1
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Hume J, Lowry K, Whiley DM, Irwin AD, Bletchly C, Sweeney EL. Application of the ViroKey® SQ FLEX assay for detection of cytomegalovirus antiviral resistance. J Clin Virol 2023; 167:105556. [PMID: 37566984 DOI: 10.1016/j.jcv.2023.105556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/13/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a viral infection which establishes lifelong latency, often reactivating and causing disease in immunosuppressed individuals, including haematopoietic stem cell transplant (HSCT) recipients. Treatment can be problematic due to antiviral resistance which substantially increases the risk of patient mortality. Diagnostic testing capabilities for CMV antiviral resistance in Australia and elsewhere have traditionally relied on gene-specific Sanger sequencing approaches, however, are now being superseded by next generation sequencing protocols. OBJECTIVE Provide a snapshot of local mutations and explore the feasibility of the ViroKeyࣨ® SQ FLEX Genotyping Assay (Vela Diagnostics Pty Ltd) by examining sequencing success. METHOD Performed sequencing on adult (n = 38) and paediatric (n = 81) plasma samples, over a large range of viral loads (above and below the assay recommended threshold of ≥1,000 International Units (IU)/mL; noting most of our paediatric samples have loads <1,000 IU/mL). RESULTS Eleven test runs (including three repeat runs; 14 to 15 samples per run) were conducted, and four runs were deemed valid. The overall individual sample success rate for the four evaluable test runs was 71.2% (42/59 samples); 80.4% (37/46) samples ≥1,000 IU/mL were valid. Ten clinically important antiviral resistance mutations were detected, the most common being A594V in the UL97 gene, found in 6 (5%) samples. CONCLUSIONS A range of technical issues were experienced, however with improvement this platform could be a useful addition to routine pathology workflows, providing timely antiviral resistance results for patients undergoing HSCT.
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Affiliation(s)
- Jocelyn Hume
- Faculty of Medicine, The University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Pathology Queensland Central Laboratory, Brisbane, Queensland, Australia
| | - Kym Lowry
- Faculty of Medicine, The University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Queensland Paediatric Infectious Diseases (QPID) Sakzewski Laboratory, Centre for Children's Health Research, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - David M Whiley
- Faculty of Medicine, The University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Pathology Queensland Central Laboratory, Brisbane, Queensland, Australia
| | - Adam D Irwin
- Faculty of Medicine, The University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Cheryl Bletchly
- Pathology Queensland Central Laboratory, Brisbane, Queensland, Australia
| | - Emma L Sweeney
- Faculty of Medicine, The University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia.
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2
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Szmit Z, Frączkiewicz J, Salamonowicz-Bodzioch M, Król A, Ussowicz M, Mielcarek-Siedziuk M, Liszka K, Marschollek P, Gorczyńska E, Kałwak K. The Impact of High CMV Viral Load and Refractory CMV Infection on Pediatric HSCT Recipients with Underlying Non-Malignant Disorder. J Clin Med 2022; 11:jcm11175187. [PMID: 36079123 PMCID: PMC9456677 DOI: 10.3390/jcm11175187] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a curative therapy for an increasing number of nonmalignant indications. Its use is restricted by severe transplant-related complications, including CMV infection; despite various prophylactic and therapeutic strategies, CMV reactivation has remarkable morbidity and mortality. The analysis included 94 children with nonmalignant disorder who underwent allogeneic HSCT in the Department of Pediatric Hematology, Oncology, and Bone Marrow Transplantation in Wrocław during years 2016–2020. Twenty-seven (29%) children presented with CMV infection, including ten (10/27; 37%) with high level CMV viremia (10,000 copies/mL). Six patients experienced subsequent CMV reactivation. The first-line ganciclovir-based (GCV) treatment was insufficient in 40% (11/27) of children. Overall survival (OS) was significantly lower in children with high CMV viremia compared to those with low levels/no CMV [1yrOS High CMV = 0.80 (95% CI 0.41–0.95) vs. 1yrOS others = 0.96 (95% CI 0.89–0.99)]. Similarly, patients with resistant and recurrent infections had greater risk of death. CMV reactivation at any level relevantly prolonged the hospital stay. CMV reactivation with high viremia load and resistant/recurrent CMV infections lead to a significant decrease in OS in children with nonmalignant disorders treated with HSCT. Our data proves there is an urgent need to introduce an effective anti-CMV prophylaxis in this cohort of patients.
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Jung JY, Nho D, Cho SY, Lee DG, Choi SM, Kim HJ, Kim M, Oh EJ. Intra-host diversity of drug-resistant cytomegalovirus: A case report of cytomegalovirus infection after allogeneic hematopoietic cell transplantation. J Infect Chemother 2022; 28:1415-1418. [PMID: 35810104 DOI: 10.1016/j.jiac.2022.05.020] [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: 03/03/2022] [Revised: 05/09/2022] [Accepted: 05/31/2022] [Indexed: 10/17/2022]
Abstract
Cytomegalovirus (CMV) is a major infectious agent causing severe complications in allogeneic hematopoietic cell transplantation (HCT) recipients, thereby warranting the need for aggressive preemptive or targeted antiviral therapy. However, prolonged or repeated use of antiviral agents, such as ganciclovir (GCV), foscarnet (FOS), and cidofovir (CDV), can result in drug-resistant CMV infection, posing challenges to successful outcomes. Here, we report a case of a patient with acute myeloid leukemia and drug-resistant CMV infection who presented with persistent CMV DNAemia, colitis, pneumonia, and encephalitis. An intra-host diversity of UL97 and UL54 mutations were detected through the genotypic resistance testing conducted on two blood samples (D+199 and D+224) and a cerebrospinal fluid (CSF) specimen (D+260) collected from the patient. UL97 L595W/L595F and L595W mutations were detected in the blood and CSF samples, respectively, that conferred GCV resistance. UL54 F412L mutation detected in all three samples conferred GCV/CDV resistance. However, the V787L mutation of UL54, conferring GCV/FOS resistance, was observed only in the D+224 blood sample. Despite combination therapy with FOS and high dose GCV and adjunctive therapy with leflunomide, the patient died from CMV infection and multiple organ failure on D+279. Further data on resistant mutations and intra-host diversity of CMV should be accumulated to elucidate the antiviral resistance and related outcomes.
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Affiliation(s)
- Ji-Yoon Jung
- Catholic Medical Center, The Catholic University of Korea, Seoul, South Korea
| | - Dukhee Nho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea; Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, South Korea; Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea; Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, South Korea; Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Su-Mi Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea; Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee-Je Kim
- Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Myungshin Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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4
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Abstract
Recipients of solid organ and hematopoietic stem cell transplantation undergo substantial immune suppression, placing them at risk for opportunistic viral infection. Few randomized controlled trials have been dedicated to the treatment of viral infections in children, and current practices are extrapolated from data generated from adult patients. Here we discuss the prevention and treatment of viral infections using available antiviral drugs, as well as novel agents that may provide benefit to pediatric patients in the future.
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Affiliation(s)
- William R. Otto
- Division of Infectious Diseases, Department of Pediatrics, The Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104-4399, USA
| | - Abby Green
- Division of Infectious Diseases, Department of Pediatrics, Washington University, 425 S. Euclid Avenue, McDonnell Pediatric Research Building, #5105, St Louis, MO 63106, USA.
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5
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Park KR, Kim YE, Shamim A, Gong S, Choi SH, Kim KK, Kim YJ, Ahn JH. Analysis of Novel Drug-Resistant Human Cytomegalovirus DNA Polymerase Mutations Reveals the Role of a DNA-Binding Loop in Phosphonoformic Acid Resistance. Front Microbiol 2022; 13:771978. [PMID: 35185843 PMCID: PMC8851065 DOI: 10.3389/fmicb.2022.771978] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/13/2022] [Indexed: 12/19/2022] Open
Abstract
The appearance of drug-resistant mutations in UL54 DNA polymerase and UL97 kinase genes is problematic for the treatment of human cytomegalovirus (HCMV) diseases. During treatment of HCMV infection in a pediatric hematopoietic cell transplant recipient, H600L and T700A mutations and E576G mutation were independently found in the UL54 gene. Foscarnet (FOS; phosphonoformic acid) resistance by T700A mutation is reported. Here, we investigated the role of novel mutations in drug resistance by producing recombinant viruses and a model polymerase structure. The H600L mutant virus showed an increase in resistance to ganciclovir (GCV) by 11-fold and to FOS and cidofovir (CDV) by 5-fold, compared to the wild type, while the E756G mutant virus showed an increase in resistance to FOS by 9-fold and modestly to CDV by 2-fold. With the FOS-resistant T700A mutation, only H600L produced increased FOS resistance up to 37-fold, indicating an additive effect of these mutations on FOS resistance. To gain insight into drug resistance mechanisms, a model structure for UL54 polymerase was constructed using the yeast DNA polymerase as a template. In this model, HCMV DNA polymerase contains a long palm loop domain of which H600 and T700 are located on each end and T700 interacts with the FOS binding pocket. Our results demonstrate that H600L and E756G mutations in UL54 polymerase are novel drug-resistant mutations and that the acquisition of both H600L and T700A mutations in the DNA-binding loop confers increased resistance to FOS treatment, providing novel insights for the mechanism acquiring foscarnet resistance.
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Affiliation(s)
- Kye Ryeong Park
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, South Korea
| | - Young-Eui Kim
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, South Korea
| | - Amen Shamim
- Department of Precision Medicine, Institute for Antimicrobial Resistance Research and Therapeutics, Sungkyunkwan University School of Medicine, Suwon, South Korea.,Department of Computer Science, University of Agriculture, Faisalabad, Pakistan
| | - Shuang Gong
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, South Korea
| | - Soo-Han Choi
- Department of Pediatrics, Pusan National University Hospital, Busan, South Korea
| | - Kyeong Kyu Kim
- Department of Precision Medicine, Institute for Antimicrobial Resistance Research and Therapeutics, Sungkyunkwan University School of Medicine, Suwon, South Korea.,Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, South Korea
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Hyun Ahn
- Department of Microbiology, Sungkyunkwan University School of Medicine, Suwon, South Korea.,Samsung Biomedical Research Institute, Samsung Medical Center, Seoul, South Korea
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Yong MK, Shigle TL, Kim YJ, Carpenter PA, Chemaly RF, Papanicolaou GA. American Society for Transplantation and Cellular Therapy Series: #4 - Cytomegalovirus treatment and management of resistant or refractory infections after hematopoietic cell transplantation. Transplant Cell Ther 2021; 27:957-967. [PMID: 34560310 DOI: 10.1016/j.jtct.2021.09.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 11/29/2022]
Abstract
The Practice Guidelines Committee of the American Society of Transplantation and Cellular Therapy (ASTCT) partnered with its Transpl. Infect. Dis. Special Interest Group (TID-SIG) to update its 2009 compendium-style infectious disease guidelines for hematopoietic cell transplantation (HCT). A new approach was employed with the goal of better serving clinical providers by publishing each standalone topic in the infectious diseases series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious diseases and HCT content experts developed and answered FAQs. Topics were finalized with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. The fourth topic in the series focuses on the management and treatment of cytomegalovirus (CMV) resistant and refractory infections. The diagnosis, definitions of resistant and refractory CMV, risk factors, virological genotypes and treatment algorithms are reviewed.
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Affiliation(s)
- Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, 3000, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, 3000, Australia; Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne Victoria, 3050, Australia.
| | - Terri Lynn Shigle
- Division of Pharmacy, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Centre, Seattle, WA, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, & Employee Health, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA
| | - Genovefa A Papanicolaou
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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7
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Hocking L, Ali GC, d’Angelo C, Deshpande A, Stevenson C, Virdee M, Guthrie S. A rapid evidence assessment exploring whether antimicrobial resistance complicates non-infectious health conditions and healthcare services, 2010-20. JAC Antimicrob Resist 2021; 3:dlab171. [PMID: 34806009 PMCID: PMC8599069 DOI: 10.1093/jacamr/dlab171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Antimicrobial resistance (AMR) is one of the greatest public health threats at this time. While there is a good understanding of the impacts of AMR on infectious diseases, an area of less focus is the effects AMR may be having on non-communicable health conditions (such as cancer) and healthcare services (such as surgery). Therefore, this study aimed to explore what impact AMR is currently having on non-communicable health conditions, or areas of health services, where AMR could be a complicating factor impacting on the ability to treat the condition and/or health outcomes. To do this, a rapid evidence assessment of the literature was conducted, involving a systematic approach to searching and reviewing the evidence. In total, 101 studies were reviewed covering surgery, organ transplants, cancer, ICUs, diabetes, paediatric patients, immunodeficiency conditions, liver and kidney disease, and physical trauma. The results showed limited research in this area and studies often use a selective population, making the results difficult to generalize. However, the evidence showed that for all health conditions and healthcare service areas reviewed, at least one study demonstrated a higher risk of death for patients with resistant infections, compared with no or drug-susceptible infections. Poor health outcomes were also associated with resistant infections in some instances, such as severe sepsis and failure of treatments, as well as a greater need for invasive medical support. While there are gaps in the evidence base requiring further research, efforts are also needed within policy and practice to better understand and overcome these challenges.
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Affiliation(s)
- Lucy Hocking
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, UK
- Corresponding author. E-mail:
| | | | | | | | | | - Mann Virdee
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, UK
| | - Susan Guthrie
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, UK
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8
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Jinnouchi F, Mori Y, Yoshimoto G, Yamauchi T, Nunomura T, Yurino A, Hayashi M, Yuda J, Shima T, Odawara J, Takashima S, Kamezaki K, Kato K, Miyamoto T, Akashi K, Takenaka K. Incidence of refractory cytomegalovirus infection after allogeneic hematopoietic stem cell transplantation. Int J Hematol 2021; 115:96-106. [PMID: 34652633 DOI: 10.1007/s12185-021-03218-3] [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: 05/13/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
Post-transplant cytomegalovirus (CMV) disease can be almost completely avoided by current infection control procedures. However, CMV reactivation occurs in more than half of patients, and some patients can develop clinically resistant CMV infections. Whether resistance is due to the host's immune status or a viral resistance mutation is challenging to confirm. Therefore, a prospective observational analysis of refractory CMV infection was conducted in 199 consecutive patients who received allogeneic hematopoietic stem cell transplantation at a single institution. Among them, 143 (72%) patients received anti-CMV drugs due to CMV reactivation, and only 17 (8.5%) exhibited refractory CMV infection. These patients had clinically refractory infection. However, viral genome analysis revealed that only one patient exhibited a mutation associated with the anti-CMV drug resistance. Clinical resistance was mainly correlated with host immune factors, and the incidence of resistance caused by gene mutations was low at the early stage after a transplantation.
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Affiliation(s)
- Fumiaki Jinnouchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Yasuo Mori
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Goichi Yoshimoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Takuji Yamauchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Takuya Nunomura
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Ayano Yurino
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Masayasu Hayashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Junichiro Yuda
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Takahiro Shima
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Jun Odawara
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Shuichiro Takashima
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Kenjiro Kamezaki
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Toshihiro Miyamoto
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, 812-8582, Japan
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Toon, Ehime, 791-0295, Japan.
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Yu U, Wang X, Zhang X, Wang C, Yang C, Zhou X, Li Y, Huang X, Wen J, Wen F, Liu S. Cytomegalovirus Infection and the Implications of Drug-Resistant Mutations in Pediatric Allogeneic Hematopoietic Stem Cell Transplant Recipients: A Retrospective Study from a Tertiary Hospital in China. Infect Dis Ther 2021; 10:1309-1322. [PMID: 33966176 PMCID: PMC8322184 DOI: 10.1007/s40121-021-00452-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Drug-resistant cytomegalovirus (CMV) infection remains a challenge in the management of pediatric recipients of hematopoietic stem cell transplantation (HSCT). In this study, we retrospectively reviewed the clinical data on pediatric recipients of HSCT and identified known and unknown drug-resistant CMV variants. METHODS A total of 221 children underwent allogeneic HSCT between October 2017 and November 2019 at Shenzhen Children's Hospital; of these, 35 patients were suspected of having drug-resistant CMV infections and were tested for drug-resistant mutations in the UL97 and UL54 genes by Sanger sequencing. RESULTS Mutations in UL97 or UL54, or in both, were detected in 11 patients. Most of these mutations have not been previously reported. The UL97 mutation (A582V) was detected in only one patient who also harbored two UL54 mutations (T760X and R876W). One patient with both the G604S and T691A mutations in the UL54 gene died of CMV pneumonia. We investigated the risk factors associated with the development of drug-resistant CMV infection. Patients in whom both the donor and recipient had positive CMV serostatuses were less likely to have drug-resistant mutations (Fisher's exact test, p < 0.05). CONCLUSION Newly and previously detected CMV mutations in UL97 and UL54 may be associated with the development of drug-resistant CMV infection. The detection of these mutations may provide guidance for the management of post-transplant CMV infections.
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Affiliation(s)
- Uet Yu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaodong Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaoling Zhang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Chunjing Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Chunlan Yang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaohui Zhou
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Yue Li
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Xiaochan Huang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Jing Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Feiqiu Wen
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China
| | - Sixi Liu
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Yitian Road No. 7019, Futian, Shenzhen, 518038, China.
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10
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Arcuri LJ, Schirmer M, Colares M, Maradei S, Tavares R, Moreira MCR, Araujo RDC, Lerner D, Pacheco AGF. Impact of Anti-CMV IgG Titers and CD34 Count Prior to Hematopoietic Stem Cell Transplantation from Alternative Donors on CMV reactivation. Biol Blood Marrow Transplant 2020; 26:e275-e279. [DOI: 10.1016/j.bbmt.2020.07.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 01/10/2023]
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11
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Resistant or refractory cytomegalovirus infections after hematopoietic cell transplantation: diagnosis and management. Curr Opin Infect Dis 2020; 32:565-574. [PMID: 31567572 DOI: 10.1097/qco.0000000000000607] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Refractory or resistant cytomegalovirus (CMV) infections are challenging complications after hematopoietic cell transplantation (HCT). Most refractory or resistant CMV infections are associated with poor outcomes and increased mortality. Prompt recognition of resistant or refractory CMV infections, understanding the resistance pathways, and the treatment options in HCT recipients are imperative. RECENT FINDINGS New definitions for refractory and resistant CMV infections in HCT recipients have been introduced for future clinical trials. Interestingly, refractory CMV infections are more commonly encountered in HCT recipients when compared with resistant CMV infections. CMV terminase complex mutations in UL56, UL89, and UL51 could be associated with letermovir resistance; specific mutations in UL56 are the most commonly encountered in clinical practice. Finally, brincidofovir, maribavir, letermovir, and CMV-specific cytotoxic T-cell therapy expanded our treatment options for refractory or resistant CMV infections. SUMMARY Many advances have been made to optimize future clinical trials for management of refractory or resistant CMV infections, and to better understand new resistance mechanisms to novel drugs. New drugs or strategies with limited toxicities are needed to improve outcomes of difficult to treat CMV infections in HCT recipients.
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12
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Kim E, Asmar BI, Thomas R, Abdel-Haq N. Cytomegalovirus viremia and resistance patterns in immunocompromised children: An 11-year experience. Pediatr Hematol Oncol 2020; 37:119-128. [PMID: 31826701 DOI: 10.1080/08880018.2019.1695031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We noted a recent increase in number of immunocompromised children with CMV viremia at our institution. The purpose of this study was to determine the frequency of CMV viremia in this population and evaluate factors associated with drug-resistant mutations. A retrospective review of immunocompromised hosts, 0-21 years of age, who had CMV viremia during 2007-2017. CMV viremia was detected using PCR assays. Genetic mutation assays were performed using PCR sequencing of the phosophotransferase UL 97 gene and the polymerase UL54 gene of CMV using Quest Diagnostics (San Juan Capistrano, CA, USA) or ARUP Labs (Salt Lake City, UT, USA). Thirty-one patients were identified, including 10 (32%) during the last 2 years. Of the 31 patients, 18 had hematopoietic stem cell transplantation (HSCT), 5 had primary immunodeficiency, 4 had malignancies, 3 had heart transplantation and 1 had new Human Immunodeficiency virus (HIV) infection. Antiviral resistance testing was performed on isolates from seven patients: five with persistent viremia (>1 mo), and two prior to starting antiviral therapy. Resistance was identified in three patients' isolates: two with common variable immunodeficiency (CVID) and one with recurrent Hodgkin's lymphoma who had undergone autologous HSCT. The two patients with CVID had chronic diarrhea and malabsorption and had received prolonged oral valganciclovir courses prior to emergence of resistance. The patient with Hodgkin's lymphoma had received a prolonged IV ganciclovir course. All three tested positive for UL97 mutation and two had both UL97 and UL54 gene mutations. Majority of our patients (21/31) with CMV viremia were transplant recipients and ganciclovir resistance developed in 10%. Two had intestinal malabsorption. Treatment with oral valganciclovir should be avoided in patients with poor gut absorption as that may increase the risk of resistance.
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Affiliation(s)
- Edward Kim
- Division of Infectious Diseases, Children's Hospital of Michigan, Detroit, USA
| | - Basim I Asmar
- Division of Infectious Diseases, Children's Hospital of Michigan, Detroit, USA.,Carman and Ann Adams Department of Pediatrics, Wayne State University, Detroit, Michigan, USA
| | - Ronald Thomas
- Carman and Ann Adams Department of Pediatrics, Wayne State University, Detroit, Michigan, USA
| | - Nahed Abdel-Haq
- Division of Infectious Diseases, Children's Hospital of Michigan, Detroit, USA.,Carman and Ann Adams Department of Pediatrics, Wayne State University, Detroit, Michigan, USA
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Global estimate of phenotypic and genotypic ganciclovir resistance in cytomegalovirus infections among HIV and organ transplant patients; A systematic review and meta-analysis. Microb Pathog 2020; 141:104012. [PMID: 32004622 DOI: 10.1016/j.micpath.2020.104012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/21/2022]
Abstract
Human cytomegalovirus (CMV), an opportunistic pathogen belonging to Herpesviridae family, is considered as one of the major causes of morbidity and mortality among wide variety of patients, particularly in transplant recipients and HIV positive patients. As this virus can be resistant to treatment, frequency of CMV in patients who receive organ transplantation and people suffering from AIDS was studied between 1980 and 2019. Medline (via PubMed), Embase, Web of Science, and the Iranian Database were reviewed, and Comprehensive Meta-Analysis (V2.0, Biostat) software analyzed all data. Finally, we used Cochran's Q-statistic to encounter heterogeneity between different studies. Meta-analyses indicated, GCV resistance was 14.1% (95% CI 11.2-17.7); however, in patients suffering from AIDS and organ transplantation were 19.5% (95% CI 14.7-25.4) and 11.4% (95% CI 8.1-15.8), respectively. There were increasing rates in the prevalence of GCV resistance in CMV among transplant recipients, and HIV positive patients. Therefore, evaluation of these refractory infections is beneficial.
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Boonsathorn S, Pasomsub E, Techasaensiri C, Apiwattanakul N. Analysis of Ganciclovir-Resistant Cytomegalovirus Infection Caused by the UL97 Gene Mutation in Codons 460 and 520 in Pediatric Patients: A Case Series. Open Forum Infect Dis 2019; 6:ofz480. [PMID: 32528998 PMCID: PMC7275293 DOI: 10.1093/ofid/ofz480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 10/31/2019] [Indexed: 11/14/2022] Open
Abstract
Background Drug-resistant cytomegalovirus (CMV) infection has been increasingly recognized. However, there are limited data in pediatric patients. In this study, the prevalence and factors associated with CMV infection with UL97 mutations in pediatric patients treated with ganciclovir but not responding to treatment were evaluated. Methods This retrospective study was conducted from January 2013 to December 2017. All patients who were suspected of having ganciclovir-resistant CMV infection and had never had ganciclovir prophylaxis were included. Genotypic assay for UL97 mutations in codons 460 and 520 conferring ganciclovir resistance was performed. Factors associated with the presence of UL97 mutations were analyzed. Results Of 34 patients included, 10 patients (29.4%) had a genotypically confirmed UL97 mutation. The median age (interquartile range [IQR]) was 3 (0.85–8.68) years. Ganciclovir resistance was tested at a median time (IQR) of 22.5 (14.3–31) days after initiation of ganciclovir. All resistant isolates harbored a UL97 mutation in codon 460. Compared with patients infected with CMV without UL97 mutation, those infected with UL97 mutation strains were younger (median age [IQR], 3.02 [0.85–8.68] vs 10.45 [2.7–16.4] years) and had a higher maximum viral load (median [IQR], 5.06 [4.74–6.05] vs 4.42 [4.03–4.87] copies/mL). Six of 10 (60%) patients were successfully treated with high-dose ganciclovir (7.5 mg/kg twice daily). Conclusions UL97 mutation ganciclovir-resistant CMV infection was not uncommon in the pediatric population. Screening for this mutation should be considered in patients experiencing virological worsening while ganciclovir is given, even if patients have not previously received ganciclovir prophylaxis.
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Affiliation(s)
- Sophida Boonsathorn
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ekawat Pasomsub
- Department of Pathology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonnamet Techasaensiri
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Poole CL, James SH. Antiviral Therapies for Herpesviruses: Current Agents and New Directions. Clin Ther 2018; 40:1282-1298. [PMID: 30104016 PMCID: PMC7728158 DOI: 10.1016/j.clinthera.2018.07.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/05/2018] [Accepted: 07/06/2018] [Indexed: 01/07/2023]
Abstract
PURPOSE The objective of this review was to summarize the recent literature describing the current burden of disease due to herpesviruses in the antiviral and transplant era; describe mechanisms of action of antiviral agents and the development of resistance; summarize the literature of recent antiviral agents brought to market as well as agents under development; and to present literature on future strategies for herpesvirus therapeutics. METHODS An extensive search of the medical literature related to antiherpesviral therapy was conducted to compose this narrative review. Literature searches were performed via PubMed and ultimately 137 articles were included as most relevant to the scope of this article. FINDINGS Herpesviruses are a family of DNA viruses that are ubiquitous throughout human populations and share the feature of establishing lifelong infections in a latent phase with the potential of periodic reactivation. With the exception of herpes simplex virus, varicella zoster virus, and Epstein-Barr virus, which have a significant disease burden in individuals with normal immune function, the morbidity and mortality of the remaining viruses are primarily associated with the immunocompromised host. Over the last half-century, several agents have been tested in large randomized, placebo-controlled trials that have resulted in safe and effective antiviral agents for the treatment of many of these infections. IMPLICATIONS With increasing use of antiherpesviral agents for extended periods, particularly in immunocompromised hosts, the emergence of resistant viruses has necessitated the development of newer agents with novel targets and better side-effect profiles.
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Affiliation(s)
- Claudette L Poole
- Division of Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Scott H James
- Division of Infectious Diseases, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
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16
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Kim SJ, Huang YT, Foldi J, Lee YJ, Maloy M, Giralt SA, Jakubowski AA, Papanicolaou GA. Cytomegalovirus resistance in CD34 + -selected hematopoietic cell transplant recipients. Transpl Infect Dis 2018; 20:e12881. [PMID: 29570237 PMCID: PMC5988949 DOI: 10.1111/tid.12881] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/02/2018] [Accepted: 02/18/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) viremia after CD34+ -selected hematopoietic stem cell transplant (HCT) often requires prolonged antiviral therapy. We report rates and outcomes of resistant CMV in a contemporary cohort of CD34+ -selected HCT recipients managed preemptively. METHODS We retrospectively reviewed 220 consecutive, CMV-seropositive recipients (R+), who received CD34+ -selected HCT at Memorial Sloan Kettering Cancer Center between June 2010 and December 2014. Patients were monitored by quantitative CMV PCR and were treated preemptively. CMV resistance was tested by a genotypic assay. RESULTS One hundred and sixty-one (73%) patients developed CMV viremia and 47 (29% of viremic and 21% of total patients) had CMV resistance testing by one-year from HCT. CMV resistance was confirmed in 19 (12% of viremic and 9% of total) patients and was identified >3 months from HCT in 90% of patients. Twelve patients had mutations in UL97 only; the remaining 7 patients had mutations in UL54 only or UL54 and UL97. By 1 year from HCT, 11 of 19 (58%) patients with mutations had CMV end-organ disease. CMV-related mortality in patients with resistance was 42%. CONCLUSIONS Nine percent of CMV R+, CD34+ -selected HCT recipients had resistant CMV by 1 year from HCT. Of 19 patients with resistant CMV, 58% had CMV end-organ disease and 42% died of CMV. Effective strategies for CMV prevention and restoration of CMV immunity are needed for CD34+ -selected HCT.
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Affiliation(s)
- Seong Jin Kim
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julia Foldi
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yeon Joo Lee
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Medical College, Cornell University, New York, NY, USA
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio A Giralt
- Weill Medical College, Cornell University, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ann A Jakubowski
- Weill Medical College, Cornell University, New York, NY, USA
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Medical College, Cornell University, New York, NY, USA
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17
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Frange P, Leruez-Ville M. Maribavir, brincidofovir and letermovir: Efficacy and safety of new antiviral drugs for treating cytomegalovirus infections. Med Mal Infect 2018; 48:495-502. [PMID: 29650261 DOI: 10.1016/j.medmal.2018.03.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 09/22/2017] [Accepted: 03/16/2018] [Indexed: 12/15/2022]
Abstract
Cytomegalovirus (CMV) infection is a common complication in immunocompromised patients, especially after hematopoietic stem cell or solid organ transplantation. Therapeutic antiviral options [(val)ganciclovir, foscarnet, cidofovir] are still limited and can expose to severe toxicities. Moreover, prolonged antiviral drug exposure and ongoing viral replication are key factors in the development of antiviral drug resistance. After many years of few tangible advances in terms of new antiviral drugs, we are now experiencing an exciting period characterized by a series of phase III clinical trials incorporating three novel agents: maribavir, brincidofovir, and letermovir. This article summarizes the current state of the prevention and treatment of CMV infections as well as data of investigational drugs in clinical development.
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Affiliation(s)
- P Frange
- Laboratoire de microbiologie clinique, hôpital Necker-Enfants-Malades, Assistance publique-Hôpitaux de Paris (AP-HP), 149, rue de Sèvres, 75015 Paris, France; Unité d'immunologie, hématologie et rhumatologie pédiatriques, hôpital Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France; EA7327, université Paris Descartes, Sorbonne Paris Cité, 12, rue de l'École-de-Médecine, 75006 Paris, France.
| | - M Leruez-Ville
- Laboratoire de microbiologie clinique, hôpital Necker-Enfants-Malades, Assistance publique-Hôpitaux de Paris (AP-HP), 149, rue de Sèvres, 75015 Paris, France; EA7328, université Paris Descartes, Sorbonne Paris Cité, 12, rue de l'École-de-Médecine, 75006 Paris, France; CNR cytomégalovirus, laboratoire associé, 149, rue de Sèvres, 75015 Paris, France
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18
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Hancer VS, Yarimcan FS, Buyukdogan M, Aki SZ, Oksuz B, Acar K, Acar M, Bulut P. A novel ganciclovir resistance mutation in the UL97 gene of the HHV-5 in an adult hematopoietic stem cell transplant recipient. Future Virol 2017. [DOI: 10.2217/fvl-2017-0085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Therapeutic management of cytomegalovirus (CMV) disease in hematopoietic stem cell transplantation patients can become a challenge because of the emergence of anti-CMV drug resistance. This case report presents a patient with clinical ganciclovir resistance due to a new mutation: histidine-to-asparagine change at residue 393 of UL97. This mutation, which is located in the nonfunctional region of the UL97 gene, is very unusual. Having more information about the mutations leading to drug resistance in CMV is important for both improved clinical management and development of new diagnostic tests and drugs.
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Affiliation(s)
- Veysel Sabri Hancer
- Department of Medical Genetics, Faculty of Medicine, Istinye University, Istanbul
| | - Filiz Saglam Yarimcan
- Department of Medical Microbiology, Faculty of Medicine, Istinye University, Istanbul
| | - Murat Buyukdogan
- Department of Medical Genetics, Faculty of Medicine, Istinye University, Istanbul
| | - Sahika Zeynep Aki
- Division of Hematology, Department of Internal Medicine, Bahcesehir University, Istanbul
| | - Burcu Oksuz
- Istinye University Genetic Diagnosis Center, Istanbul
| | - Kadir Acar
- Division of Hematology, Department of Internal Medicine, Altinbas University, Istanbul
| | - Muradiye Acar
- Istinye University Genetic Diagnosis Center, Istanbul
| | - Pelin Bulut
- Istinye University Genetic Diagnosis Center, Istanbul
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Affiliation(s)
- Margaret L Green
- University of Washington, 1959 NE Pacific Street, Box 359930, Seattle, WA 98195, USA; Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA 98109, USA.
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20
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Chan ST, Logan AC. The clinical impact of cytomegalovirus infection following allogeneic hematopoietic cell transplantation: Why the quest for meaningful prophylaxis still matters. Blood Rev 2017; 31:173-183. [DOI: 10.1016/j.blre.2017.01.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 12/16/2016] [Accepted: 01/31/2017] [Indexed: 11/28/2022]
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Campos AB, Ribeiro J, Pinho Vaz C, Campilho F, Branca R, Campos A, Baldaque I, Medeiros R, Boutolleau D, Sousa H. Genotypic resistance of cytomegalovirus to antivirals in hematopoietic stem cell transplant recipients from Portugal: A retrospective study. Antiviral Res 2017; 138:86-92. [DOI: 10.1016/j.antiviral.2016.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/24/2016] [Indexed: 01/22/2023]
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22
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How I treat resistant cytomegalovirus infection in hematopoietic cell transplantation recipients. Blood 2016; 128:2624-2636. [PMID: 27760756 DOI: 10.1182/blood-2016-06-688432] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/17/2016] [Indexed: 12/20/2022] Open
Abstract
Cytomegalovirus (CMV) infection is a significant complication in hematopoietic cell transplantation (HCT) recipients. Four antiviral drugs are used for preventing or treating CMV: ganciclovir, valganciclovir, foscarnet, and cidofovir. With prolonged and repeated use of these drugs, CMV can become resistant to standard therapy, resulting in increased morbidity and mortality, especially in HCT recipients. Antiviral drug resistance should be suspected when CMV viremia (DNAemia or antigenemia) fails to improve or continue to increase after 2 weeks of appropriately dosed and delivered antiviral therapy. CMV resistance is diagnosed by detecting specific genetic mutations. UL97 mutations confer resistance to ganciclovir and valganciclovir, and a UL54 mutation confers multidrug resistance. Risk factors for resistance include prolonged or previous anti-CMV drug exposure or inadequate dosing, absorption, or bioavailability. Host risk factors include type of HCT and degree of immunosuppression. Depending on the genotyping results, multiple strategies can be adopted to treat resistant CMV infections, albeit no randomized clinical trials exist so far, after reducing immunosuppression (if possible): ganciclovir dose escalation, ganciclovir and foscarnet combination, and adjunct therapy such as CMV-specific cytotoxic T-lymphocyte infusions. Novel therapies such as maribavir, brincidofovir, and letermovir should be further studied for treatment of resistant CMV.
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Bauters T, Bordon V, Florin L, Padalko E, Andrei G, Gillemot S, Fiten P, Opdenakker G, Snoeck R, Laureys G. Multidrug-resistant cytomegalovirus infection in a pediatric stem cell transplantation patient. Antiviral Res 2016; 132:149-53. [DOI: 10.1016/j.antiviral.2016.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 05/12/2016] [Accepted: 05/26/2016] [Indexed: 11/16/2022]
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Abstract
PURPOSE OF REVIEW The purpose of this study is to provide updated information on diagnosis of cytomegalovirus (CMV) drug resistance, treatments for drug-resistant infection and potential uses of experimental antiviral compounds. RECENT FINDINGS For established CMV antivirals, uncommon viral UL97 kinase and UL54 DNA polymerase drug resistance mutations are sporadically described that expand an extensive existing database. Some novel mutations reported from treated patients have no drug-resistant phenotype and may be genotyping artefacts. Next-generation sequencing technology may enable earlier detection of emerging resistance mutations in treated patients. Management options for drug-resistant infection include optimization of host defenses, antiviral dose escalation, substitutions or combinations of standard or experimental antivirals. Maribavir and letermovir have antiviral targets distinct from the classic DNA polymerase. UL97 mutations elicited by ganciclovir and maribavir are different, although a single p-loop mutation can confer significant cross-resistance. High-grade resistance mutations in the UL56 terminase gene are readily selected in vitro under letermovir and await clinical correlation. SUMMARY Technical advancements can enhance the accurate and timely genotypic detection of drug resistance. Antivirals undergoing clinical trial offer the prospect of new viral targets and drug combinations, but unresolved issues exist with regard to their therapeutic potential for drug-resistant CMV and their genetic barriers to resistance.
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Abstract
PURPOSE OF REVIEW The purpose of this study is to explore the latest developments in the risk factors, prevention and treatment of cytomegalovirus (CMV) infection in immunocompromised children, including those with congenital immunodeficiency or iatrogenic immune suppression related to solid organ transplantation (SOT) or haematopoietic cell transplantation (HCT). RECENT FINDINGS CMV viral load measurements now have international standards, allowing for more reliable comparison across sites and within individuals. Preemptive and prophylactic therapy with routine CMV monitoring in transplant patients has yielded significant reduction in CMV morbidity and mortality in these patients. The majority of U.S. states have adopted routine newborn screening for severe combined immunodeficiency (SCID). Viral infections, including CMV, are a major obstacle preventing optimal curative transplantation in these patients. Several new antiviral agents are currently being investigated for CMV infection in immunocompromised patients. Knowledge on CMV drug resistance in children is emerging and requires further study. SUMMARY Conditions that diminish cell-mediated immunity impact the development of CMV infection and disease. These conditions include certain congenital immunodeficiencies and SOT and HCT. Infants identified as having SCID should be screened for CMV risk factors. A preemptive or prophylactic strategy should be chosen for CMV management in children who are high risk posttransplantation. In those who develop disease, viral loads should be monitored and resistance testing considered if response is not deemed adequate. Oral valganciclovir is being used as an alternative to ganciclovir in children, although pharmacokinetic data are limited. Other oral antiviral agents under development are promising future options for paediatric CMV therapy.
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Campos AB, Ribeiro J, Boutolleau D, Sousa H. Human cytomegalovirus antiviral drug resistance in hematopoietic stem cell transplantation: current state of the art. Rev Med Virol 2016; 26:161-82. [DOI: 10.1002/rmv.1873] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/09/2016] [Accepted: 02/01/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Ana Bela Campos
- Molecular Oncology and Viral Pathology Group (CI-IPOP); Porto Portugal
- Faculty of Medicine; University of Porto; Porto Portugal
| | - Joana Ribeiro
- Molecular Oncology and Viral Pathology Group (CI-IPOP); Porto Portugal
- Virology Service; Portuguese Oncology Institute of Porto; Porto Portugal
- Faculty of Medicine; University of Porto; Porto Portugal
| | - David Boutolleau
- Sorbonne Universités; UPMC Université Paris 06, CR7, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris); Paris France
- INSERM, U1135, CIMI-Paris; Paris France
- AP-HP, Hôpitaux Universitaires La Pitié-Salpêtrière - Charles Foix; Service de Virologie; Paris France
| | - Hugo Sousa
- Molecular Oncology and Viral Pathology Group (CI-IPOP); Porto Portugal
- Virology Service; Portuguese Oncology Institute of Porto; Porto Portugal
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Patients with refractory cytomegalovirus (CMV) infection following allogeneic haematopoietic stem cell transplantation are at high risk for CMV disease and non-relapse mortality. Clin Microbiol Infect 2015; 21:1121.e9-15. [DOI: 10.1016/j.cmi.2015.06.009] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 05/10/2015] [Accepted: 06/08/2015] [Indexed: 11/23/2022]
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28
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Seol CA, Ko YJ, Kim SH, Kim MN, Sung H, Lee JH. The First Case of Ganciclovir-Resistant Cytomegalovirus Colitis with a 597-600 Deletion in UL97Gene after Stem Cell Transplantation in Korea. ANNALS OF CLINICAL MICROBIOLOGY 2015. [DOI: 10.5145/acm.2015.18.2.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Chang Ahn Seol
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Koera
| | - Young Jin Ko
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Koera
| | - Sung-Han Kim
- Department of Internal Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Koera
| | - Mi-Na Kim
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Koera
| | - Heungsup Sung
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Koera
| | - Je-Hwan Lee
- Department of Internal Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Koera
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