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Swartling L, Engman ML, Eriksen J, Fischler B, Friman V, Hobell H, Ljungman P, Mellgren K, Navér L, Nyström K, Otto G, Pauksens K, Pettersson K, Rydén I, Westman G, Magnusson J. Management of cytomegalovirus infections - Swedish recommendations 2023. Infect Dis (Lond) 2024:1-11. [PMID: 39185773 DOI: 10.1080/23744235.2024.2392789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 08/08/2024] [Accepted: 08/08/2024] [Indexed: 08/27/2024] Open
Abstract
Cytomegalovirus (CMV) infection, which mostly causes a subclinical infection early in life, has important clinical consequences in certain patient groups. CMV is the most common congenital infection and can cause permanent disabilities such as hearing loss and motor- and cognitive deficits in affected infants. In allogeneic haematopoietic stem cell and solid organ transplant recipients, CMV still is an important infectious complication with a risk for life-threatening disease. The previous Swedish recommendations for the management of CMV infections were updated by an expert group under the guidance of The Swedish Reference Group for Antiviral Treatment (RAV) and published at the website of RAV in August 2023 (https://www.sls.se/rav/rekommendationer/cytomegalovirus/). We here provide a translation of the updated recommendations, with minor modifications regarding diagnosis of CMV pneumonia. In the present recommendations, we discuss aspects of old and new CMV antivirals, including dosing for different age groups, and cover the management of congenital infections and CMV in immunocompromised patients. The recommendations are evidence-graded in accordance with the Oxford Centre for Evidence-Based Medicine.
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Affiliation(s)
- Lisa Swartling
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Mona-Lisa Engman
- Department of Pediatrics, Karolinska University Hospital and Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Jaran Eriksen
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Unit of Infectious diseases/Venhälsan, Stockholm South General Hospital, Stockholm, Sweden
| | - Björn Fischler
- Department of Pediatrics, Karolinska University Hospital and Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Vanda Friman
- Department of Infectious Diseases, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hanna Hobell
- Department of Pediatrics, Karolinska University Hospital and Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Karolinska Comprehensive Cancer Center, Stockholm, Sweden
- Division of Hematology, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Karin Mellgren
- Department of Pediatric Oncology, The Queen Silvia's Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Navér
- Department of Neonatology, Karolinska University Hospital and CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Nyström
- Department of Clinical Microbiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gisela Otto
- Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden
| | - Karlis Pauksens
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Karin Pettersson
- Division of Obstetrics and Gynaecology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ingehla Rydén
- Department of Pediatrics, Pediatric Drug Therapy Group, Karolinska University Hospital, Stockholm, Sweden
| | - Gabriel Westman
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
- Swedish Medical Products Agency, Uppsala, Sweden
| | - Jesper Magnusson
- Department of Pulmonary Medicine, Institute of Internal Medicine, University of Gothenburg, Gothenburg, Sweden
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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Raval AD, Kistler KD, Tang Y, Murata Y, Snydman DR. Epidemiology, risk factors, and outcomes associated with cytomegalovirus in adult kidney transplant recipients: A systematic literature review of real-world evidence. Transpl Infect Dis 2020; 23:e13483. [PMID: 33012092 DOI: 10.1111/tid.13483] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/21/2022]
Abstract
Kidney transplant recipients (KTRs) have increased risk for cytomegalovirus (CMV) infection/disease given the necessity of drug-induced immunosuppression. A comprehensive review of published literature reporting real-world data on prevention strategies utilized and associated CMV burden outcomes is limited. Such data could help inform future clinical practice and identify unmet needs in CMV management. We conducted a systematic review of observational studies published in Medline or EMBASE from January 2008 to November 2018 to identify current real-world CMV management approaches, CMV infection/disease risk factors, and outcomes associated with CMV infection. Descriptive statistics and pooled quantitative analyses were conducted. From 1608 records screened, 86 citations, including 69 803 adult KTR, were included. Prophylaxis and preemptive therapy (PET) were predominant approaches among D+/R- and R + CMV serostatus transplants, respectively. Valganciclovir and ganciclovir were frequently utilized across CMV risk strata. Despite prevention approaches, approximately one-fourth of KTR developed CMV infection. Age and D+/R- CMV serostatus were consistent risk factors for CMV infection/disease. CMV infection/disease was associated with increased mortality and graft loss. CMV was similarly associated with acute rejection (AR) risk, but with high heterogeneity among studies. Limited data were available on CMV and opportunistic infections (OIs) risk. CMV remains a significant issue. New strategies may be needed to optimize CMV management.
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Noble J, Gatault P, Sautenet B, Gaudy-Graffin C, Beby-Defaux A, Thierry A, Essig M, Halimi JM, Munteanu E, Alain S, Buchler M. Predictive factors of spontaneous CMV DNAemia clearance in kidney transplantation. J Clin Virol 2018; 99-100:38-43. [DOI: 10.1016/j.jcv.2017.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/18/2017] [Accepted: 12/20/2017] [Indexed: 12/26/2022]
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Torre-Cisneros J, Aguado J, Caston J, Almenar L, Alonso A, Cantisán S, Carratalá J, Cervera C, Cordero E, Fariñas M, Fernández-Ruiz M, Fortún J, Frauca E, Gavaldá J, Hernández D, Herrero I, Len O, Lopez-Medrano F, Manito N, Marcos M, Martín-Dávila P, Monforte V, Montejo M, Moreno A, Muñoz P, Navarro D, Pérez-Romero P, Rodriguez-Bernot A, Rumbao J, San Juan R, Vaquero J, Vidal E. Management of cytomegalovirus infection in solid organ transplant recipients: SET/GESITRA-SEIMC/REIPI recommendations. Transplant Rev (Orlando) 2016; 30:119-43. [DOI: 10.1016/j.trre.2016.04.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 04/02/2016] [Accepted: 04/04/2016] [Indexed: 02/06/2023]
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Reischig T, Kacer M. The efficacy and cost-effectiveness of valacyclovir in cytomegalovirus prevention in solid organ transplantation. Expert Rev Pharmacoecon Outcomes Res 2014; 14:771-9. [PMID: 25252996 DOI: 10.1586/14737167.2014.965157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Prevention of cytomegalovirus infection using antiviral prophylaxis or the pre-emptive therapy approach is an integral part of management of patients after solid organ transplantation. Regarding renal transplantation, valacyclovir is currently the only antiviral agent recommended for prophylaxis as an alternative to valganciclovir. This review article discusses studies documenting the efficacy and safety of valacyclovir prophylaxis as well as those comparing valacyclovir with other prophylactic regimens or with pre-emptive therapy. Also addressed are the economic aspects supporting the cost-effectiveness of valacyclovir prophylaxis and demonstrating lower costs compared with other cytomegalovirus preventive strategies.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Alej Svobody 80, 304 60 Pilsen, Czech Republic
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Jongsma H, Bouts AH, Cornelissen EAM, Beersma MFC, Cransberg K. Cytomegalovirus prophylaxis in pediatric kidney transplantation: the Dutch experience. Pediatr Transplant 2013; 17:510-7. [PMID: 23890076 DOI: 10.1111/petr.12115] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 11/30/2022]
Abstract
Many children receiving a kidney transplant are seronegative for CMV and therefore, highly susceptible to a primary CMV infection. This study aims at evaluating incidence, time of occurrence, and severity of CMV infection in the first year post-transplantation in relation to different types of CMV prophylaxis. Transplantations in three centers in the Netherlands between 1999 and 2010 were included. Retrospective, observational, multicenter study. Clinical data and PCR measurements of CMV were collected. Prophylaxis in high-risk patients (CMV serostatus D+R-) consisted of (val)ganciclovir during three months, or acyclovir plus CMV immunoglobulin at a former stage. Intermediate-risk patients (R+) received (val)acyclovir, or acyclovir plus CMV immunoglobulin at a former stage. Low-risk patients (D-R-) did not receive prophylaxis. Infection was defined as CMV PCR above 50 geq/mL plasma or whole blood, a clinically relevant infection above 1000 geq/mL. One hundred and fifty-nine transplantations were included. CMV infection was documented for 41% of high-risk, 24% of intermediate-risk, and 13% of low-risk patients, in the latter two groups typically during the first three months. The infection rate was highest in the high-risk group after cessation of valganciclovir prophylaxis. Valganciclovir provided better protection than did acyclovir + CMV immunoglobulin. Adding an IL2-receptor blocker to the immunosuppressive regimen did not affect the infection rate. Acute graft rejection was not related with CMV infection. Valganciclovir prophylaxis effectively prevents CMV infection in high-risk pediatric kidney recipients, but only during prophylaxis. Valacyclovir prophylaxis in intermediate-risk patients is less effective.
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Affiliation(s)
- Hidde Jongsma
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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