
- Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Erin K Barthelmess
- Department of Pharmacy, Children's Hospital Colorado, Aurora, Colorado, USA
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11
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Dulek DE. Update on Epidemiology and Outcomes of Infection in Pediatric Organ Transplant Recipients. Infect Dis Clin North Am 2023; 37:561-575. [PMID: 37532391 DOI: 10.1016/j.idc.2023.06.002] [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] [Indexed: 08/04/2023]
Abstract
Pediatric solid organ transplant (SOT) recipients are at risk for infection following transplantation. Data from adult SOT recipients are often used to guide prevention and treatment of infections associated with organ transplantation in children. This article highlights key recent pediatric SOT-specific publications for an array of infectious complications of organ transplantation. Attention is given to areas of need for future study.
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Affiliation(s)
- Daniel E Dulek
- Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
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12
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Hume J, Sweeney EL, Lowry K, Fraser C, Clark JE, Whiley DM, Irwin AD. Cytomegalovirus in children undergoing haematopoietic stem cell transplantation: a diagnostic and therapeutic approach to antiviral resistance. Front Pediatr 2023; 11:1180392. [PMID: 37325366 PMCID: PMC10267881 DOI: 10.3389/fped.2023.1180392] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Cytomegalovirus (CMV) is a ubiquitous virus which causes a mild illness in healthy individuals. In immunocompromised individuals, such as children receiving haematopoietic stem cell transplantation, CMV can reactivate, causing serious disease and increasing the risk of death. CMV can be effectively treated with antiviral drugs, but antiviral resistance is an increasingly common complication. Available therapies are associated with adverse effects such as bone marrow suppression and renal impairment, making the choice of appropriate treatment challenging. New agents are emerging and require evaluation in children to establish their role. This review will discuss established and emerging diagnostic tools and treatment options for CMV, including antiviral resistant CMV, in children undergoing haematopoietic stem cell transplant.
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Affiliation(s)
- Jocelyn Hume
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Central Microbiology, Pathology Queensland, Brisbane, QLD, Australia
| | - Emma L. Sweeney
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Kym Lowry
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Chris Fraser
- Blood and Bone Marrow Transplant Program, Queensland Children’s Hospital, Brisbane, QLD, Australia
| | - Julia E. Clark
- Infection Management and Prevention Service, Queensland Children’s Hospital, Brisbane, QLD, Australia
| | - David M. Whiley
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Central Microbiology, Pathology Queensland, Brisbane, QLD, Australia
| | - Adam D. Irwin
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Infection Management and Prevention Service, Queensland Children’s Hospital, Brisbane, QLD, Australia
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13
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Kuhn A, Puttkammer J, Madigan T, Dinnes L, Khan S, Ferdjallah A, Kohorst M. Letermovir as Cytomegalovirus Prophylaxis in a Pediatric Cohort: A Retrospective Analysis. Transplant Cell Ther 2023; 29:62.e1-62.e4. [PMID: 36244677 DOI: 10.1016/j.jtct.2022.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/20/2022] [Accepted: 10/06/2022] [Indexed: 11/09/2022]
Abstract
Letermovir is an attractive cytomegalovirus (CMV) prophylactic agent, but published data in children are scarce. This retrospective chart review aimed to describe our experience using letermovir as CMV prophylaxis in pediatric hematopoietic cell transplantation (HCT) recipients. Pediatric patients (age <20 years) undergoing allogeneic HCT and receiving letermovir prophylaxis in the Mayo Clinic Pediatric Bone Marrow Transplant Program were eligible for inclusion in this retrospective chart review. Medical records were reviewed to evaluate letermovir dosing, CMV levels, laboratory values, and reports of adverse effects. Between October 2020 and April 2022, 9 patients age 4 to 19 years undergoing allogeneic HCT in the Pediatric Bone Marrow Transplant Program received letermovir prophylaxis, either 240 mg or 480 mg daily at a mean and median dose of 10 mg/kg/day. Letermovir was crushed and administered via nasogastric tube in 4 of 9 patients. Two patients received letermovir for secondary CMV prophylaxis after initial treatment with ganciclovir/valganciclovir, and the remaining 7 received letermovir for primary prophylaxis. One patient, a 20-kg 6-year-old female receiving 240 mg (12 mg/kg), experienced low-level CMV viremia while on letermovir. No other patients experienced CMV reactivation while on letermovir prophylaxis. In 2 patients, transient mild transaminitis was noted within the first weeks of letermovir therapy, which resolved without intervention, and its relationship to letermovir could not be clearly established. Letermovir administration was feasible and well tolerated as CMV prophylaxis in our small cohort of pediatric patients undergoing HCT. Larger, prospective studies are warranted to confirm the safety and efficacy of letermovir in children. © 2022 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Alexis Kuhn
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota.
| | - Jenna Puttkammer
- Department of Pharmacy, North Memorial Health Hospital, Robbinsdale, Minnesota
| | - Theresa Madigan
- Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Laura Dinnes
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Shakila Khan
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, Minnesota
| | - Asmaa Ferdjallah
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, Minnesota
| | - Mira Kohorst
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, Minnesota
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14
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Hiskey L, Madigan T, Ristagno EH, Razonable RR, Ferdjallah A. Prevention and management of human cytomegalovirus in pediatric HSCT recipients: A review. Front Pediatr 2022; 10:1039938. [PMID: 36507142 PMCID: PMC9727199 DOI: 10.3389/fped.2022.1039938] [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: 09/08/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Cytomegalovirus (CMV), like other herpesviruses, has the unique ability to establish latent infection with subsequent reactivation during periods of stress and immunosuppression. Herpesviruses cause potentially devastating disease, particularly in hematopoietic stem cell transplant (HSCT) recipients. CMV is especially of concern in HSCT recipients given the high community seroprevalence, high risk of reactivation and high risk of transmission from HSCT donors to recipients causing primary infection after transplantation. The risk of CMV infection and severity of CMV disease varies depending on the underlying disease of the HSCT recipient, donor and recipient CMV status prior to HSCT, type of conditioning therapy in preparation for HSCT, allogeneic versus autologous HSCT, donor graft source, timing of infection in relation to HSCT, and other patient comorbidities. Different strategies exist for prevention (e.g., preemptive therapy vs. universal prophylaxis) as well as management of CMV disease (e.g., antiviral therapy, augmenting immune reconstitution, cytotoxic T-cell therapy). The purpose of this narrative review is to discuss diagnosis, prevention, and management of CMV infection and disease at different stages of HSCT, including key points illustrated through presentations of complex cases and difficult clinical scenarios. Traditional and novel strategies for CMV management will be discussed in the context of these unique clinical cases.
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Affiliation(s)
- Lisa Hiskey
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
| | - Theresa Madigan
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
| | - Elizabeth H Ristagno
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
| | - Raymund R Razonable
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, United States
| | - Asmaa Ferdjallah
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
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