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Leong E, Cifuentes-González C, Hu Y W J, Perumal Samy R, Khairallah M, Rojas-Carabali W, Putera I, de-la-Torre A, Agrawal R. Clinical Insights: Antimicrobial Therapy for Infectious Uveitis. Ocul Immunol Inflamm 2024:1-21. [PMID: 38759216 DOI: 10.1080/09273948.2024.2345848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 04/16/2024] [Indexed: 05/19/2024]
Abstract
Infectious uveitis is a major global cause of vision impairment. Despite the eye's immune privilege, afforded by the blood-ocular barrier that restricts microbial entry, several pathogens such as bacteria, viruses, fungi, and parasites can still infiltrate and cause ocular infections and complications. Clinicians often encounter significant challenges in treating infectious uveitis due to limited or ineffective treatment options. Modern molecular techniques and imaging can aid in diagnosing and assessing intraocular infections. Various antimicrobial therapies exist, spanning topical and systemic treatments, but these are constrained by issues like drug concentration, penetration, effective duration, toxicity, and side effects. Treatment approaches also differ based on the infection's etiology. This review provides recent updates on antimicrobial therapies from a clinical perspective, covering topical, systemic, and regional treatments for infectious uveitis.
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Affiliation(s)
- Evangeline Leong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Carlos Cifuentes-González
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
- Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jeremy Hu Y W
- Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Ramar Perumal Samy
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Ocular Infections and Antimicrobial Group, Singapore Eye Research Institute, Singapore, Singapore
| | - Moncef Khairallah
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - William Rojas-Carabali
- Neuroscience Research Group (NEUROS), Neurovitae Center for Neuroscience, Institute of Translational Medicine (IMT), Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
- Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Ikhwanuliman Putera
- Department of Ophthalmology, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Kirana Eye Hospital, Jakarta, Indonesia
- Department of Immunology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Alejandra de-la-Torre
- Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore
- Ocular Infections and Antimicrobial Group, Singapore Eye Research Institute, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Duke NUS Medical School, Singapore, Singapore
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Vernooij RW, Michael M, Ladhani M, Webster AC, Strippoli GF, Craig JC, Hodson EM. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2024; 5:CD003774. [PMID: 38700045 PMCID: PMC11066972 DOI: 10.1002/14651858.cd003774.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND The risk of cytomegalovirus (CMV) infection in solid organ transplant recipients has resulted in the frequent use of prophylaxis to prevent the clinical syndrome associated with CMV infection. This is an update of a review first published in 2005 and updated in 2008 and 2013. OBJECTIVES To determine the benefits and harms of antiviral medications to prevent CMV disease and all-cause death in solid organ transplant recipients. SEARCH METHODS We contacted the information specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 5 February 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing antiviral medications with placebo or no treatment, comparing different antiviral medications or different regimens of the same antiviral medications for CMV prophylaxis in recipients of any solid organ transplant. Studies examining pre-emptive therapy for CMV infection are studied in a separate review and were excluded from this review. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility, risk of bias and extracted data. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS This 2024 update found four new studies, bringing the total number of included studies to 41 (5054 participants). The risk of bias was high or unclear across most studies, with a low risk of bias for sequence generation (12), allocation concealment (12), blinding (11) and selective outcome reporting (9) in fewer studies. There is high-certainty evidence that prophylaxis with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment is more effective in preventing CMV disease (19 studies: RR 0.42, 95% CI 0.34 to 0.52), all-cause death (17 studies: RR 0.63, 95% CI 0.43 to 0.92), and CMV infection (17 studies: RR 0.61, 95% CI 0.48 to 0.77). There is moderate-certainty evidence that prophylaxis probably reduces death from CMV disease (7 studies: RR 0.26, 95% CI 0.08 to 0.78). Prophylaxis reduces the risk of herpes simplex and herpes zoster disease, bacterial and protozoal infections but probably makes little to no difference to fungal infection, acute rejection or graft loss. No apparent differences in adverse events with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment were found. There is high certainty evidence that ganciclovir, when compared with aciclovir, is more effective in preventing CMV disease (7 studies: RR 0.37, 95% CI 0.23 to 0.60). There may be little to no difference in any outcome between valganciclovir and IV ganciclovir compared with oral ganciclovir (low certainty evidence). The efficacy and adverse effects of valganciclovir or ganciclovir were probably no different to valaciclovir in three studies (moderate certainty evidence). There is moderate certainty evidence that extended duration prophylaxis probably reduces the risk of CMV disease compared with three months of therapy (2 studies: RR 0.20, 95% CI 0.12 to 0.35), with probably little to no difference in rates of adverse events. Low certainty evidence suggests that 450 mg/day valganciclovir compared with 900 mg/day valganciclovir results in little to no difference in all-cause death, CMV infection, acute rejection, and graft loss (no information on adverse events). Maribavir may increase CMV infection compared with ganciclovir (1 study: RR 1.34, 95% CI: 1.10 to 1.65; moderate certainty evidence); however, little to no difference between the two treatments were found for CMV disease, all-cause death, acute rejection, and adverse events at six months (low certainty evidence). AUTHORS' CONCLUSIONS Prophylaxis with antiviral medications reduces CMV disease and CMV-associated death, compared with placebo or no treatment, in solid organ transplant recipients. These data support the continued routine use of antiviral prophylaxis in CMV-positive recipients and CMV-negative recipients of CMV-positive organ transplants.
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Affiliation(s)
- Robin Wm Vernooij
- Department of Nephrology and Hypertension and Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Maleeka Ladhani
- Nephrology, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - Angela C Webster
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Westmead Applied Research Centre, The University of Sydney at Westmead, Westmead, Australia
- Centre for Transplant and Renal Medicine, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elisabeth M Hodson
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Ruenroengbun N, Sapankaew T, Chaiyakittisopon K, Phoompoung P, Ngamprasertchai T. Efficacy and Safety of Antiviral Agents in Preventing Allograft Rejection Following CMV Prophylaxis in High-Risk Kidney Transplantation: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Front Cell Infect Microbiol 2022; 12:865735. [PMID: 35433502 PMCID: PMC9010655 DOI: 10.3389/fcimb.2022.865735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/07/2022] [Indexed: 11/15/2022] Open
Abstract
Many antiviral agents have been studied in clinical trials for allograft rejection prevention following cytomegalovirus (CMV) prophylaxis in high-risk kidney transplant patients. However, data on the most effective and safest treatment are lacking. We conducted a systematic review and network meta-analysis to rank CMV prophylaxis agents for allograft rejection prevention following CMV prophylaxis in high-risk kidney transplant patients according to their efficacy and safety. We conducted searches on the MEDLINE, Embase, SCOPUS, and CENTRAL databases, as well as the reference lists of selected studies up to December 2021, for published and peer-reviewed randomized controlled trials assessing the efficacy of CMV prophylaxis agents in high-risk kidney transplant patients. Thirteen studies were independently selected by three reviewers and included post-kidney transplant patients indicated for CMV prophylaxis who had been randomized to receive prophylactic antiviral agents or standard of care. The reviewers independently extracted data from the included studies, and direct and network meta-analyses were applied to assess the study outcomes. The probability of efficacy and safety was evaluated, and the drugs were assigned a numerical ranking. We evaluated the risk of bias using the Cochrane Risk of Bias 2.0 tool. The primary outcome was an incidence of biopsy-proven acute rejection, whereas the secondary outcome was a composite of major adverse drug reactions. Each outcome referred to the definition provided in the original studies. Valganciclovir, valacyclovir, and ganciclovir were identified to significantly decrease the incidence of biopsy-proven acute rejection with pooled risk differences (RDs) of −20.53% (95% confidence interval [CI] = −36.09% to −4.98%), −19.3% (95% CI = −32.7% to −5.93%), and −10.4% (95% CI = −19.7% to −0.12%), respectively. The overall major adverse drug reaction was 5.7% without a significant difference when compared with placebo. Valganciclovir had the best combined efficacy and safety among the examined antiviral agents and was the most effective and safest antiviral agent overall for allograft rejection prevention following CMV prophylaxis. Valacyclovir was the optimal alternative antiviral agent for patients who were unable to tolerate intravenous ganciclovir or access oral valganciclovir as financial problem. However, compliance and dose-related toxicities should be closely monitored.
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Affiliation(s)
- Narisa Ruenroengbun
- Department of Pharmaceutics (Clinical Pharmacy), Faculty of Pharmacy, Slipakorn University, Nakornprathom, Thailand
| | - Tunlanut Sapankaew
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Kamolpat Chaiyakittisopon
- Department of Community Pharmacy and Administrations, Faculty of Pharmacy, Slipakorn University, Nakornprathom, Thailand
| | - Pakpoom Phoompoung
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thundon Ngamprasertchai
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Ruenroengbun N, Numthavaj P, Sapankaew T, Chaiyakittisopon K, Ingsathit A, Mckay GJ, Attia J, Thakkinstian A. Efficacy and safety of conventional antiviral agents in preventive strategies for cytomegalovirus infection after kidney transplantation: a systematic review and network meta-analysis. Transpl Int 2021; 34:2720-2734. [PMID: 34580930 PMCID: PMC9298054 DOI: 10.1111/tri.14122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/27/2021] [Accepted: 09/03/2021] [Indexed: 02/03/2023]
Abstract
Cytomegalovirus (CMV) infection is common in kidney transplantation (KT). Antiviral-agents are used as universal prophylaxis. Our purpose aimed to compare and rank efficacy and safety. MEDLINE, Embase, SCOPUS, and CENTRAL were used from inception to September 2020 regardless language restriction. We included randomized clinical trials (RCTs) comparing the CMV infection/disease prophylaxis among antiviral-agents in adult KT recipients. Of 24 eligible RCTs, prophylactic valganciclovir (VGC) could significantly lower the overall CMV infection and disease risks than placebo with pooled risk differences (RDs) [95% confidence interval (CI)] of -0.36 (-0.54, -0.18) and -0.28 (-0.48, -0.08), respectively. Valacyclovir (VAC) and ganciclovir (GC) significantly decreased risks with the corresponding RDs of -0.25 (-0.32, -0.19) and -0.30 (-0.37, -0.22) for CMV infection and -0.26 (-0.40, -0.12) and -0.22 (-0.31, -0.12) for CMV disease. For subgroup analysis by seropositive-donor and seronegative-recipient (D+/R-), VGC and GC significantly lowered the risk of CMV infection/disease with RDs of -0.42 (-0.84, -0.01) and -0.35 (-0.60, -0.12). For pre-emptive strategies, GC lowered the incidence of CMV disease significantly with pooled RDs of -0.33 (-0.47, -0.19). VGC may be the best in prophylaxis of CMV infection/disease follow by GC. VAC might be an alternative where VGC and GC are not available.
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Affiliation(s)
- Narisa Ruenroengbun
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Pharmaceutics, Clinical Pharmacy, Slipakorn University, Nakorn Prathom, Thailand
| | - Pawin Numthavaj
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tunlanut Sapankaew
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kamolpat Chaiyakittisopon
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Department of Community Pharmacy and Administrations, Faculty of Pharmacy, Slipakorn University, Nakorn Prathom, Thailand
| | - Atiporn Ingsathit
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Gareth J Mckay
- School of Medicine, Dentistry and Biomedical Sciences, Center for Public Health, Queen's University Belfast, Belfast, UK
| | - John Attia
- School of Medicine and Public Health, Centre for Clinical Epidemiology and Biostatistics, Hunter Medical Research Institute, University of Newcastle, New Lambton, NSW, Australia
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Ko EJ, Yu JH, Yang CW, Chung BH. Usefulness of valacyclovir prophylaxis for cytomegalovirus infection after anti-thymocyte globulin as rejection therapy. Korean J Intern Med 2019; 34:375-382. [PMID: 29237252 PMCID: PMC6406088 DOI: 10.3904/kjim.2017.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/15/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND/AIMS Anti-thymocyte globulin (ATG) treatment for acute T-cell mediated rejection (TCMR) can increase the risk of cytomegalovirus (CMV) infection. We aimed to evaluate the effect of valacyclovir prophylaxis against CMV infection after ATG administration as anti-rejection therapy. METHODS We retrospectively analyzed 55 kidney transplant recipients (KTRs) receiving ATG for steroid resistant TCMR. In all KTRs, we used intravenous ganciclovir during ATG injection. In 34 KTRs treated before July 2013, we performed preemptive therapy for CMV infection after ATG therapy. They were regarded as the historic control group (CONT). After July 2013, we used valacyclovir maintenance for 1 month after ATG therapy in 21 patients (VAL). The primary outcome was the incidence of CMV infection, and the secondary outcomes were subsequent acute rejection, and graft and patient outcome. RESULTS Valacyclovir prophylaxis significantly reduced the incidence of CMV infection (VAL, 9.6% vs. CONT, 67.6%; p < 0.001), and CMV-free survival rate was higher in the VAL group compared to the CONT group (p = 0.009). In the VAL group, two cases of CMV infection were limited to CMV viremia, but CMV disease or syndrome (n = 3) was detected in the CONT group. There was no difference in graft failure (CONT, 70.5% vs. VAL, 47.6%; p = 0.152), incidence of subsequent rejection after ATG treatment (CONT, 41.1% vs. VAL, 33.3%; p = 0.776), and graft or patient survival between the two groups. There were no major adverse events associated with valacyclovir prophylaxis. CONCLUSION In conclusion, valacyclovir prophylaxis is effective in the prevention of CMV infection after ATG treatment for steroid resistant TCMR.
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Affiliation(s)
- Eun Jeong Ko
- Transplant Research Center and Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Ji Hyun Yu
- Transplant Research Center and Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chul Woo Yang
- Transplant Research Center and Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Byung Ha Chung
- Transplant Research Center and Division of Nephrology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Byung Ha Chung, M.D. Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6066 Fax: +82-2-536-3589 E-mail:
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Celebi ZK, Calayoglu R, Yalcı AK, Akturk S, Sengul S, Kutlay S, Nergizoglu G, Erturk S, Duman N, Ates K, Keven K. Cytomegalovirus disease in patients with glomerular diseases treated by immunosuppressive treatment. Int Urol Nephrol 2014; 46:2357-60. [PMID: 25260403 DOI: 10.1007/s11255-014-0849-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 09/18/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Cytomegalovirus (CMV) infection is an important complication in organ and bone marrow recipients as well as patients infected with HIV. Although screening and prophylaxis have been defined in these patients, there are few data about the frequency of CMV disease in glomerular diseases treated by immunosuppression. METHODS We recruited 133 patients with glomerular diseases treated by immunosuppression between 2006 and 2013. Patients who had any symptoms suggestive of CMV disease were screened for viral DNA. Immunosuppressive treatments were as follows: Group 1, steroid only; Group 2, steroid with cyclophosphamide (CP); Group 3, steroid with cyclosporine A; and Group 4, steroid with mycophenolate mofetil or azathioprine. RESULTS Patients developing CMV and non-CMV disease were compared for age, sex, renal pathology, hypertension, diabetes, baseline creatinine, and estimated glomerular filtration rate, and immunosuppressive regimen. At follow-up, 55 patients were tested for CMV disease during immunosuppressive treatment. Twenty-six patients had CMV DNA positivity of 1,112-205,500 copies/mL. Patients with CMV disease were all seen within the first 5 months of immunosuppressive treatment, and the disease was observed most commonly (14 patients, 53 %) in the first 2 months of treatment. Multiple regression analysis revealed that high baseline creatinine levels, older age, and use of steroids with CP were independent risk factors for development of CMV disease. CONCLUSIONS CMV disease is not an uncommon complication in patients with glomerular diseases treated by immunosuppression. Further prospective studies and prophylaxis should be addressed in future studies, including particular groups of patients.
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Affiliation(s)
- Zeynep Kendi Celebi
- Nephrology Department, Ankara University School of Medicine, Ibni Sina Hospital 14th Floor, Samanpazari/Altindag, 06100, Ankara, Turkey,
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Reischig T, Kacer M. The efficacy and cost-effectiveness of valacyclovir in cytomegalovirus prevention in solid organ transplantation. Expert Rev Pharmacoecon Outcomes Res 2014; 14:771-9. [PMID: 25252996 DOI: 10.1586/14737167.2014.965157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Prevention of cytomegalovirus infection using antiviral prophylaxis or the pre-emptive therapy approach is an integral part of management of patients after solid organ transplantation. Regarding renal transplantation, valacyclovir is currently the only antiviral agent recommended for prophylaxis as an alternative to valganciclovir. This review article discusses studies documenting the efficacy and safety of valacyclovir prophylaxis as well as those comparing valacyclovir with other prophylactic regimens or with pre-emptive therapy. Also addressed are the economic aspects supporting the cost-effectiveness of valacyclovir prophylaxis and demonstrating lower costs compared with other cytomegalovirus preventive strategies.
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Affiliation(s)
- Tomas Reischig
- Department of Internal Medicine I, Charles University Medical School and Teaching Hospital, Alej Svobody 80, 304 60 Pilsen, Czech Republic
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Reischig T. Cytomegalovirus-associated renal allograft rejection: new challenges for antiviral preventive strategies. Expert Rev Anti Infect Ther 2014; 8:903-10. [DOI: 10.1586/eri.10.63] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Owers DS, Webster AC, Strippoli GFM, Kable K, Hodson EM. Pre-emptive treatment for cytomegalovirus viraemia to prevent cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2013; 2013:CD005133. [PMID: 23450558 PMCID: PMC6823220 DOI: 10.1002/14651858.cd005133.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) is a significant cause of morbidity and mortality in solid organ transplant recipients. Pre-emptive treatment of patients with CMV viraemia using antiviral agents has been suggested as an alternative to routine prophylaxis to prevent CMV disease. This is an update of a Cochrane review first published in 2005. OBJECTIVES This review was conducted to evaluate the efficacy of pre-emptive treatment with antiviral medications in preventing symptomatic CMV disease. SEARCH METHODS For this update, we searched the Cochrane Renal Group's Specialised Register (to 16 January 2013) through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA We included randomised controlled trials (RCTs) of pre-emptive treatment compared with placebo, no specific treatment or with antiviral prophylaxis in solid organ transplant recipients. DATA COLLECTION AND ANALYSIS Four authors assessed the quality and extracted all data. Analyses used a random-effects model and results were expressed as risk ratio (RR) and 95% confidence intervals (CI). MAIN RESULTS We identified 15 eligible studies (1098 participants). Of these, six investigated pre-emptive treatment versus placebo or treatment of CMV when disease occurred (standard care), eight looked at pre-emptive treatment versus antiviral prophylaxis, and one reported on oral versus intravenous pre-emptive treatment.Assessment of risk of bias identified that the processes reported for sequence generation and allocation concealment were at low risk of bias in only five and three studies, respectively. All studies were considered to be at low risk of attrition bias, and seven studies were considered to be at low risk of bias for selective reporting. Only one study reported adequate blinding of participants and personnel; no study reported blinding of outcome assessment.Compared with placebo or standard care, pre-emptive treatment significantly reduced the risk of CMV disease (6 studies, 288 participants: RR 0.29, 95% CI 0.11 to 0.80) but not acute rejection (3 studies, 185 participants: RR 1.21, 95% CI 0.69 to 2.12) or all-cause mortality (3 studies, 176 participants: RR 1.23, 95% CI 0.35 to 4.30). Comparative studies of pre-emptive therapy versus prophylaxis showed no significant differences in preventing CMV disease between pre-emptive and prophylactic therapy (7 studies, 753 participants: RR 1.00, 95% CI 0.36 to 2.74) but there was significant heterogeneity (I² = 63%). Leucopenia was significantly less common with pre-emptive therapy compared with prophylaxis (6 studies, 729 participants: RR 0.42, 95% CI 0.20 to 0.90). Other adverse effects did not differ significantly or were not reported. There were no significant differences in the risks of all-cause mortality, graft loss, acute rejection and infections other than CMV. AUTHORS' CONCLUSIONS Few RCTs have evaluated the effects of pre-emptive therapy to prevent CMV disease. Pre-emptive therapy is effective compared with placebo or standard care. Despite the inclusion of five additional studies in this update, the efficacy of pre-emptive therapy compared with prophylaxis to prevent CMV disease remains unclear due to significant heterogeneity between studies. Additional head-to-head studies are required to determine the relative benefits and harms of pre-emptive therapy and prophylaxis to prevent CMV disease in solid organ transplant recipients.
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Affiliation(s)
- Daniel S Owers
- Australian National UniversityAustralian National University Medical SchoolCanberraAustralia0200
| | | | | | - Kathy Kable
- Westmead HospitalDepartment of Renal Medicine and TransplantationDarcy RdWestmeadAustralia2145
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Hodson EM, Ladhani M, Webster AC, Strippoli GFM, Craig JC. Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients. Cochrane Database Syst Rev 2013:CD003774. [PMID: 23450543 DOI: 10.1002/14651858.cd003774.pub4] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The risk of cytomegalovirus (CMV) infection in solid organ transplant recipients has resulted in the frequent use of prophylaxis with the aim of preventing the clinical syndrome associated with CMV infection. This is an update of a review first published in 2005 and updated in 2008. OBJECTIVES To determine the benefits and harms of antiviral medications to prevent CMV disease and all-cause mortality in solid organ transplant recipients. SEARCH METHODS We searched MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials (CENTRAL) in The Cochrane Library to February 2004 for the first version of this review. The Cochrane Renal Group's specialised register was searched to February 2007 and to July 2011 for the first and current updates of the review without language restriction. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing antiviral medications with placebo or no treatment, comparing different antiviral medications and comparing different regimens of the same antiviral medications in recipients of any solid organ transplant. Studies examining pre-emptive therapy were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility, risk of bias and extracted data. Results were reported as risk ratios (RR) or risk differences (RD) with 95% confidence intervals (CI) for dichotomous outcomes and by mean difference (MD) with 95% CI for continuous outcomes. Statistical analyses were performed using the random-effects model. Subgroup analysis and univariate meta-regression were performed using restricted maximum-likelihood to estimate the between study variance. Multivariate meta-regression was performed to investigate whether the results were altered after allowing for differences in drugs used, organ transplanted, and recipient CMV serostatus at the time of transplantation. MAIN RESULTS We identified 37 studies (4342 participants). Risk of bias attributes were poorly performed or reported with low risk of bias reported for sequence generation, allocation concealment, blinding and selective outcome reporting in 25% or fewer studies.Prophylaxis with aciclovir, ganciclovir or valaciclovir compared with placebo or no treatment significantly reduced the risk for CMV disease (19 studies; RR 0.42, 95% CI 0.34 to 0.52), CMV infection (17 studies; RR 0.61, 95% CI 0.48 to 0.77), and all-cause mortality (17 studies; RR 0.63, 95% CI 0.43 to 0.92) primarily due to reduced mortality from CMV disease (7 studies; RR 0.26, 95% CI 0.08 to 0.78). Prophylaxis reduced the risk of herpes simplex and herpes zoster disease, bacterial and protozoal infections but not fungal infection, acute rejection or graft loss.Meta-regression showed no significant difference in the relative benefit of treatment (risk of CMV disease or all-cause mortality) by organ transplanted or CMV serostatus; no conclusions were possible for CMV negative recipients of negative organs.Neurological dysfunction was more common with ganciclovir and valaciclovir compared with placebo/no treatment. In direct comparison studies, ganciclovir was more effective than aciclovir in preventing CMV disease (7 studies; RR 0.37, 95% CI 0.23 to 0.60) and leucopenia was more common with aciclovir. Valganciclovir and IV ganciclovir were as effective as oral ganciclovir. The efficacy and adverse effects of valganciclovir/ganciclovir did not differ from valaciclovir in three small studies. Extended duration prophylaxis significantly reduced the risk of CMV disease compared with three months therapy (2 studies; RR 0.20, 95% CI 0.12 to 0.35). Leucopenia was more common with extended duration prophylaxis but severe treatment associated adverse effects did not differ between extended and three month durations of treatment. AUTHORS' CONCLUSIONS Prophylaxis with antiviral medications reduces CMV disease and CMV-associated mortality in solid organ transplant recipients. These data suggest that antiviral prophylaxis should be used routinely in CMV positive recipients and in CMV negative recipients of CMV positive organ transplants.
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Affiliation(s)
- Elisabeth M Hodson
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia.
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Clinical outcome with low-dose valacyclovir in high-risk renal transplant recipients: a 10-year experience. Nephrol Dial Transplant 2012; 28:758-65. [DOI: 10.1093/ndt/gfs531] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Zheng C, Nikolov NP, Alevizos I, Cotrim AP, Liu S, McCullagh L, Chiorini JA, Illei GG, Baum BJ. Transient detection of E1-containing adenovirus in saliva after the delivery of a first-generation adenoviral vector to human parotid gland. J Gene Med 2010; 12:3-10. [PMID: 19941317 DOI: 10.1002/jgm.1416] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Radiation-induced salivary hypofunction is a common side-effect of treatment for head and neck cancers. Patients suffer significant morbidity and there is no suitable conventional therapy. We are conducting a Phase I clinical trial, using a first-generation serotype 5 adenoviral (Ad5) vector encoding human aquaporin-1 (AdhAQP1) to treat such patients. One week after the administration of AdhAQP1 to an enrolled, generally healthy patient, E1-containing adenovirus was detected in parotid saliva. METHODS The real-time quantitative polymerase chain reaction (PCR) was used to measure the Ad5 E1 gene and AdhAQP1 in saliva and serum. PCR and sequencing were used to characterize viral/vector DNA extracted from saliva. The presence of infectious adenovirus was assessed by the inoculation of A549 cells with aliquots of saliva. Serum Ad5 neutralizing antibodies were measured by the inhibition of 293-cell transduction with an Ad5 vector encoding luciferase. Multiple clinical evaluations were performed. RESULTS On day 7 after AdhAQP1 delivery, low levels of the Ad5 E1 gene were detected in parotid saliva (82 copies/microl). In addition, significant levels of AdhAQP1 were also detected (1.5 x 10(3) copies/microl). The patient was asymptomatic and subsequent analysis of parotid saliva samples prior to day 7 and after day 7 until day 42 was negative for both virus and vector. No virus or vector was detected in serum at any time. Detailed PCR analyses of DNA extracted from the day 7 parotid saliva sample suggested the absence of a recombination event, and no infectious virus was found. CONCLUSIONS The patient most likely had a latent Ad5 infection in the targeted parotid gland that was activated after gene transfer and was without clinical consequence.
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Affiliation(s)
- Changyu Zheng
- Molecular Physiology and Therapeutics Branch, National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892-1190, USA
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Wong SSY, Yuen KY. Antiviral therapy for respiratory tract infections. Respirology 2008; 13:950-71. [PMID: 18922142 PMCID: PMC7192202 DOI: 10.1111/j.1440-1843.2008.01404.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 07/10/2008] [Accepted: 08/04/2008] [Indexed: 12/24/2022]
Abstract
Viruses are important pathogens causing respiratory tract infections both in the community and health-care facility settings. They are extremely common causes of morbidity in the competent hosts and some are associated with significant mortality in the compromised individuals. With wider application of molecular techniques, novel viruses are being described and old viruses are found to have new significance in different epidemiological and clinical settings. Some of these emerging pathogens may have the potential to cause pandemics or global spread of a severe disease, as exemplified by severe acute respiratory syndrome and avian influenza. Antiviral therapy of viral respiratory infections is often unnecessary in the competent hosts because most of them are selflimiting and effective agents are not always available. In the immunocompromised individuals or for infections caused by highly pathogenic viruses, such as avian influenza viruses (AIV), antiviral treatment is highly desirable, despite the fact that many of the agents may not have undergone stringent clinical trials. In immunocompetent hosts, antiviral therapy can be stopped early because adaptive immune response can usually be mounted within 5-14 days. However, the duration of antiviral therapy in immunosuppressed hosts depends on clinical and radiological resolution, the degree and duration of immunosuppression, and therefore maintenance therapy is sometimes needed after the initial response. Immunotherapy and immunoprophylaxis appear to be promising directions for future research. Appropriate and targeted immunomodulation may play an important adjunctive role in some of these infections by limiting the extent of end-organ damage and multi-organ failure in some fulminant infections.
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Affiliation(s)
- Samson S Y Wong
- Department of Microbiology, Research Centre of Infection and Immunology, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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Reischig T, Jindra P, Hes O, Svecová M, Klaboch J, Treska V. Valacyclovir prophylaxis versus preemptive valganciclovir therapy to prevent cytomegalovirus disease after renal transplantation. Am J Transplant 2008; 8:69-77. [PMID: 17973956 DOI: 10.1111/j.1600-6143.2007.02031.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Both preemptive therapy and universal prophylaxis are used to prevent cytomegalovirus (CMV) disease after transplantation. Randomized trials comparing both strategies are sparse. Renal transplant recipients at risk for CMV (D+/R-, D+/R+, D-/R+) were randomized to 3-month prophylaxis with valacyclovir (2 g q.i.d., n = 34) or preemptive therapy with valganciclovir (900 mg b.i.d. for a minimum of 14 days, n = 36) for significant CMV DNAemia (>/=2000 copies/mL by quantitative PCR in whole blood) assessed weekly for 16 weeks and at 5, 6, 9 and 12 months. The 12-month incidence of CMV DNAemia was higher in the preemptive group (92% vs. 59%, p < 0.001) while the incidence of CMV disease was not different (6% vs. 9%, p = 0.567). The onset of CMV DNAemia was delayed in the valacyclovir group (37 +/- 22 vs. 187 +/- 110 days, p < 0.001). Significantly higher rate of biopsy-proven acute rejection during 12 months was observed in the preemptive group (36% vs. 15%, p = 0.034). The average CMV-associated costs per patient were $5525 and $2629 in preemptive therapy and valacyclovir, respectively (p < 0.001). However, assuming the cost of $60 per PCR test, there was no difference in overall costs. In conclusion, preemptive valganciclovir therapy and valacyclovir prophylaxis are equally effective in the prevention of CMV disease after renal transplantation.
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Affiliation(s)
- T Reischig
- Department of Internal Medicine I, Charles Medical School and Teaching Hospital, Pilsen, Czech Republic.
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Puius YA, Snydman DR. Prophylaxis and treatment of cytomegalovirus disease in recipients of solid organ transplants: current approach and future challenges. Curr Opin Infect Dis 2007; 20:419-24. [PMID: 17609603 DOI: 10.1097/qco.0b013e32821f6026] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Cytomegalovirus infection is a major cause of morbidity and mortality in solid-organ transplant recipients, in terms of cytomegalovirus disease itself and the associated outcomes of organ rejection and death. This review focuses on recent literature concerning prevention and treatment of cytomegalovirus disease in this population. RECENT FINDINGS Two major strategies for the prevention of cytomegalovirus infection in solid-organ transplant recipients - preemptive and prophylactic treatment - are reviewed. Both strategies result in a lower incidence of cytomegalovirus disease when compared to a 'wait and treat' approach, and are generally considered cost-effective. Neither prophylaxis nor preemption has yet been shown to be superior. Newer trials are also reviewed, which are beginning to evaluate protocols of preemption or prophylaxis representative of current practice, as well as to explore alternative dosing strategies, the benefits of cytomegalovirus immune globulin, and the potential benefit of a longer course of prophylaxis. Concerns for the selection of ganciclovir-resistant strains of cytomegalovirus are also addressed. SUMMARY The consensus is that there is benefit for the treatment of solid-organ transplant patients with an antiviral agent before clinical evidence of cytomegalovirus disease. So far, there has been no demonstration of the superiority of prophylactic or preemptive regimens, nor has the exact nature and dosing of the oral antiviral agent of choice been established.
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Affiliation(s)
- Yoram A Puius
- Division of Geographic Medicine and Infectious Diseases, Tufts-New England Medical Center, Boston, Massachusetts, USA
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Cavanaugh TM, Martin JE. Update on Pharmacoeconomics in Transplantation. Prog Transplant 2007; 17:103-19; quiz 120. [PMID: 17624133 DOI: 10.1177/152692480701700206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose To provide current information on pharmacoeconomic outcomes in transplantation for the past 6 years. Methods An extensive literature search was undertaken using PubMed and other authenticated Internet sources. Key words used to elicit pertinent studies were “pharmacoeconomics,” “transplantation,” “cost-effectiveness,” “cost-benefit,” “cost-minimization” and “cost-utility” analyses. Studies included in the review contain updated pharmacoeconomic data generated during the past 6 years on economic, clinical, and humanistic outcomes. These data are used to describe and analyze the cost of drug therapy used in transplantation. Results Background information is included in the review to provide a context from which to evaluate new study material. Data extracted from the studies include significant findings and study limitations. Data were stratified into understanding pharmacoeconomic methods and their application to transplantation, maintenance and induction therapies, and management of and costs associated with adverse events and quality-of-life issues. Conclusions Continued evolution of pharmacoeconomic analysis is needed so that optimal care can be provided in the most cost-effective manner. Pharmacoeconomic study, done rationally and logically, is an indispensable tool in determining optimal transplantation regimens.
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Affiliation(s)
- Teresa M Cavanaugh
- University Hospital, University of Cincinnati College of Pharmacy, Cincinnati, OH, USA
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