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Royston L, Papanicolaou GA, Neofytos D. Refractory/Resistant Cytomegalovirus Infection in Transplant Recipients: An Update. Viruses 2024; 16:1085. [PMID: 39066247 PMCID: PMC11281367 DOI: 10.3390/v16071085] [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: 05/06/2024] [Revised: 06/26/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024] Open
Abstract
Despite the significant progress made, CMV infection is one of the most frequent infectious complications in transplant recipients. CMV infections that become refractory or resistant (R/R) to the available antiviral drugs constitute a clinical challenge and are associated with increased morbidity and mortality. Novel anti-CMV therapies have been recently developed and introduced in clinical practice, which may improve the treatment of these infections. In this review, we summarize the treatment options for R/R CMV infections in adult hematopoietic cell transplant and solid organ transplant recipients, with a special focus on newly available antiviral agents with anti-CMV activity, including maribavir and letermovir.
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Affiliation(s)
- Léna Royston
- Division of Infectious Diseases, University Hospital of Geneva, 1211 Geneva, Switzerland
| | - Genovefa A. Papanicolaou
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, 1211 Geneva, Switzerland
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2
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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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Monday LM, Keri V, Chandrasekar PH. Advances in pharmacotherapies for cytomegalovirus infection: what is the current state of play? Expert Opin Pharmacother 2024; 25:685-694. [PMID: 38717943 DOI: 10.1080/14656566.2024.2353627] [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: 01/18/2024] [Accepted: 05/07/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Cytomegalovirus (CMV) remains a serious opportunistic infection in hematopoietic cell transplant (HCT) and solid-organ transplant (SOT) recipients. Traditional anti-CMV drugs are limited by toxicities and the development of resistance. Letermovir and maribavir are newly approved antivirals for the prevention and treatment of CMV. AREAS COVERED Prior reviews have discussed use of letermovir for prevention of CMV after HCT and maribavir for resistant or refractory (R/R) CMV post HCT or SOT. Subsequent data have expanded their use including letermovir for primary CMV prophylaxis in high-risk renal transplant recipients and new recommendations for extending prophylaxis through day + 200 in certain HCT patients. Data on the use of maribavir for first asymptomatic CMV infection post-HCT has also been published. This review compares the pharmacology of anti-CMV agents and discusses the updated literature of these new drugs in the prevention and treatment of CMV. EXPERT OPINION Letermovir and maribavir are much needed tools that spare toxicities of ganciclovir, foscarnet, and cidofovir. High cost is a challenge preventing their integration into clinical practice in resource-limited countries. Transplant centers need to exercise restraint in overuse to avoid resistance, particularly in the setting of high viral loads.
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Affiliation(s)
- Lea M Monday
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Vishakh Keri
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA
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Yang D, Yao Y, Sun Y, Jiang E. Refractory cytomegalovirus infections in Chinese patients receiving allogeneic hematopoietic cell transplantation: a review of the literature. Front Immunol 2023; 14:1287456. [PMID: 38187387 PMCID: PMC10770847 DOI: 10.3389/fimmu.2023.1287456] [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: 09/01/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024] Open
Abstract
In the absence of prophylactic therapy, cytomegalovirus (CMV) viremia is a common complication following allogeneic hematopoietic cell transplantation (allo-HCT) and represents a significant cause of morbidity and mortality. Approximately 25% of allo-HCT happen in China, where the development and refinement of the 'Beijing protocol' has enabled frequent and increasing use of haploidentical donors. However, refractory CMV infection (an increase by >1 log10 in blood or serum CMV DNA levels after at least 2 weeks of an appropriately dosed anti-CMV medication) is more common among patients with haploidentical donors than with other donor types and has no established standard of care. Here, we review the literature regarding refractory CMV infection following allo-HCT in China.
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Affiliation(s)
- Donglin Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | | | - Yi Sun
- MRL Global Medical Affairs, Shanghai, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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5
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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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Duan Z, Zhang X, Liu Y, Li F, Shen H, Chen R, Zhu H, Qiu H, Miao K. Risk factors and survival of refractory cytomegalovirus reactivation after allogeneic peripheral blood stem cell transplantation. J Glob Antimicrob Resist 2022; 31:279-285. [PMID: 36265801 DOI: 10.1016/j.jgar.2022.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/22/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Refractory cytomegalovirus reactivation (RCR) after allo-hematopoietic stem cell transplantation (HSCT) is associated with poor outcomes. Current studies for the risk factors and survival of patients with post-transplantation RCR remain limited. METHODS 163 patients with Cytomegalovirus (CMV) reactivation undergoing allo-HSCT in Jiangsu Province hospital from Jan 2013 to Dec 2020 were analyzed retrospectively. RESULTS Multivariate analysis revealed that highest CMV viremia>1 × 104copies/mL (hazard ratio [HR] 16.895, 95% confidence interval [CI] 3.394-84.109, P = 0.001) and platelet count at Day 90 of more than 87.3 × 109/L (HR 0.381, 95% CI 0.154-0.945, P = 0.037) were independent risk factors affecting RCR. As for prognosis of patients with CMV reactivation, results showed that patients with RCR had higher risk of non-relapse mortality (NRM) (39.5% vs. 22.5%, P = 0.045), and RCR was an independent risk factor for NRM (HR 2.216, 95% CI 1.137-4.317, P = 0.019). There was no significance between patients with or without RCR in terms of overall survival (OS) (50.7% vs. 55.6%, P = 0.281) and relapse-free survival (RFS) (43.6% vs. 52.0%, P = 0.179). The landmark analysis showed that patients with RCR had higher NRM (P = 0.01), worse OS (P = 0.02), and RFS (P =0.01) within 100 days after transplantation. Patients with hemorrhagic cystitis (40.9% vs. 64.5%, P =0.028) and who developed viremia>1 × 105copies/mL (43.4% vs. 58.4%, P = 0.033) were associated with worse OS. CONCLUSION Factors such as higher viral load, thrombocytopenia, and ATG used in conditioning therapy increased the incidence of RCR. Patients with RCR had worse NRM, OS, and RFS within 100 days after transplantation.
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Affiliation(s)
- Ziwen Duan
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China
| | - Xiao Zhang
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China
| | - Yanping Liu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China
| | - Fang Li
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China
| | - Haorui Shen
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China
| | - Ruize Chen
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China
| | - Han Zhu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China
| | - Hairong Qiu
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.
| | - Kourong Miao
- Department of Hematology, the First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, People's Republic of China.
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Avery RK, Alain S, Alexander BD, Blumberg EA, Chemaly RF, Cordonnier C, Duarte RF, Florescu DF, Kamar N, Kumar D, Maertens J, Marty FM, Papanicolaou GA, Silveira FP, Witzke O, Wu J, Sundberg AK, Fournier M. Maribavir for Refractory Cytomegalovirus Infections With or Without Resistance Post-Transplant: Results From a Phase 3 Randomized Clinical Trial. Clin Infect Dis 2021; 75:690-701. [PMID: 34864943 PMCID: PMC9464078 DOI: 10.1093/cid/ciab988] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Therapies for refractory cytomegalovirus infections (with or without resistance [R/R]) in transplant recipients are limited by toxicities. Maribavir has multimodal anti-cytomegalovirus activity through the inhibition of UL97 protein kinase. METHODS In this phase 3, open-label study, hematopoietic-cell and solid-organ transplant recipients with R/R cytomegalovirus were randomized 2:1 to maribavir 400 mg twice daily or investigator-assigned therapy (IAT; valganciclovir/ganciclovir, foscarnet, or cidofovir) for 8 weeks, with 12 weeks of follow-up. The primary endpoint was confirmed cytomegalovirus clearance at end of week 8. The key secondary endpoint was achievement of cytomegalovirus clearance and symptom control at end of week 8, maintained through week 16. RESULTS 352 patients were randomized (235 maribavir; 117 IAT). Significantly more patients in the maribavir versus IAT group achieved the primary endpoint (55.7% vs 23.9%; adjusted difference [95% confidence interval (CI)]: 32.8% [22.80-42.74]; P < .001) and key secondary endpoint (18.7% vs 10.3%; adjusted difference [95% CI]: 9.5% [2.02-16.88]; P = .01). Rates of treatment-emergent adverse events (TEAEs) were similar between groups (maribavir, 97.4%; IAT, 91.4%). Maribavir was associated with less acute kidney injury versus foscarnet (8.5% vs 21.3%) and neutropenia versus valganciclovir/ganciclovir (9.4% vs 33.9%). Fewer patients discontinued treatment due to TEAEs with maribavir (13.2%) than IAT (31.9%). One patient per group had fatal treatment-related TEAEs. CONCLUSIONS Maribavir was superior to IAT for cytomegalovirus viremia clearance and viremia clearance plus symptom control maintained post-therapy in transplant recipients with R/R cytomegalovirus. Maribavir had fewer treatment discontinuations due to TEAEs than IAT. Clinical Trials Registration. NCT02931539 (SOLSTICE).
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Affiliation(s)
- Robin K Avery
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sophie Alain
- Department of Virology and National Reference Center for Herpesviruses, Limoges University Hospital, UMR Inserm 1092, University of Limoges, Limoges, France
| | - Barbara D Alexander
- Division of Infectious Diseases and International Health, Duke University, Durham, North Carolina, USA
| | - Emily A Blumberg
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Catherine Cordonnier
- Haematology Department, Henri Mondor Hospital and University Paris-Est-Créteil, Créteil, France
| | - Rafael F Duarte
- Department of Haematology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Diana F Florescu
- Infectious Diseases Division, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, INFINITY-Inserm U1291-CNRS U5051, University Paul Sabatier, Toulouse, France
| | - Deepali Kumar
- Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Johan Maertens
- Haematology Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | | | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA,Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Fernanda P Silveira
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Oliver Witzke
- Department of Infectious Diseases, West German Centre of Infectious Diseases, University Medicine Essen, University Duisburg-Essen, Essen, Germany
| | - Jingyang Wu
- Biostatistics, Takeda Development Center Americas, Inc, Lexington, Massachusetts, USA
| | - Aimee K Sundberg
- Clinical Sciences, Takeda Development Center Americas, Inc, Lexington, Massachusetts, USA
| | - Martha Fournier
- Correspondence: M. Fournier, Takeda Development Center Americas, Inc, 300 Shire Way, Lexington, MA 02421 ()
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8
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Infection risk and prophylaxis in patients with lymphoid cancer. Blood 2021; 139:1517-1528. [PMID: 34748625 DOI: 10.1182/blood.2019003687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/05/2021] [Indexed: 11/20/2022] Open
Abstract
Infections are a common cause of morbidity and mortality in patients with lymphoid cancer. With evolving cancer therapeutics, including new targeted and immunotherapies, clinicians need to be aware of additional risk factors and infections that may arise in patients treated with these agents. This "How I Treat" article will highlight fundamental issues including risk factors for infection, infectious diseases screenings and antimicrobial prophylaxis recommendations in patients with lymphoid cancers. We present 4 scenarios of patients with lymphoid cancers with varied infections and describe a treatment approach based on a combination of evidence-based data and experience, as there are limitations in objective infection data especially with newer agents. The goal of this discussion is to provide a framework for institutions and health care providers to develop their own approach in preventing and treating infections in patients with lymphoid cancer.
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Sassine J, Khawaja F, Shigle TL, Handy V, Foolad F, Aitken S, Jiang Y, Champlin R, Shpall E, Rezvani K, Ariza-Heredia EJ, Chemaly RF. Refractory and Resistant Cytomegalovirus after Hematopoietic Cell Transplant in the Letermovir Primary Prophylaxis Era. Clin Infect Dis 2021; 73:1346-1354. [PMID: 33830182 DOI: 10.1093/cid/ciab298] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) reactivation is one of the most common infectious complications after allogeneic hematopoietic cell transplant (HCT) and may result in significant morbidity and mortality. Primary prophylaxis with letermovir demonstrated a reduction in clinically significant CMV infections (CS-CMVi) in clinical trials of CMV-seropositive HCT recipients. This study aims at exploring the effect of primary letermovir prophylaxis in this population on the incidence and outcomes of refractory or resistant CMV infections. METHODS This is a single-center, retrospective cohort study of 537 consecutive CMV-seropositive allogeneic HCT recipients cared for during March 2016 to October 2018. Baseline demographics, HCT characteristics, CMV infections, treatment and mortality data were collected from the electronic medical record. CMV outcomes were defined according to the recently standardized definitions for clinical trials. Characteristics and outcomes were assessed according to receipt of primary letermovir prophylaxis. RESULTS Of 537 patients identified, 123 received letermovir for primary prophylaxis during the first 100 days after HCT, and 414 did not. In a multivariate analysis, primary prophylaxis with letermovir was associated with reductions in CS-CMVi (hazard ratio [HR] 0.26, 95% CI 0.16-0.41), CMV end-organ disease (HR 0.23, 95% CI 0.10-0.52), refractory or resistant CMV infection (HR 0.15, 95% CI 0.04-0.52), and non-relapse mortality at week 48 (HR 0.55, 95% CI 0.32-0.93). There was neither resistant CMV nor CMV-related mortality in the primary letermovir prophylaxis group. CONCLUSIONS Primary letermovir prophylaxis effectively prevents refractory or resistant CMV infections and decreases non-relapse mortality at week 48, as well as CS-CMVi and CMV disease after allogeneic HCT.
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Affiliation(s)
- Joseph Sassine
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Division of Infectious Diseases, Department of Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Fareed Khawaja
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Terri Lynn Shigle
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Victoria Handy
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farnaz Foolad
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samuel Aitken
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ying Jiang
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katy Rezvani
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ella J Ariza-Heredia
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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10
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Limaye AP, Babu TM, Boeckh M. Progress and Challenges in the Prevention, Diagnosis, and Management of Cytomegalovirus Infection in Transplantation. Clin Microbiol Rev 2020; 34:34/1/e00043-19. [PMID: 33115722 PMCID: PMC7920732 DOI: 10.1128/cmr.00043-19] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hosts with compromised or naive immune systems, such as individuals living with HIV/AIDS, transplant recipients, and fetuses, are at the highest risk for complications from cytomegalovirus (CMV) infection. Despite substantial progress in prevention, diagnostics, and treatment, CMV continues to negatively impact both solid-organ transplant (SOT) and hematologic cell transplant (HCT) recipients. In this article, we summarize important developments in the field over the past 10 years and highlight new approaches and remaining challenges to the optimal control of CMV infection and disease in transplant settings.
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Affiliation(s)
- Ajit P Limaye
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Tara M Babu
- Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York, USA
- Department of Infectious Diseases, Overlake Medical Center, Bellevue, Washington, USA
| | - Michael Boeckh
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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Advances in the genotypic diagnosis of cytomegalovirus antiviral drug resistance. Antiviral Res 2020; 176:104711. [PMID: 31940472 DOI: 10.1016/j.antiviral.2020.104711] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/22/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022]
Abstract
Cytomegalovirus (CMV) drug resistance mutation maps are updated with recent information for polymerase inhibitors, the terminase inhibitor letermovir and the UL97 kinase inhibitor maribavir. Newly mapped mutations and their phenotypes provide more detail on cross-resistance properties and suggest the need to expand the CMV gene regions covered in diagnostic testing. Next-generation deep sequencing technology offers a more sensitive, higher resolution view of emerging antiviral resistance and is recommended for use in clinical trials. Issues of standardization and diagnostic utility in comparison with traditional Sanger sequencing remain unresolved. Quality control is important for the accurate and reproducible detection of mutant viral populations in clinical specimens.
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