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Qiu Y, Zhang Y, Teng M, Cheng S, Du Q, Yang L, Wang Q, Wang T, Wang Y, Dong Y, Dong H. Efficacy, Safety, and Cost-effectiveness Analysis of Antiviral Agents for Cytomegalovirus Prophylaxis in Allogeneic Hematopoietic Stem Cell Transplantation Recipients. Transplantation 2024; 108:1021-1032. [PMID: 38049935 DOI: 10.1097/tp.0000000000004856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is associated with higher non-relapse mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). But the preferred drug for preventing cytomegalovirus infection is still controversial. We evaluate the efficacy, safety, and cost-effectiveness of antiviral agents based on the most recent studies. METHODS A pairwise and network meta-analysis was conducted to obtain direct and indirect evidence of antivirals. The cost of allo-HSCT recipients in a teaching hospital was collected, and a cost-effectiveness analysis using a decision tree combined with Markov model was completed from the perspective of allo-HSCT recipients over a lifetime horizon. RESULTS A total of 19 RCTs involving 3565 patients (8 antivirals) were included. In the network meta-analysis, relative to placebo, letermovir, valacyclovir, and ganciclovir significantly reduced CMV infection incidence; ganciclovir significantly reduced CMV disease incidence; ganciclovir significantly increased the incidence of serious adverse event; none of antivirals significantly reduced all-cause mortality. Based on meta-analysis and Chinese medical data, the incremental cost-effectiveness ratios (ICER) per quality-adjusted life year (QALY) saved for maribavir, acyclovir, valacyclovir, ganciclovir, and letermovir relative to placebo corresponded to US$216 635.70, US$11 590.20, US$11 816.40, US$13 049.90, and US$12 189.40, respectively. One-way sensitivity analysis showed the most influential parameter was discount rate. The probabilistic sensitivity analysis indicated a 53.0% probability of letermovir producing an ICER below the willingness-to-pay threshold of US$38 824.23/QALY. The scenario analysis demonstrated prophylaxis with letermovir is considered cost-effective in the United States. CONCLUSIONS Currently, letermovir is an effective and well-tolerated treatment for preventing CMV infection, and it might be a cost-effective choice in allo-HSCT recipients in China.
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Affiliation(s)
- Yulan Qiu
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yijing Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mengmeng Teng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shiqi Cheng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qian Du
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Luting Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Quanfang Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yan Wang
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Haiyan Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Otto WR, Vora SB, Dulek DE. Cytomegalovirus Cell-mediated Immunity Assays in Pediatric Transplantation. J Pediatric Infect Dis Soc 2024; 13:S22-S30. [PMID: 38417088 DOI: 10.1093/jpids/piae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/23/2024] [Indexed: 03/01/2024]
Abstract
Cytomegalovirus (CMV) is a significant cause of morbidity and mortality in pediatric transplantation. However, currently utilized CMV prevention paradigms have limitations, leading to research aimed at novel strategies for mitigation of CMV infection. Cell-mediated immunity (CMI) is crucial in controlling CMV infection and the use of CMV-specific CMI assays to guide prevention and treatment of CMV infection in both solid organ transplant and hematopoietic cell transplant recipients shows great promise. In this article, we review the immune response to CMV infection to highlight the rationale for CMI assays, describe available commercial assays and strategies for their use, and summarize relevant literature regarding the use of CMI assays in transplant recipients.
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Affiliation(s)
- William R Otto
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Surabhi B Vora
- Division of Infectious Diseases, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Daniel E Dulek
- Division of Pediatric Infectious Diseases, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Hinman B, Cox J, Umoru G, Kamble R, Musick W. Extended duration letermovir in allogeneic hematopoietic stem cell transplant. Transpl Immunol 2023; 81:101936. [PMID: 37770000 DOI: 10.1016/j.trim.2023.101936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 09/17/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES Despite the use of antiviral prophylaxis in recipients of allogeneic hematopoietic cell transplants (HCT), cytomegalovirus (CMV) is a common clinically significant infection and is associated with significant morbidity and mortality in this patient population. Based on current approval, letermovir is initiated within 28 days following allogeneic HCT for CMV seropositive recipients and continued through 100 days post-transplant. However, it is unknown whether patients who receive extended duration CMV prophylaxis with letermovir would result in less CMV reactivation and reactivation compared to those who do not. This study aimed to evaluate the efficacy of letermovir prophylaxis in CMV seropositive patients when continued for greater than 100 days post-allogeneic stem cell transplant. METHODS A single-center retrospective chart review was conducted on recipients of allogeneic HCT from November 2017 to July 2021. Patients were eligible for inclusion if they were at least 18 years of age, received an allogeneic HCT, CMV seropositive, and initiated letermovir between days 0-28 post-transplant. The primary endpoint of this study is to compare rates of CMV reactivation in patients who stopped letermovir prophylaxis at 100 days post-transplant (standard duration group) versus those who continued letermovir prophylaxis past day 100 (extended duration group). RESULTS A total of 87 patients met the eligibility criteria for inclusion. The median duration of letermovir prophylaxis was 78 days in the standard duration group versus and 132 days in the extended duration group. There were more CMV reactivations in the standard duration group versus the extended duration group, 28% versus 19% respectively. CMV pneumonitis was observed in one of the patients in the standard duration group. All-cause mortality at day 200 post-transplant was similar between the two groups. CONCLUSION The results of this study suggest that extended duration letermovir prophylaxis may be associated with less CMV reactivation compared to the standard duration of prophylaxis.
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Affiliation(s)
- Breanna Hinman
- Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
| | - James Cox
- Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
| | - Godsfavour Umoru
- Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
| | - Rammurti Kamble
- Center for Cell and Gene Therapy, Baylor College of Medicine and Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
| | - Will Musick
- Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
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Kabut T, Weinbergerová B, Folber F, Lengerová M, Mayer J. High-dose aciclovir in CMV infection prophylaxis after allogeneic HSCT: a single-center long-term experience. Bone Marrow Transplant 2023; 58:1229-1236. [PMID: 37612466 PMCID: PMC10622319 DOI: 10.1038/s41409-023-02081-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 08/25/2023]
Abstract
There is only limited data on cytomegalovirus (CMV) prophylaxis with high-dose (HD) aciclovir after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We performed a retrospective analysis on a total of 179 patients who underwent their allo-HSCT with HD-aciclovir prophylaxis at our center. A clinically significant CMV infection (cs-CMVi) was observed in 56 (31%) cases with a median time of 49 (range 25-147) days after HSCT. A significantly higher CMV infection rate was observed in seropositive recipients with a seronegative donor (74%) compared to seropositive recipients with a seropositive donor, and seronegative recipients with seropositive and seronegative donors (24%, 18%, 7% respectively; p < 0.001). The CMV serostatus was the only significant risk factor for CMV infection in our analysis. CMV disease developed in three patients with CMV-related death in two cases. During HD-aciclovir prophylaxis, we did not observe any medical condition attributable to HD-aciclovir's adverse effects. Compared to published results, we observed a low incidence of cs-CMVi with HD-aciclovir prophylaxis in several patient subgroups, especially in seropositive recipients with a seropositive donor. With respect to the determined threshold, HD-aciclovir prophylaxis seems to have good efficacy in an intermediate cs-CMVi risk patients, but prospective randomized trials would be needed for definite conclusions.
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Affiliation(s)
- Tomáš Kabut
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Barbora Weinbergerová
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic.
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - František Folber
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martina Lengerová
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiří Mayer
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Cheng J, Huang J, Cao W, Huang L, Mao X, Chen L, Zhou J, Wang N. Case Report: Fatal cytomegalovirus pneumonia after CAR-T cell therapy in the long-term follow-up. Front Immunol 2023; 14:1226148. [PMID: 37849765 PMCID: PMC10577281 DOI: 10.3389/fimmu.2023.1226148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 09/15/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction The rapidly developed CAR-T cell therapy has a unique profile of side effects, which perhaps has not been totally realized and understood, especially the late-phase toxicity. CMV is prevalent world-wide and establishes a life-long latency infection. It can lead to life-threatening complications in immunocompromised host, and little is known about CMV disease in patients after CAR-T cell therapy. Here, we report a patient who developed possible CMV-pneumonia three months after anti-CD19 and anti-CD22 CAR-T cell therapy for relapsed B-ALL, contributing to the understanding of severe side-effects mediated by virus infection or reactivation in patients receiving CAR-T cell infusion. Case presentation A 21-year old male patient with relapsed B-ALL received anti-CD19/22 CAR-T cell therapy, and achieved complete remission 2 weeks after the infusion. However, three months later, the patient was hospitalized again with a 10-day history of fever and cough and a 3-day history of palpitations and chest tightness. He was diagnosed with possible CMV pneumonia. Under treatment with antiviral medicine (ganciclovir/penciclovir), intravenous gamma globulin and methylprednisolone and the use of BiPAP ventilator, his symptoms improved, but after removing penciclovir his symptoms went out of control, and the patient died of respiratory failure 22 days after admission. Conclusion CMV infection/reactivation can occur in patients long after receiving anti-CD19/22 CAR-T cell therapy, and induce fatal pneumonia, which reminds us of the late side effects associated with immunosuppression after CAR-T cell infusion.
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Affiliation(s)
| | | | | | | | | | | | | | - Na Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Malespini J, Lei M, Tavares E, Hammond SP, Chen YB, Luk SO, DeFilipp Z. Letermovir and tacrolimus interaction effects in hematopoietic cell transplantation recipients receiving moderate cytochrome P450 3A4 inhibitors for antifungal prophylaxis. J Oncol Pharm Pract 2023; 29:1574-1579. [PMID: 36398324 DOI: 10.1177/10781552221139772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Letermovir inhibits cytomegalovirus replication and is approved for the prevention of cytomegalovirus infection in cytomegalovirus seropositive hematopoietic cell transplantation recipients. Studies have found that letermovir coadministration has minimal effect on tacrolimus levels prior to the start of voriconazole, a strong cytochrome P450 (CYP) 3A4 inhibitor. However, data are lacking for hematopoietic cell transplantation recipients receiving letermovir and tacrolimus with moderate CYP 3A4 inhibitors as antifungal prophylaxis. METHODS In this retrospective single-center analysis, we reviewed the charts of 92 consecutive adult allogeneic hematopoietic cell transplantation recipients receiving letermovir, tacrolimus, and moderate CYP3A4 inhibitors for antifungal prophylaxis. RESULTS Tacrolimus concentration/dose (C/D) ratios were evaluated for the first 7 days pre-letermovir and for the first and second 7-day periods after letermovir. The tacrolimus mean C/D ratios [(ng/mL)/(mg/kg/day)] increased significantly with the addition of letermovir: 172.99 (95% confidence interval (CI): 158.2-187.78) pre-letermovir, 268.66 (95% CI: 244.34-292.98) first-week letermovir, and 312.19 (95% CI: 279.39-344.99) second-week letermovir (P < 0.001). The average dosages (mg/kg) of tacrolimus also decreased significantly across the three-time intervals (P < 0.001). Only four patients experienced clinically significant cytomegalovirus reactivation which required systemic treatment. CONCLUSION These results demonstrate a reduction in tacrolimus dosing requirements for patients receiving tacrolimus and letermovir with concomitant moderate CYP3A4 inhibitors. The results of this interaction suggest that frequent monitoring of tacrolimus trough levels is warranted when starting letermovir and that empiric reduction of tacrolimus dosing upon letermovir initiation should be considered.
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Affiliation(s)
- Jack Malespini
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Matthew Lei
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Erica Tavares
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah P Hammond
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA, USA
| | - Samantha O Luk
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA, USA
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Recio V, González I, Tarragó D. Cytomegalovirus drug resistance mutations in transplant recipients with suspected resistance. Virol J 2023; 20:153. [PMID: 37464399 PMCID: PMC10355059 DOI: 10.1186/s12985-023-02127-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
Resistant CMV infections are challenging complications after SOT and HSCT. Prompt recognition of ARMs is imperative for appropriate therapy. 108 plasma samples from 96 CMV + transplant recipients with suspected resistance were analysed in CNM in a retrospective nationwide study from January 2018 to July 2022 for resistance genotyping. ARMs in UL97 and UL54 were found in 26.87% (18/67) and 10.60% (7/66) of patients, respectively. Patients' ARM distribution in UL97 was as follows: L595S n = 3; L595S/M460I n = 1; L595S/N510S n = 1; L595W n = 1; C603W n = 4; A594V n = 3; A594E n = 1; C607Y n = 1; L397R/T409M/H411L/M460I n = 1; L397I n = 1; H520Q n = 1; four patients showed ARMs in UL54 as well (F412C n = 1; T503I n = 2; P522S n = 1), whereas three patients exhibited ARMs in UL54 only (L501I/T503I/L516R/A834P n = 1; A987G n = 2). L516R in UL54 and L397R/I and H411L in UL97 have been found for the first time in a clinical sample. L595S/W was the most prevalent ARM found to lend resistance to GCV. In UL54 all ARMs lent resistance to GCV and CDV. In addition, A834P, found in one patient, also lent resistance to FOS. CMV load did not differ significantly in patients with or without ARMs, and no differences were found either between patients with ARMs in UL97 or in UL97 and UL54. Despite extensive use of classical antivirals for the treatment of CMV infection after HSCT and SOT, ARMs occurred mainly in viral UL97 kinase, which suggests that CDV and mostly FOS continue to be useful alternatives to nucleoside analogues after genotypic detection of ARMs.
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Affiliation(s)
- Vanessa Recio
- Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda- Pozuelo km 2, Madrid, 28220, Spain
| | - Irene González
- Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda- Pozuelo km 2, Madrid, 28220, Spain
| | - David Tarragó
- Centro Nacional de Microbiología, Instituto de Salud Carlos III, Majadahonda- Pozuelo km 2, Madrid, 28220, Spain.
- CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain.
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Sepassi A, Saunders IM, Bounthavong M, Taplitz RA, Logan C, Watanabe JH. Effectiveness of letermovir for cytomegalovirus prophylaxis in allogeneic hematopoietic stem cell transplant recipients: A global systematic review. J Am Pharm Assoc (2003) 2023; 63:1138-1149. [PMID: 37207713 DOI: 10.1016/j.japh.2023.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/30/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE(S) Letermovir (LET), a novel antiviral, has largely supplanted more traditional preemptive therapy (PET) for cytomegalovirus (CMV) prophylaxis in allogeneic hematopoietic stem cell transplant (allo-HCT) patients. Use of LET demonstrated efficacy against placebo in phase III randomized controlled trials, but is considerably more expensive than PET. This review aimed to evaluate the real-world effectiveness of LET in preventing clinically significant CMV infection (csCMVi) for allo-HCT recipients and related outcomes. DESIGN A systematic literature review was performed using an a priori protocol using PubMed, Scopus, and ClinicalTrials.gov from January 2010 to October 2021. SETTING AND PARTICIPANTS Studies were included if they met the following criteria: LET compared with PET, CMV-related outcomes, patients aged 18 years or older, and English language-only articles. Descriptive statistics were used to summarize study characteristics and outcomes. OUTCOME MEASURES CMV viremia, csCMVi, CMV end-organ disease, graft-versus-host-disease, all-cause mortality. RESULTS A total of 233 abstracts were screened, with 30 included in this review. Randomized trials demonstrated efficacy of LET prophylaxis in preventing csCMVi. Observational studies demonstrated varying degrees of effectiveness of LET prophylaxis compared with use of PET alone. All studies with a comparator group resulted in lower rates of csCMVi for patients using LET. Included studies varied widely by CMV viral load threshold cutoff and CMV test units, limiting synthesis of results owing to high heterogeneity. CONCLUSION LET reduces risk of csCMVi, but lack of standardized clinical definitions on how to evaluate csCMVi and related outcomes largely prevent synthesis of results. Clinicians must consider this limitation in the context of evaluating the effectiveness of LET to other antiviral therapies, especially for patients at risk of late-onset CMV. Future studies should focus on prospective data collection through registries and concordance of diagnostic definitions to mitigate study heterogeneity.
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Sepassi A, Saunders IM, Bounthavong M, Taplitz RA, Logan C, Watanabe JH. Cost Effectiveness of Letermovir for Cytomegalovirus Prophylaxis Compared with Pre-Emptive Therapy in Allogeneic Hematopoietic Stem Cell Transplant Recipients in the United States. PHARMACOECONOMICS - OPEN 2023; 7:393-404. [PMID: 36840894 PMCID: PMC10169956 DOI: 10.1007/s41669-023-00398-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE The aim of this study was to assess the cost effectiveness of letermovir prophylaxis with the option for subsequent pre-emptive therapy (PET) for the prevention of cytomegalovirus (CMV) infection compared with a PET-only scenario in adult allogeneic hematopoietic stem cell transplant (allo-HCT) recipients in the United States over a 10-year time horizon. MATERIALS AND METHODS A publicly available decision tree model was constructed using a commercial third-party payer perspective to simulate an allo-HCT recipient's clinical trajectory in the first-year post-transplant, followed by entry to a Markov model to simulate years 2 through 10. Clinical inputs and utility estimates were derived from published literature. Costs were derived from published literature and US Department of Veterans Affairs Federal Supply Schedule drug pricing. Outcomes assessed included life expectancy, quality-adjusted life-years (QALYs), direct medical costs, and the incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses (PSA) were performed to test the robustness of the findings. RESULTS Compared with PET alone, letermovir prophylaxis was projected to increase life-years per person (4.99 vs. 4.70 life-years), and increase QALYs (3.29 vs. 3.08) and costs (US$83.411 vs. US$70,698), yielding an ICER of US$59,356 per QALY gained. One-way sensitivity analyses indicated our model was sensitive to mortality (ICER: $164,771/QALY) and utility (letermovir ICER: $117,447/QALY; PET ICER: $107,290/QALY) in the first-year post-transplant. In 57.1% of the PSA simulations, letermovir was a cost-effective option using a willingness-to-pay threshold of US$100,000 per QALY. CONCLUSIONS Letermovir prophylaxis is cost effective compared with PET alone with a willingness-to-pay threshold of US$100,000 per QALY gained. Sensitivity analysis results indicate future research is required to understand the impact of mortality and quality of life in the first-year post-transplant to arrive at a conclusive decision on letermovir adoption.
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Affiliation(s)
- Aryana Sepassi
- Department of Clinical Pharmacy Practice, University of California, Irvine School of Pharmacy and Pharmaceutical Sciences, Irvine, CA, USA.
| | - Ila M Saunders
- Division of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA
| | - Mark Bounthavong
- Division of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA
- Department of Veteran Affairs, Health Economic Resource Center, Menlo Park, CA, USA
| | | | - Cathy Logan
- Division of Infectious Diseases and Global Health, University of California, San Diego, La Jolla, CA, USA
| | - Jonathan H Watanabe
- Department of Clinical Pharmacy Practice, University of California, Irvine School of Pharmacy and Pharmaceutical Sciences, Irvine, CA, USA
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Perchetti GA, Biernacki MA, Xie H, Castor J, Joncas-Schronce L, Ueda Oshima M, Kim Y, Jerome KR, Sandmaier BM, Martin PJ, Boeckh M, Greninger AL, Zamora D. Cytomegalovirus breakthrough and resistance during letermovir prophylaxis. Bone Marrow Transplant 2023; 58:430-436. [PMID: 36693927 DOI: 10.1038/s41409-023-01920-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
Letermovir is a relatively new antiviral for prophylaxis against cytomegalovirus (CMV) after allogeneic hematopoietic cell transplantation (HCT). CMV-seropositive HCT recipients who received letermovir prophylaxis from 2018 to 2020 at our center were evaluated for letermovir resistance and breakthrough CMV reactivation. Two-hundred twenty-six letermovir recipients were identified and 7/15 (47%) with CMV DNAemia ≥200 IU/mL were successfully genotyped for UL56 resistance. A single C325Y resistance mutation was identified in an umbilical cord blood recipient. Ninety-five (42%), 43 (19%), and 15 (7%) patients had breakthrough CMV at any level, ≥150 IU/mL, and ≥500 IU/mL, respectively. Risk factors for breakthrough CMV reactivation at each viral threshold were examined. Cumulative steroid exposure was the strongest risk factor for CMV at all evaluated viral thresholds. Graft-versus-host disease prophylaxis with post-transplantation cyclophosphamide (aHR 2.34, 95% CI 1.28-4.28, p = 0.001) or calcineurin inhibitors plus mycophenolate (aHR 2.24, 95% CI 1.30-3.86, p = 0.004) were also associated with an increased risk of CMV reactivation at any level. De novo letermovir resistance is rare and can be successfully treated using other antivirals. Letermovir effectively prevents clinically significant CMV, however, subclinical CMV reactivation occurs frequently at our center.
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Affiliation(s)
- Garrett A Perchetti
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Melinda A Biernacki
- Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jared Castor
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Laurel Joncas-Schronce
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Masumi Ueda Oshima
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Medical Oncology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
| | - YoungJun Kim
- Department of Pathology, University of Virginia, School of Medicine, Charlottesville, VA, USA
| | - Keith R Jerome
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Brenda M Sandmaier
- Division of Medical Oncology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Paul J Martin
- Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Alexander L Greninger
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Danniel Zamora
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA.
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11
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Sourisseau M, Faure E, Béhal H, Chauvet P, Srour M, Capes A, Coiteux V, Magro L, Alfandari S, Alidjinou EK, Simon N, Vuotto F, Karam M, Faure K, Yakoub-Agha I, Beauvais D. The promising efficacy of a risk-based letermovir use strategy in CMV-positive allogeneic hematopoietic cell recipients. Blood Adv 2023; 7:856-865. [PMID: 36350752 PMCID: PMC9986711 DOI: 10.1182/bloodadvances.2022008667] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/21/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
Abstract
Letermovir is the first approved drug for cytomegalovirus (CMV) infection prophylaxis in adult patients who are CMV positive undergoing allogeneic hematopoietic cell transplantation (allo-HCT). Because CMV infection risk varies from patient to patient, we evaluated whether a risk-based strategy could be effective. In this single-center study, all consecutive adult patients who were CMV positive and underwent allo-HCT between 2015 and 2021 were included. During period 1 (2015-2017), letermovir was not used, whereas during period 2 (2018-2021), letermovir was used in patients at high risk but not in patients at low risk, except in those receiving corticosteroids. In patients at high risk, the incidence of clinically significant CMV infection (csCMVi) in period 2 was lower than that in period 1 (P < .001) by week 14 (10.5% vs 51.6%) and week 24 (16.9% vs 52.7%). In patients at low risk, although only 28.6% of patients received letermovir in period 2, csCMVi incidence was also significantly lower (P = .003) by week 14 (7.9% vs 29.0%) and week 24 (11.2% vs 33.3%). Among patients at low risk who did not receive letermovir (n = 45), 23 patients (51.1%) experienced transient positive CMV DNA without csCMVi, whereas 17 patients (37.8%) experienced negative results. In both risk groups, the 2 periods were comparable for CMV disease, overall survival, progression-free survival, relapse, and nonrelapse mortality. We concluded that a risk-based strategy for letermovir use is an effective strategy which maintains the high efficacy of letermovir in patients at high risk but allows some patients at low risk to not use letermovir.
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Affiliation(s)
- Mathilde Sourisseau
- Department of Infectious Disease, CHU Lille, University of Lille, Lille, France
| | - Emmanuel Faure
- Department of Infectious Disease, CHU Lille, University of Lille, Lille, France
- U1019-UMR 9017-Center for Infection and Immunity of Lille, INSERM, Centre National de la Recherche Scientifique, Institut Pasteur de Lille, University of Lille, Lille, France
| | - Hélène Béhal
- Department of Biostatistics, ULR 2694 - METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, CHU Lille, University of Lille, Lille, France
| | - Paul Chauvet
- Hematology Department, CHU Lille, Lille, France
- Infinite U1286, INSERM, University of Lille, Lille, France
| | - Micha Srour
- Hematology Department, CHU Lille, Lille, France
- Infinite U1286, INSERM, University of Lille, Lille, France
| | | | | | | | - Serge Alfandari
- Infectious Disease Department, Gustave Dron Hospital, Tourcoing, France
| | | | - Nicolas Simon
- ULR 7365 – GRITA – Groupe de Recherche sur les formes Injectables et les Technologies Associées, CHU Lille, University of Lille, Lille, France
| | - Fanny Vuotto
- Department of Infectious Disease, CHU Lille, University of Lille, Lille, France
| | | | - Karine Faure
- Department of Infectious Disease, CHU Lille, University of Lille, Lille, France
- U1019-UMR 9017-Center for Infection and Immunity of Lille, INSERM, Centre National de la Recherche Scientifique, Institut Pasteur de Lille, University of Lille, Lille, France
| | - Ibrahim Yakoub-Agha
- Hematology Department, CHU Lille, Lille, France
- Infinite U1286, INSERM, University of Lille, Lille, France
| | - David Beauvais
- Hematology Department, CHU Lille, Lille, France
- Infinite U1286, INSERM, University of Lille, Lille, France
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12
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A Successful Bridge Therapy Combining Hypomethylating Agents with Venetoclax for Adult Patients with Newly Diagnosed or Relapsed/Refractory Acute Myeloid Leukemia. Cancers (Basel) 2023; 15:cancers15061666. [PMID: 36980551 PMCID: PMC10046472 DOI: 10.3390/cancers15061666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/11/2023] Open
Abstract
Recently, the combination of VEN-HMA has been shown to achieve durable responses in patients with both newly diagnosed (ND) and R/R-AML. We retrospectively evaluated the post-allo-HCT outcomes of 50 patients who received VEN-HMA therapy. In total, 10 were ND and 40 were R/R and, at the time of HCT, the median age was 53 years. In the ND- and R/R-AML groups, the percentage of patients who achieved CR/CRi or MLFS was 90% and 92.5%, respectively. In all, after a median follow-up of 13.7 months, the probabilities of overall survival (OS), relapse-free survival (RFS), cumulative incidence of relapse (CIR), and nonrelapse mortality (NRM) at 1 year were 63.7%, 59.3%, 28.5%, and 12.2%, respectively. In addition, the cumulative incidences of grade II–IV acute graft-versus-host disease (GVHD) and moderate–severe chronic GVHD at 1 year were 28.4% and 37.4%, respectively. In multivariate analysis, the factors associated with a statistically significant impact on OS were VEN-HMA cycle (p = 0.021), ELN risk group (p = 0.041), and the response to VEN-HMA therapy before allo-HCT (p = 0.003). Although 80% of our patients had R/R-AML and 30% underwent a second allo-HCT, our data still suggest that allo-HCT following VEN-HMA therapy is a safe and effective treatment option.
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13
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Douglas G, Yong MK, Tio SY, Chau M, Prabahran A, Sasadeusz J, Slavin M, Ritchie D, Chee L. Effective CMV prophylaxis with high-dose valaciclovir in allogeneic hematopoietic stem-cell recipients at a high risk of CMV infection. Transpl Infect Dis 2023; 25:e13994. [PMID: 36413495 DOI: 10.1111/tid.13994] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/29/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection increases mortality and morbidity following allogeneic hematopoietic stem-cell transplantation (alloHSCT). Universal antiviral prophylaxis with letermovir is effective but unsubsidized in Australia. Valaciclovir demonstrates anti-CMV activity in high doses, but few current real-world studies explore its use as primary prophylaxis in high-risk patients post-alloHSCT. METHODS We performed a retrospective analysis of alloHSCT recipients at high risk of clinically significant CMV infection (cs-CMVi), defined as a plasma CMV DNA viral load of >400 IU/ml requiring preemptive therapy, or CMV disease. High-risk recipients were CMV seropositive and underwent T-cell depleted, haploidentical or umbilical cord stem-cell transplants. Consecutive patients transplanted from July 2018 to January 2020, treated with valaciclovir 2 g TDS from day +7 to +100 (HD-VALA), were compared to a historical cohort (July 2017-June 2018) who only received preemptive CMV therapy, and standard valaciclovir (SD-VALA) for varicella/herpes prophylaxis. We compared incidence of and time to cs-CMVi. RESULTS In the SD-VALA cohort (n = 27, median CMV follow-up duration 259 days), 23/27 (85%) developed cs-CMVi at a median of 39 days. For the HD-VALA cohort (n = 35, median CMV follow-up duration 216 days), 19/35 (54%) developed cs-CMVi, at a median of 68 days. Time to cs-CMVi was significantly longer in HD-VALA cohort (p < .0001). On multivariate analysis, HD VALA reduced the risk of cs-CMVi (HR 0.32, p = .0005). CONCLUSIONS In alloHSCT recipients at high risk for cs-CMVi, HD-VALA resulted in lower cumulative reactivation, and delayed reactivation, reducing requirement for preemptive CMV therapy in the early post-engraftment period.
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Affiliation(s)
- Genevieve Douglas
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia
| | - Michelle K Yong
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Australia.,National Centre for Infections in Cancer, Parkville, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Shio Yen Tio
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Australia.,National Centre for Infections in Cancer, Parkville, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Maggie Chau
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia.,Pharmacy Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Ashvind Prabahran
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia
| | - Joe Sasadeusz
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Australia
| | - Monica Slavin
- Department of Infectious Diseases, Royal Melbourne Hospital, Parkville, Australia.,National Centre for Infections in Cancer, Parkville, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - David Ritchie
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Lynette Chee
- Department of Clinical Haematology and Bone Marrow Transplantation, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
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14
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Efficacy of Cytomegalovirus Specific Immunoglobulins to Reduce CMV Reactivation in Pediatric Hematopoietic Stem Cell Transplant Recipients. J Pediatr Hematol Oncol 2023; 45:e82-e86. [PMID: 36162011 DOI: 10.1097/mph.0000000000002553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 07/15/2022] [Indexed: 02/03/2023]
Abstract
Cytomegalovirus (CMV) infection is a serious complication of pediatric hematopoietic stem cell transplant (HSCT). To date, antiviral therapy has been the mainstay of prophylaxis, with conflicting results regarding the benefits of CMV-specific immunoglobulins (CMV-Ig). After introducing prophylactic CMV-Ig to HSCT recipients at risk (seropositive recipient and/or donor), we conducted a single-center retrospective study comparing the incidence and severity of CMV infection with and without CMV-Ig. We identified 49 'at risk' recipients from 76 consecutive HSCTs over 3.5 years, in addition to standard antiviral prophylaxis, 10 patients received CMV-Ig and 39 did not. There was no significant difference in donor type, cell source, conditioning, or CMV status between the groups. We observed a potential trend toward reduction of incidence of CMV reactivation in patients exposed to CMV-Ig (30%) compared with those who weren't (38.4%). Besides, no symptomatic or lethal infection was observed in the CMV-Ig group, and time to recovery seemed shorter (21 [±7] vs 51.4 [±55] days) and peak titers lower (4578 [±4788] vs 24131 [±49257]) with CMV-Ig. No adverse events were noted. The statistical significance of the results was limited by the small sample size. These data raise interest in prophylactic CMV-Ig as a safe way of potentially reducing the severity and duration of CMV reactivation in HSCT.
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15
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Kuhn A, Puttkammer J, Madigan T, Dinnes L, Khan S, Ferdjallah A, Kohorst M. Letermovir as Cytomegalovirus Prophylaxis in a Pediatric Cohort: A Retrospective Analysis. Transplant Cell Ther 2023; 29:62.e1-62.e4. [PMID: 36244677 DOI: 10.1016/j.jtct.2022.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/20/2022] [Accepted: 10/06/2022] [Indexed: 11/09/2022]
Abstract
Letermovir is an attractive cytomegalovirus (CMV) prophylactic agent, but published data in children are scarce. This retrospective chart review aimed to describe our experience using letermovir as CMV prophylaxis in pediatric hematopoietic cell transplantation (HCT) recipients. Pediatric patients (age <20 years) undergoing allogeneic HCT and receiving letermovir prophylaxis in the Mayo Clinic Pediatric Bone Marrow Transplant Program were eligible for inclusion in this retrospective chart review. Medical records were reviewed to evaluate letermovir dosing, CMV levels, laboratory values, and reports of adverse effects. Between October 2020 and April 2022, 9 patients age 4 to 19 years undergoing allogeneic HCT in the Pediatric Bone Marrow Transplant Program received letermovir prophylaxis, either 240 mg or 480 mg daily at a mean and median dose of 10 mg/kg/day. Letermovir was crushed and administered via nasogastric tube in 4 of 9 patients. Two patients received letermovir for secondary CMV prophylaxis after initial treatment with ganciclovir/valganciclovir, and the remaining 7 received letermovir for primary prophylaxis. One patient, a 20-kg 6-year-old female receiving 240 mg (12 mg/kg), experienced low-level CMV viremia while on letermovir. No other patients experienced CMV reactivation while on letermovir prophylaxis. In 2 patients, transient mild transaminitis was noted within the first weeks of letermovir therapy, which resolved without intervention, and its relationship to letermovir could not be clearly established. Letermovir administration was feasible and well tolerated as CMV prophylaxis in our small cohort of pediatric patients undergoing HCT. Larger, prospective studies are warranted to confirm the safety and efficacy of letermovir in children. © 2022 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
- Alexis Kuhn
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota.
| | - Jenna Puttkammer
- Department of Pharmacy, North Memorial Health Hospital, Robbinsdale, Minnesota
| | - Theresa Madigan
- Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Laura Dinnes
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Shakila Khan
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, Minnesota
| | - Asmaa Ferdjallah
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, Minnesota
| | - Mira Kohorst
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, Minnesota
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16
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Zafarani A, Taghavi-Farahabadi M, Razizadeh MH, Amirzargar MR, Mansouri M, Mahmoudi M. The Role of NK Cells and Their Exosomes in Graft Versus Host Disease and Graft Versus Leukemia. Stem Cell Rev Rep 2023; 19:26-45. [PMID: 35994137 DOI: 10.1007/s12015-022-10449-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 02/07/2023]
Abstract
Natural killer (NK) cells are one of the innate immune cells that play an important role in preventing and controlling tumors and viral diseases, but their role in hematopoietic stem cell transplantation (HCT) is not yet fully understood. However, according to some research, these cells can prevent infections and tumor relapse without causing graft versus host disease (GVHD). In addition to NK cells, several studies are about the anti-leukemia effects of NK cell-derived exosomes that can highlight their roles in graft-versus-leukemia (GVL). In this paper, we intend to investigate the results of various articles on the role of NK cells in allogeneic hematopoietic cell transplantation and also their exosomes in GVL. Also, we have discussed the antiviral effects of these cells in post-HCT cytomegalovirus infection.
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Affiliation(s)
- Alireza Zafarani
- Department of Hematology and Blood Banking, Faculty of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahsa Taghavi-Farahabadi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Reza Amirzargar
- Department of Hematology and Blood Banking, Faculty of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mansoure Mansouri
- Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahmoudi
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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17
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The Ten Most Common Questions on Cytomegalovirus Infection in Hematopoietic Stem Cell Transplant Patients. Clin Hematol Int 2022; 5:21-28. [PMID: 36577863 PMCID: PMC9797381 DOI: 10.1007/s44228-022-00025-3] [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: 09/06/2022] [Accepted: 11/15/2022] [Indexed: 12/30/2022] Open
Abstract
With the rising number of patients undergoing hematopoietic stem cell transplantation (HSCT), clinicians are more likely to encounter infectious complications in immunocompromised hosts, particularly cytomegalovirus (CMV) infection. Besides the high mortality of CMV end-organ disease, patients with detectable CMV viremia may have worse outcomes and decreased survival even in the absence of end-organ disease. In view of the implications on morbidity and mortality, clinicians should maintain a high index of suspicion and initiate antiviral drugs promptly when CMV infection is confirmed. High-risk patients should be identified in order to provide optimal management. Additionally, novel antiviral agents with a good safety profile and minor adverse events are now available for prophylaxis in high-risk patients and for treatment of resistant or refractory CMV infection. The following review provides concise, yet comprehensive, guidance on the burden and risk factors of CMV in this population, as well as an update on the latest evidence for the management of CMV infection.
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18
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Plotogea M, Isam AJ, Frincu F, Zgura A, Bacinschi X, Sandru F, Duta S, Petca RC, Edu A. An Overview of Cytomegalovirus Infection in Pregnancy. Diagnostics (Basel) 2022; 12:diagnostics12102429. [PMID: 36292118 PMCID: PMC9600407 DOI: 10.3390/diagnostics12102429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/22/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
The objective of this review was to bring to attention cytomegalovirus (CMV) infection during pregnancy, taking into consideration all relevant aspects, such as maternal diagnosis, fetal infection and prevention, prenatal diagnosis, and postnatal prognosis. A literature review was performed regarding adult and congenital infection. General information regarding this viral infection and potential related medical conditions was provided, considering the issues of maternal infection during pregnancy, transmission to the fetus, and associated congenital infection management. Prenatal diagnosis includes maternal serum testing and the confirmation of the infection in amniotic fluid or fetal blood. Additionally, prenatal diagnosis requires imaging techniques, ultrasound, and complementary magnetic resonance to assess cortical and extracortical anomalies. Imaging findings can predict both fetal involvement and the postnatal prognosis of the newborn, but they are difficult to assess, even for highly trained physicians. In regard to fetal sequelae, the early diagnosis of a potential fetal infection is crucial, and methods to decrease fetal involvement should be considered. Postnatal evaluation is also important, because many newborns may be asymptomatic and clinical anomalies can be diagnosed when sequelae are permanent.
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Affiliation(s)
- Mihaela Plotogea
- Department of Obstetrics and Gynecology, “Nicolae Malaxa” Clinical Hospital, 022441 Bucharest, Romania
| | - Al Jashi Isam
- Faculty of Medicine, “Titu Maiorescu” University, 031593 Bucharest, Romania
- Correspondence: (A.J.I.); (F.F.)
| | - Francesca Frincu
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence: (A.J.I.); (F.F.)
| | - Anca Zgura
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Xenia Bacinschi
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Florica Sandru
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Simona Duta
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Razvan Cosmin Petca
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Antoine Edu
- Department of Obstetrics and Gynecology, “Nicolae Malaxa” Clinical Hospital, 022441 Bucharest, Romania
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
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19
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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: 0] [Impact Index Per Article: 0] [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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20
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Aristizabal AM, Perez P, Patiño Niño JA, Franco A, Tarapues EM, Beltran E, Medina D. Risk factors and incidence of cytomegalovirus viremia and disease in pediatric patients with allogeneic hematopoietic stem cell transplantation: An 8-year single-center experience in Latin America. Pediatr Transplant 2022; 26:e14324. [PMID: 35647735 DOI: 10.1111/petr.14324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 03/21/2022] [Accepted: 04/29/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cytomegalovirus infection represents a significant cause of morbidity and mortality after hematopoietic stem cell transplantation. This study aimed to evaluate the incidence of viremia and disease due to cytomegalovirus and the risk factors in pediatric patients with hematopoietic stem cell transplantation in our institution. METHODS This was a retrospective cohort of patients under 19 years of age who underwent allogeneic hematopoietic stem cell transplantation due to any indication between 2012 and 2019. The analysis included the diagnosis of cytomegalovirus viremia or disease during post-transplant follow-up, evaluation of risk factors, and outcomes. The statistical analysis included univariate and multivariate analyses, and the cumulative incidence of cytomegalovirus viremia was determined by the Kaplan-Meier method using STATA 14 statistical software. RESULTS A total of 182 transplants were included. At 100 days, the cumulative incidence of cytomegalovirus viremia was 70.5%, and that of cytomegalovirus disease was 4.7%. Overall survival at 2 years was 74%, and event-free survival was 64%. The remaining demographic characteristics were not predictors of infection. There was no association between viremia and relapse or survival of the patients. Higher mortality was noted in cytomegalovirus disease. CONCLUSIONS During the study period, the incidence of cytomegalovirus disease was similar to that of other pediatric reports, but the incidence of viremia was higher. Pre-emptive therapy has diminished disease rates and death due to infection. Viral load cutoff points should be standardized to guide treatment and avoid myelotoxicity.
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Affiliation(s)
- Ana M Aristizabal
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | - Paola Perez
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Grupo de Infectología Pediátrica, Cali, Colombia
| | - Jaime A Patiño Niño
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Grupo de Infectología Pediátrica, Cali, Colombia
| | - Alexis Franco
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Unidad de trasplante de médula ósea, Cali, Colombia
| | - Eliana Manzi Tarapues
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | - Estefania Beltran
- Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
| | - Diego Medina
- Facultad de ciencias de la salud, Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia.,Departamento Materno-Infantil, Fundación Valle del Lili, Unidad de trasplante de médula ósea, Cali, Colombia
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21
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P Daukshus N, Cirincione A, Siver M, Mathew S, Kunvarjee B, Chan A, Boelens JJ, Seo SK, Papanicolaou GA, Kernan NA. Letermovir for Cytomegalovirus Prevention in Adolescent Patients Following Hematopoietic Cell Transplantation. J Pediatric Infect Dis Soc 2022; 11:337-340. [PMID: 35472147 PMCID: PMC9989834 DOI: 10.1093/jpids/piac017] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/07/2022] [Indexed: 01/07/2023]
Abstract
There are limited data for letermovir as primary cytomegalovirus (CMV) prophylaxis in patients less than 18 years of age. We report 9 adolescent patients who received letermovir following hematopoietic cell transplantation. No patients developed clinically significant CMV while taking letermovir. Letermovir was well tolerated and efficacious in preventing CMV infections.
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Affiliation(s)
- Nicole P Daukshus
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Molly Siver
- Department of Pharmacy, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Sherry Mathew
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Binni Kunvarjee
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amelia Chan
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Susan K Seo
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Nancy A Kernan
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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22
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Wright LR, Wright DL, Weller SK. Viral Nucleases from Herpesviruses and Coronavirus in Recombination and Proofreading: Potential Targets for Antiviral Drug Discovery. Viruses 2022; 14:v14071557. [PMID: 35891537 PMCID: PMC9324378 DOI: 10.3390/v14071557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 02/05/2023] Open
Abstract
In this review, we explore recombination in two very different virus families that have become major threats to human health. The Herpesviridae are a large family of pathogenic double-stranded DNA viruses involved in a range of diseases affecting both people and animals. Coronaviridae are positive-strand RNA viruses (CoVs) that have also become major threats to global health and economic stability, especially in the last two decades. Despite many differences, such as the make-up of their genetic material (DNA vs. RNA) and overall mechanisms of genome replication, both human herpes viruses (HHVs) and CoVs have evolved to rely heavily on recombination for viral genome replication, adaptation to new hosts and evasion of host immune regulation. In this review, we will focus on the roles of three viral exonucleases: two HHV exonucleases (alkaline nuclease and PolExo) and one CoV exonuclease (ExoN). We will review the roles of these three nucleases in their respective life cycles and discuss the state of drug discovery efforts against these targets.
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Affiliation(s)
- Lee R. Wright
- Department of Pharmaceutical Sciences, University of Connecticut School of Pharmacy, Storrs, CT 06269, USA; (L.R.W.); (D.L.W.)
| | - Dennis L. Wright
- Department of Pharmaceutical Sciences, University of Connecticut School of Pharmacy, Storrs, CT 06269, USA; (L.R.W.); (D.L.W.)
| | - Sandra K. Weller
- Department of Molecular Biology and Biophysics, University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030, USA
- Correspondence: ; Tel.: +1-(860)-679-2310; Fax: +1-(860)-679-1239
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23
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Yoshimura H, Satake A, Ishii Y, Ichikawa J, Saito R, Konishi A, Hotta M, Nakanishi T, Fujita S, Ito T, Ishii K, Nomura S. Real-world efficacy of letermovir prophylaxis for cytomegalovirus infection after allogeneic hematopoietic stem cell transplantation: A single-center retrospective analysis. J Infect Chemother 2022; 28:1317-1323. [PMID: 35725529 DOI: 10.1016/j.jiac.2022.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 04/30/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection is a common complication following allogeneic hematopoietic stem cell transplantation (aHSCT) and is associated with increased mortality. Letermovir (LET) is a novel antiviral drug used to prevent CMV infection. METHODS We analyzed 111 consecutive patients who underwent aHSCT, retrospectively, to evaluate the efficacy of LET prophylaxis for clinically significant CMV infection (csCMVi) in real-world situations. In addition, we analyzed the influence of LET on transplant outcomes. Thirty-eight patients who were administered LET prophylactically were compared with 73 patients without LET prophylaxis after aHSCT. RESULTS On day 180, the cumulative incidence of csCMVi in patients who received LET prophylaxis was significantly lower than that in patients without LET prophylaxis (29.7% vs. 56.2%, P < 0.001). Among the patients who developed csCMVi, the interval from aHSCT to the initiation of preemptive therapy was significantly longer in patients who received LET prophylaxis than in those who did not (129.5 days vs. 42 days, P < 0.001). The six-month overall survival was 86.1% in patients who received LET prophylaxis and 66.8% in the non-LET group (P = 0.035). CONCLUSION LET prophylaxis was highly effective in preventing csCMVi and could potentially improve transplant outcomes, particularly when initiated early after transplantations.
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Affiliation(s)
- Hideaki Yoshimura
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Atsushi Satake
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan.
| | - Yuka Ishii
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Jun Ichikawa
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Ryo Saito
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Akiko Konishi
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Masaaki Hotta
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Takahisa Nakanishi
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Shinya Fujita
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Kazuyoshi Ishii
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
| | - Shosaku Nomura
- First Department of Internal Medicine, Kansai Medical University, Osaka, 573-1010, Japan
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24
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Cheng CN, Li SS, Yeh YH, Shen CF, Chen JS. Letermovir prophylaxis for cytomegalovirus reactivation in children who underwent hematopoietic stem cell transplantation: A single-institute experience in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2022; 55:323-327. [PMID: 35241378 DOI: 10.1016/j.jmii.2022.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 11/24/2021] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Abstract
From January 2019 to May 2021, 11 children underwent allogeneic stem cell transplantation at our institute. Four of them received letermovir for cytomegalovirus prophylaxis. Three children, none of whom received prophylaxis, experienced cytomegalovirus reactivation. Letermovir is a promising medication for use in cytomegalovirus prophylaxis in children. Further studies are warranted.
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Affiliation(s)
- Chao-Neng Cheng
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sin-Syue Li
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yun-Hsuan Yeh
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Fen Shen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jiann-Shiuh Chen
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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25
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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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26
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Cytomegalovirus and other herpesviruses after hematopoietic cell and solid organ transplantation: From antiviral drugs to virus-specific T cells. Transpl Immunol 2022; 71:101539. [PMID: 35051589 DOI: 10.1016/j.trim.2022.101539] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 12/13/2022]
Abstract
Herpesviruses can either cause primary infection or may get reactivated after both hematopoietic cell and solid organ transplantations. In general, viral infections increase post-transplant morbidity and mortality. Prophylactic, preemptive, or therapeutically administered antiviral drugs may be associated with serious side effects and may induce viral resistance. Virus-specific T cells represent a valuable addition to antiviral treatment, with high rates of response and minimal side effects. Even low numbers of virus-specific T cells manufactured by direct selection methods can reconstitute virus-specific immunity after transplantation and control viral replication. Virus-specific T cells belong to the advanced therapy medicinal products, and their production is regulated by appropriate legislation; also, strict safety regulations are required to minimize their side effects.
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27
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Cytomegalovirus gastroenteritis in patients with acute graft-versus-host disease. Blood Adv 2021; 6:574-584. [PMID: 34788389 PMCID: PMC8791573 DOI: 10.1182/bloodadvances.2021005885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/26/2021] [Indexed: 11/20/2022] Open
Abstract
A pre-emptive strategy has successfully decreased cytomegalovirus (CMV) disease after allogeneic hematopoietic cell transplantation (HCT). However, some recipients still develop CMV gastroenteritis, especially after acute graft-versus-host disease (aGVHD), and its incidence, risk factors, and prognostic impact remain to be elucidated. We retrospectively analyzed 3759 consecutive adult patients who developed grade II-IV aGVHD using a Japanese registry database. The cumulative incidence of CMV gastroenteritis was 5.7% by day 365 from the development of grade II-IV aGVHD. Advanced age (hazard ratio [HR], 1.60; 95% confidence interval [CI], 1.16-2.22; P = 0.004), GVHD prophylaxis with mycophenolate mofetil and calcineurin inhibitor (HR, 1.73; 95% CI, 1.08-2.77; P = 0.024), lower-gut aGVHD (HR, 2.17; 95% CI, 1.58-2.98; P < 0.001), and the use of systemic steroids (HR, 1.78; 95% CI, 1.16-2.74; P = 0.008) were independent risk factors for CMV gastroenteritis. Development of CMV gastroenteritis was associated with an increased risk of nonrelapse mortality (HR, 1.89; 95% CI, 1.50-2.39; P < 0.001). Moreover, letermovir prophylaxis significantly reduced both the incidence of CMV gastroenteritis (HR, 0.50; 95% CI, 0.25-0.99; P = 0.047) and the risk of nonrelapse mortality (HR, 0.72; 95% CI, 0.52-0.99; P = 0.043). In summary, CMV gastroenteritis is a life-threatening complication that sets the need for preventive strategies with letermovir and targeted surveillance.
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28
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Wolfe D, Zhao Q, Siegel E, Puto M, Murphy D, Roddy J, Efebera Y, Tossey J. Letermovir Prophylaxis and Cytomegalovirus Reactivation in Adult Hematopoietic Cell Transplant Recipients with and without Acute Graft Versus Host Disease. Cancers (Basel) 2021; 13:cancers13215572. [PMID: 34771734 PMCID: PMC8583331 DOI: 10.3390/cancers13215572] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/31/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Cytomegalovirus (CMV) infection and graft versus host disease (GVHD) both contribute to increased morbidity and mortality following allogeneic hematopoietic cell transplantation (allo-HCT). Since the development of GVHD can increase a patient’s risk of developing CMV infection post-allo-HCT, the aim of our retrospective study was to assess the effectiveness of letermovir prophylaxis in preventing CMV infection in these patients at high risk for CMV reactivation. Letermovir is an antiviral approved for the prevention of CMV infection. This study demonstrated that patients with GVHD had significantly fewer CMV infections when they received letermovir prophylaxis compared to patients who did not receive letermovir. Abstract Cytomegalovirus (CMV) is the most clinically significant infection after allogeneic hematopoietic-cell transplantation (allo-HCT) and is associated with increased mortality. The risk for CMV reactivation increases with graft versus host disease (GVHD). GVHD contributes to significant morbidity and mortality and is treated with immunosuppressive therapies that can further increase CMV infection risk. Prophylaxis with letermovir, an oral antiviral approved to prevent CMV, has been shown to decrease the incidence of CMV infection post-allo-HCT in patients at high risk of CMV reactivation, but there is a lack of data confirming this benefit in patients with GVHD. In this single-center, retrospective study, we assessed the incidence of clinically significant CMV infection (CS-CMVi) in allo-HCT patients who received letermovir prophylaxis (n = 119) and who developed aGVHD compared to a control group (n = 143) who did not receive letermovir. Among aGVHD patients, letermovir prophylaxis decreased CS-CMVi in patients with aGVHD (HR 0.08 [95% CI 0.03–0.27], p < 0.001), reduced non-relapsed mortality (p = 0.04) and improved overall survival (p = 0.04). This data suggests that letermovir prophylaxis improves outcomes by preventing CS-CMVi in patients with aGVHD.
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Affiliation(s)
- Delaney Wolfe
- Comprehensive Cancer Center, James Cancer Hospital Solove Research Institute, The Ohio State University, 460 West 10th St., Columbus, OH 43210, USA; (Q.Z.); (E.S.); (M.P.); (D.M.); (J.R.); (Y.E.); (J.T.)
- Franciscan Health Indianapolis, 8111 South Emerson Avenue, Indianapolis, IN 46237, USA
- Correspondence:
| | - Qiuhong Zhao
- Comprehensive Cancer Center, James Cancer Hospital Solove Research Institute, The Ohio State University, 460 West 10th St., Columbus, OH 43210, USA; (Q.Z.); (E.S.); (M.P.); (D.M.); (J.R.); (Y.E.); (J.T.)
| | - Emma Siegel
- Comprehensive Cancer Center, James Cancer Hospital Solove Research Institute, The Ohio State University, 460 West 10th St., Columbus, OH 43210, USA; (Q.Z.); (E.S.); (M.P.); (D.M.); (J.R.); (Y.E.); (J.T.)
| | - Marcin Puto
- Comprehensive Cancer Center, James Cancer Hospital Solove Research Institute, The Ohio State University, 460 West 10th St., Columbus, OH 43210, USA; (Q.Z.); (E.S.); (M.P.); (D.M.); (J.R.); (Y.E.); (J.T.)
| | - Danielle Murphy
- Comprehensive Cancer Center, James Cancer Hospital Solove Research Institute, The Ohio State University, 460 West 10th St., Columbus, OH 43210, USA; (Q.Z.); (E.S.); (M.P.); (D.M.); (J.R.); (Y.E.); (J.T.)
- Rush University Medical Center, 1620 W Harrison St., Chicago, IL 60612, USA
| | - Julianna Roddy
- Comprehensive Cancer Center, James Cancer Hospital Solove Research Institute, The Ohio State University, 460 West 10th St., Columbus, OH 43210, USA; (Q.Z.); (E.S.); (M.P.); (D.M.); (J.R.); (Y.E.); (J.T.)
| | - Yvonne Efebera
- Comprehensive Cancer Center, James Cancer Hospital Solove Research Institute, The Ohio State University, 460 West 10th St., Columbus, OH 43210, USA; (Q.Z.); (E.S.); (M.P.); (D.M.); (J.R.); (Y.E.); (J.T.)
- OhioHealth Blood and Marrow Transplant, 3535 Olentangy River Road, Columbus, OH 43214, USA
| | - Justin Tossey
- Comprehensive Cancer Center, James Cancer Hospital Solove Research Institute, The Ohio State University, 460 West 10th St., Columbus, OH 43210, USA; (Q.Z.); (E.S.); (M.P.); (D.M.); (J.R.); (Y.E.); (J.T.)
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29
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In-depth summary over cytomegalovirus infection in allogeneic hematopoietic stem cell transplantation recipients. Virusdisease 2021; 32:422-434. [PMID: 34631973 DOI: 10.1007/s13337-021-00728-w] [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: 10/20/2020] [Accepted: 07/06/2021] [Indexed: 10/20/2022] Open
Abstract
In this study, we reviewed various aspects of cytomegalovirus infection, including pathophysiology, diagnosis methods, and antiviral treatments. Background: Infections continue to be a major reason of complications like high non-relapse morbidity and mortality rate after allogenic hematopoietic stem cell transplantation. Cytomegalovirus is the most common infection in immunocompromised patients or those with graft-versus-host disease. The Latent-cytomegalovirus disease could increase the risk of reactivation in allogenic hematopoietic stem cell transplantation patients and lead to profound adverse effects on transplantation outcomes. Cytomegalovirus-specific CD4 + and CD8 + T cells reconstitution is crucial for protection against the virus reactivation. Different prophylactic, pre-emptive, and therapeutic anti-viral drugs are available to prevent cytomegalovirus infection/reactivation and treat resistant infections. Conclusion: Although there has been introduced various CMV antiviral treatment strategies like antiviral drugs, Vaccination, passive immunotherapies and adoptive transfer of CMV-specific T cells, further clinical trials are required to approve current therapies.
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30
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Martino M, Pitino A, Gori M, Bruno B, Crescimanno A, Federico V, Picardi A, Tringali S, Ingrosso C, Carluccio P, Pastore D, Musuraca G, Paviglianiti A, Vacca A, Serio B, Storti G, Mordini N, Leotta S, Cimminiello M, Prezioso L, Loteta B, Ferreri A, Colasante F, Merla E, Giaccone L, Busca A, Musso M, Scalone R, Di Renzo N, Marotta S, Mazza P, Musto P, Attolico I, Selleri C, Canale FA, Pugliese M, Tripepi G, Porto G, Martinelli G, Carella AM, Cerchione C. Letermovir Prophylaxis for Cytomegalovirus Infection in Allogeneic Stem Cell Transplantation: A Real-World Experience. Front Oncol 2021; 11:740079. [PMID: 34616684 PMCID: PMC8489185 DOI: 10.3389/fonc.2021.740079] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/13/2021] [Indexed: 12/15/2022] Open
Abstract
Despite effective treatments, cytomegalovirus (CMV) continues to have a significant impact on morbidity and mortality in allogeneic stem cell transplant (allo-SCT) recipients. This multicenter, retrospective, cohort study aimed to evaluate the reproducibility of the safety and efficacy of commercially available letermovir for CMV prophylaxis in a real-world setting. Endpoints were rates of clinically significant CMV infection (CSCI), defined as CMV disease or CMV viremia reactivation within day +100-+168. 204 adult CMV-seropositive allo-SCT recipients from 17 Italian centres (median age 52 years) were treated with LET 240 mg/day between day 0 and day +28. Overall, 28.9% of patients underwent a haploidentical, 32.4% a matched related, and 27.5% a matched unrelated donor (MUD) transplant. 65.7% were considered at high risk of CSCI and 65.2% had a CMV seropositive donor. Low to mild severe adverse events were observed in 40.7% of patients during treatment [gastrointestinal toxicity (36.3%) and skin rash (10.3%)]. Cumulative incidence of CSCI at day +100 and day +168 was 5.4% and 18.1%, respectively, whereas the Kaplan-Meier event rate was 5.8% (95% CI: 2.4-9.1) and 23.3% (95% CI: 16.3-29.7), respectively. Overall mortality was 6.4% at day +100 and 7.3% at day +168. This real-world experience confirms the efficacy and safety of CMV.
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Affiliation(s)
- Massimo Martino
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Annalisa Pitino
- Istituto di Fisiologia Clinica del Consiglio Nazionale delle Ricerche (CNR), Roma, Italy
| | - Mercedes Gori
- Istituto di Fisiologia Clinica del Consiglio Nazionale delle Ricerche (CNR), Roma, Italy
| | - Benedetto Bruno
- Dipartimento di Oncologia, SSD Trapianto Allogenico di Cellule Staminali, AOU Città della Salute e della Scienza di Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, Divisione di Ematologia, Università di Torino, Torino, Italy
| | | | - Vincenzo Federico
- Ematologia e Trapianto di Cellule Staminali, Polo Ospedaliero "Vito Fazzi", Lecce, Italy
| | - Alessandra Picardi
- UOC Ematologia con Trapianto CSE, AORN "Antonio Cardarelli", Napoli, Italy.,Dipartimento di Biomedicina e Prevenzione, Università di Roma Tor Vergata, Roma, Italy
| | | | - Claudia Ingrosso
- Ematologia e Trapianto di Midollo Osseo, Ospedale "San Giuseppe Moscati", Taranto, Italy
| | - Paola Carluccio
- UOC di Ematologia con Trapianto, Dipartimento di Emergenza e Trapianti d'Organo, Università degli Studi "Aldo Moro" e AOUC Policlinico di Bari, Bari, Italy
| | - Domenico Pastore
- Divisione di Ematologia, Ospedale "Antonio Perrino", Brindisi, Italy
| | - Gerardo Musuraca
- Unità di Ematologia, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Annalisa Paviglianiti
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Adriana Vacca
- UO Ematologia - CTMO, Polo Ospedaliero "Armando Businco", Cagliari, Italy
| | - Bianca Serio
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Università di Salerno, Salerno, Italy
| | - Gabriella Storti
- Unità di Ematologia, Azienda Ospedaliera "San Giuseppe Moscati", Avellino, Italy
| | - Nicola Mordini
- SC Ematologia, Azienda Ospedaliera "S. Croce e Carle", Cuneo, Italy
| | - Salvatore Leotta
- Programma di Trapianto Emopoietico, Azienda Policlinico "Vittorio Emanuele", Catania, Italy
| | | | - Lucia Prezioso
- Ematologia e Centro Trapianti Midollo Osseo (CTMO), Dipartimento ad Attività Integrata Medicina Generale e Specialistica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Barbara Loteta
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Anna Ferreri
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Fabrizia Colasante
- Ospedale I.R.C.C.S. Casa Sollievo della Sofferenza - Centro Trapianti di Cellule Staminali, San Giovanni Rotondo, Italy
| | - Emanuela Merla
- Ospedale I.R.C.C.S. Casa Sollievo della Sofferenza - Centro Trapianti di Cellule Staminali, San Giovanni Rotondo, Italy
| | - Luisa Giaccone
- Dipartimento di Oncologia, SSD Trapianto Allogenico di Cellule Staminali, AOU Città della Salute e della Scienza di Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, Divisione di Ematologia, Università di Torino, Torino, Italy
| | - Alessandro Busca
- Dipartimento di Oncologia, SSD Trapianto Allogenico di Cellule Staminali, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Maurizio Musso
- Unità Operativa di Oncoematologia e TMO, Istituto "La Maddalena", Palermo, Italy
| | - Renato Scalone
- Unità Operativa di Oncoematologia e TMO, Istituto "La Maddalena", Palermo, Italy
| | - Nicola Di Renzo
- Ematologia e Trapianto di Cellule Staminali, Polo Ospedaliero "Vito Fazzi", Lecce, Italy
| | - Serena Marotta
- UOC Ematologia con Trapianto CSE, AORN "Antonio Cardarelli", Napoli, Italy
| | - Patrizio Mazza
- Ematologia e Trapianto di Midollo Osseo, Ospedale "San Giuseppe Moscati", Taranto, Italy
| | - Pellegrino Musto
- UOC di Ematologia con Trapianto, Dipartimento di Emergenza e Trapianti d'Organo, Università degli Studi "Aldo Moro" e AOUC Policlinico di Bari, Bari, Italy
| | - Immacolata Attolico
- UOC di Ematologia con Trapianto, Dipartimento di Emergenza e Trapianti d'Organo, Università degli Studi "Aldo Moro" e AOUC Policlinico di Bari, Bari, Italy
| | - Carmine Selleri
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Università di Salerno, Salerno, Italy
| | - Filippo Antonio Canale
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Marta Pugliese
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Giovanni Tripepi
- Istituto di Fisiologia Clinica del Consiglio Nazionale delle Ricerche (CNR), Reggio Calabria, Italy
| | - Gaetana Porto
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Giovanni Martinelli
- Unità di Ematologia, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Angelo Michele Carella
- Ospedale I.R.C.C.S. Casa Sollievo della Sofferenza - Centro Trapianti di Cellule Staminali, San Giovanni Rotondo, Italy
| | - Claudio Cerchione
- Unità di Ematologia, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
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31
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Chou S. Opposite effects of cytomegalovirus UL54 exonuclease domain mutations on acyclovir and cidofovir susceptibility. Antiviral Res 2021; 195:105181. [PMID: 34560144 DOI: 10.1016/j.antiviral.2021.105181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 11/18/2022]
Abstract
Acyclovir has weak activity against human cytomegalovirus (CMV). Despite some efficacy as prophylaxis, more potent anti-CMV drugs are preferred. Acyclovir resistance of CMV has been little studied. The viral UL97 kinase phosphorylates acyclovir, and cross-resistance of ganciclovir-resistant mutants is documented. However, UL54 exonuclease domain mutants may confer ganciclovir and cidofovir resistance by a mechanism that does not apply to acyclovir as an obligate chain terminator. To test for differential susceptibilities, 11 exonuclease domain mutants were tested for their 50% inhibitory concentrations (EC50s) of acyclovir in comparison with cidofovir. The 5 mutants with the highest cidofovir EC50s (>10-fold increased over wild type) all had acyclovir EC50s less than 20% of wild type. The relatively common N408K mutant had an acyclovir EC50 of 6 μM, comparable to that reported for wild type varicella-zoster virus. Several foscarnet-resistant UL54 mutants outside the exonuclease domains, some with low-grade ganciclovir/cidofovir cross-resistance, showed various degrees of acyclovir resistance. Based on these in vitro data, acyclovir may become a therapeutic option when a highly cidofovir-resistant exonuclease mutation is present without a simultaneous mutation in UL97.
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Affiliation(s)
- Sunwen Chou
- Division of Infectious Diseases, Oregon Health and Science University and Department of Veterans Affairs Medical Center, Portland, OR, USA
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Hakki M, Aitken SL, Danziger-Isakov L, Michaels MG, Carpenter PA, Chemaly RF, Papanicolaou GA, Boeckh M, Marty FM. American Society for Transplantation and Cellular Therapy Series: #3-Prevention of Cytomegalovirus Infection and Disease After Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:707-719. [PMID: 34452721 DOI: 10.1016/j.jtct.2021.05.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 11/20/2022]
Abstract
The Practice Guidelines Committee of the American Society for Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to update its 2009 compendium-style infectious diseases guidelines for the care of hematopoietic cell transplant (HCT) recipients. A new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease 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 third topic in the series focuses on the prevention of cytomegalovirus infection and disease in HCT recipients by reviewing prophylaxis and preemptive therapy approaches; key definitions, relevant risk factors, and diagnostic monitoring considerations are also reviewed.
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Affiliation(s)
- Morgan Hakki
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon.
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lara Danziger-Isakov
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Marian G Michaels
- Division of Pediatric Infectious Diseases, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and the University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Vaccine and Infectious Disease Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Francisco M Marty
- Division of Infectious Diseases, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
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Jakharia N, Howard D, Riedel DJ. CMV Infection in Hematopoietic Stem Cell Transplantation: Prevention and Treatment Strategies. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2021; 13:123-140. [PMID: 34305463 PMCID: PMC8294301 DOI: 10.1007/s40506-021-00253-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 12/15/2022]
Abstract
Purpose of Review Cytomegalovirus (CMV) remains a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (Allo-HSCT). New strategies and methods for prevention and management of CMV infection are urgently needed. We aim to review the new developments in diagnostics, prevention, and management strategies of CMV infection in Allo-HSCT recipients. Recent Findings The approval of the novel anti-CMV drug letermovir in 2017 has led to an increase in the use of antiviral prophylaxis as a preferred approach for prevention in many centers. Real-world studies have shown efficacy similar to the clinical trial. CMV-specific T cell-mediated immunity assays identify patients with immune reconstitution and predict disease progression. Phase 2 trials of maribavir have shown its efficacy as preemptive therapy and treatment of resistant and refractory CMV infections. Adoptive T cell therapy is an emerging option for treatment of refractory and resistant CMV. Of the different CMV vaccine trials, PepVax has shown promising results in a phase 1 trial. Summary CMV cell-mediated immunity assays have potential to be used as an adjunctive test to develop individualized management plan by identifying the patients who develop immune reconstitution; however, further prospective interventional studies are needed. Maribavir and adoptive T cell therapy are promising new therapies for treatment of CMV infections. CMV vaccine trials for prevention are also under way.
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Affiliation(s)
- Niyati Jakharia
- Department of Internal Medicine, Section of Infectious Diseases, Stanford University Hospital, 300 Pasteur Dr., Lane L 134, Stanford, CA 94305 USA
| | - Dianna Howard
- Department of Internal Medicine, Section of Hematology-Oncology, Wake Forest Baptist Medical Center, Winston-Salem, NC USA
| | - David J Riedel
- Department of Internal Medicine, Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, MD USA
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34
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Immune control of cytomegalovirus reactivation in stem cell transplantation. Blood 2021; 139:1277-1288. [PMID: 34166512 DOI: 10.1182/blood.2020010028] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/22/2021] [Indexed: 11/20/2022] Open
Abstract
The reactivation of viruses from latency after allogeneic stem cell transplantation (SCT) continues to represent a major clinical challenge requiring sophisticated monitoring strategies in the context of prophylactic and/or pre-emptive antiviral drugs that are associated with significant expense, toxicity, and rates of failure. Accumulating evidence has demonstrated the association of polyfunctional virus-specific T-cells with protection from viral reactivation, affirmed by the ability of adoptively transferred virus-specific T-cells to prevent and treat reactivation and disease. The roles of innate cells (NK cells) in early viral surveillance, and dendritic cells in priming of T-cells have also been delineated. Most recently, a role for strain-specific humoral responses in preventing early cytomegalovirus (CMV) reactivation has been demonstrated in preclinical models. Despite these advances, many unknowns remain: what are the critical innate and adaptive responses over time, is the origin (e.g. recipient versus donor) and localization (e.g. in parenchymal tissue versus lymphoid organs) of these responses important, how does GVHD and the prevention/treatment thereof (e.g. high dose steroids) impact the functionality and relevance of a particular immune axis, do the immune parameters that control latency, reactivation and dissemination differ, and what is the impact of new antiviral drugs on the development of enduring antiviral immunity. Thus, whilst antiviral drugs have provided major improvements over the last two decades, understanding the immunological paradigms underpinning protective antiviral immunity after SCT offers the potential to generate non-toxic immune-based therapeutic approaches for lasting protection from viral reactivation.
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Alsumali A, Chemaly RF, Graham J, Jiang Y, Merchant S, Miles L, Schelfhout J, Yang J, Tang Y. Cost-effectiveness analysis of cytomegalovirus prophylaxis in allogeneic hematopoietic cell transplant recipients from a US payer perspective. J Med Virol 2021; 93:3786-3794. [PMID: 32844453 DOI: 10.1002/jmv.26462] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/19/2020] [Accepted: 08/22/2020] [Indexed: 12/16/2022]
Abstract
To evaluate the cost-effectiveness of letermovir versus no prophylaxis for the prevention of cytomegalovirus infection and disease in adult cytomegalovirus-seropositive allogeneic hematopoietic cell transplantation (allo-HCT) recipients. A decision model for 100 patients was developed to estimate the probabilities of cytomegalovirus infection, cytomegalovirus disease, various other complications, and death in patients receiving letermovir versus no prophylaxis. The probabilities of clinical outcomes were based on the pivotal phase 3 trial of letermovir use for cytomegalovirus prophylaxis versus placebo in adult cytomegalovirus-seropositive recipients of an allo-HCT. Costs of prophylaxis with letermovir and of each clinical outcome were derived from published sources or the trial clinical study reports. Incremental cost-effectiveness ratios (ICERs) in terms of cost per quality-adjusted life year (QALY) gained were used in the model. One-way and probabilistic sensitivity analyses were conducted to explore uncertainty around the base-case analysis. In this model, the use of letermovir prophylaxis would lead to an increase of QALYs (619) and direct medical cost ($1 733 794) compared with no prophylaxis (578 QALYs; $710 300) in cytomegalovirus-seropositive recipients of an allo-HCT. Letermovir use for cytomegalovirus prophylaxis was a cost-effective option versus no prophylaxis with base-case analysis ICER $25 046/QALY gained. One-way sensitivity analysis showed the most influential parameter was mortality rate. The probabilistic sensitivity analysis showed a 92% probability of letermovir producing an ICER below the commonly accepted willingness-to-pay threshold of $100 000/QALY gained. Based on this model, letermovir use for cytomegalovirus prophylaxis was a cost-effective option in adult cytomegalovirus-seropositive recipients of an allo-HCT.
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Affiliation(s)
- Adnan Alsumali
- Center for Observational and Real-world Evidence, Merck & Co, Inc, Kenilworth, New Jersey
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jonathan Graham
- Health Economics, RTI Health Solutions, Research Triangle Park, North Carolina
| | - Yiling Jiang
- Center for Observational and Real-world Evidence, MSD Ltd, Hoddesdon, Hertfordshire, UK
| | - Sanjay Merchant
- Center for Observational and Real-world Evidence, Merck & Co, Inc, Kenilworth, New Jersey
| | - LaStella Miles
- Health Economics, RTI Health Solutions, Research Triangle Park, North Carolina
| | - Jonathan Schelfhout
- Center for Observational and Real-world Evidence, Merck & Co, Inc, Kenilworth, New Jersey
| | - Joe Yang
- Center for Observational and Real-world Evidence, Merck & Co, Inc, Kenilworth, New Jersey
| | - Yuexin Tang
- Center for Observational and Real-world Evidence, Merck & Co, Inc, Kenilworth, New Jersey
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36
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Heterogeneous impact of cytomegalovirus reactivation on nonrelapse mortality in hematopoietic stem cell transplantation. Blood Adv 2021; 4:1051-1061. [PMID: 32191806 DOI: 10.1182/bloodadvances.2019000814] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/22/2020] [Indexed: 11/20/2022] Open
Abstract
Cytomegalovirus (CMV) infection is a major complication in allogeneic stem cell transplantation. The utility of CMV prophylaxis with letermovir has been reported; however, the specific applications remain unclear. In this study, we retrospectively analyzed large-scale registry data (N = 10 480) to clarify the risk factors for nonrelapse mortality (NRM) in connection with CMV reactivation. First, we identified risk factors for CMV reactivation using multivariate analysis and developed a scoring model. Although the model effectively stratified reactivation risk into 3 groups (43.7% vs 60.9% vs 71.5%; P < .001), the 3-year NRM was significantly higher in patients with CMV reactivation, even in the low (20.9% vs 13.0%, P < .001), intermediate (21.4% vs 15.6%; P < .001), and high (29.3% vs 18.0%; P < .001) reactivation risk groups. Next, survival analysis considering competing risks, time-dependent covariates, and interaction terms for exploring the heterogeneous impact of CMV reactivation on NRM in the training cohort revealed that chronic myeloid leukemia (CML) (hazard ratio [HR], 1.76; 95% confidence interval [CI], 1.05-2.96; P = .033), good performance status (PS) (HR, 1.42; 95% CI, 1.04-1.94; P = .028), HLA-matched donor (HR, 1.34; 95% CI, 1.06-1.70; P = .013), and standard-risk disease (HR, 1.28; 95% CI, 1.04-1.58; P = .022) were associated with increased NRM. In the test cohort, CMV reactivation was significantly associated with increased 3-year NRM among patients with 2 to 4 factors (22.1% vs 13.1%; P < .001) but was comparable among patients with 0 or 1 factor (23.2% vs 20.4%; P = .62). We propose that CMV prophylaxis should be determined based on reactivation risk, as well as these other factors.
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37
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Lam S, Boan P, Polistena P, Cannell P, Cooney J, Wright M, Purtill D. High dose valaciclovir to prevent cytomegalovirus infection in allogeneic haematopoietic stem cell transplant recipients. Transpl Infect Dis 2021; 23:e13633. [PMID: 33978289 DOI: 10.1111/tid.13633] [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: 02/21/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 11/30/2022]
Abstract
Cytomegalovirus (CMV) infection causes morbidity and mortality after allogeneic haematopoietic stem cell transplantation (HSCT). We investigated whether prophylaxis with high dose valaciclovir is effective at reducing the incidence of clinically significant CMV infection (csCMVi) within six months of allogeneic HSCT. Consecutive allogeneic HSCT recipients who received 2g valaciclovir orally four times daily from transplant until day 100 (prophylaxis group) were compared to subsequent patients who received no CMV prophylaxis (control group). Forty-nine patients in the prophylaxis group and 59 in the control group were included. The cumulative incidence of csCMVi at 6 months was 20% (95% confidence interval (CI): 9%-27%) in the prophylaxis group and 39% (95% CI: 26%-47%) in the control group (P = .009). There was no CMV disease in the prophylaxis group and three cases in the control group. There was no difference in time to neutrophil or platelet recovery nor graft failure between groups. On multivariable analysis, lack of high dose valaciclovir prophylaxis, positive recipient CMV IgG and age were associated with greater likelihood of csCMVi. There was no significant difference in acute graft versus host disease, non-relapse mortality or overall survival between groups. In this retrospective cohort study, high dose valaciclovir prophylaxis resulted in a lower incidence of csCMVi within six months of HSCT.
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Affiliation(s)
- Stephanie Lam
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
| | - Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, Australia
| | - Paola Polistena
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
| | - Paul Cannell
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
| | - Julian Cooney
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
| | - Matthew Wright
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
| | - Duncan Purtill
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
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38
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Yong MK, Gottlieb D, Lindsay J, Kok J, Rawlinson W, Slavin M, Ritchie D, Bajel A, Grigg A. New advances in the management of cytomegalovirus in allogeneic haemopoietic stem cell transplantation. Intern Med J 2021; 50:277-284. [PMID: 31403736 DOI: 10.1111/imj.14462] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 08/06/2019] [Accepted: 08/06/2019] [Indexed: 12/11/2022]
Abstract
Cytomegalovirus (CMV) viraemia continues to be a frequent complication in the post-haemopoietic stem cell transplantation period despite a low incidence of CMV end-organ disease. Several significant advances in the understanding and management of CMV infection have occurred in the last few years including improved diagnostics, monitoring of CMV immunity, availability of novel anti-CMV drugs, and emerging use of immunotherapies including CMV-specific T-cell infusions. In addition to reviewing these advances we also explore some of the more practical prescribing issues of the older and newer CMV drugs including cost, toxicity and drug interactions to help clinicians navigate this new era of CMV management.
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Affiliation(s)
- Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - David Gottlieb
- Department of Haematology and Bone Marrow Transplantation, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia.,Sydney Cellular Therapies Laboratory, Westmead Hospital, Sydney, New South Wales, Australia
| | - Julian Lindsay
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Pharmacy Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jen Kok
- Centre for Infectious Diseases and Microbiology Laboratory Services, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Sydney, New South Wales, Australia
| | - William Rawlinson
- NSW Health Pathology, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Monica Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Peter Doherty Institute for Infection and Immunity, The University of Melbourne and Royal Melbourne Hospital, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - David Ritchie
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ashish Bajel
- Department of Clinical Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Andrew Grigg
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Clinical Haematology and Olivia Newton John Cancer Research Institute, Austin Hospital, Melbourne, Victoria, Australia
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39
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Chen K, Arbona-Haddad E, Cheng MP, McDonnell AM, Gooptu M, Orejas JL, Timblin K, Silverman E, Al-Hamed R, Soiffer RJ, Hammond SP, Marty FM. Cytomegalovirus events in high-risk allogeneic hematopoietic-cell transplantation patients who received letermovir prophylaxis. Transpl Infect Dis 2021; 23:e13619. [PMID: 33866648 DOI: 10.1111/tid.13619] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 11/30/2022]
Abstract
Letermovir is approved for the prevention of cytomegalovirus (CMV) reactivation and clinical disease in patients undergoing allogeneic hematopoietic-cell transplantation (HCT). However, there is uncertainty about letermovir's ability to prevent clinical events during the period of prophylaxis as well as after the discontinuation of prophylaxis in the post-transplant setting. We performed a retrospective cohort study in CMV-seropositive allogeneic HCT recipients at high risk of CMV events, who received letermovir for primary prophylaxis from November 2017 through December 2019. We analyzed CMV outcomes for these patients during and after prophylaxis was discontinued. Patient outcomes were followed through June 2020. Sixty patients received letermovir for a median of 13 weeks (range, 1-72 weeks). Thirteen (22%) patients had quantifiable CMV DNAemia (reactivation) during letermovir prophylaxis a median of 9 days (range, 1-59 days) after starting letermovir. Five (8%) of these patients discontinued prophylaxis and received preemptive therapy (PET) with valganciclovir; eight (13%) continued letermovir as prophylaxis and CMV DNAemia resolved without PET. Thirteen patients (22%) had post-prophylaxis CMV reactivation a median of 33 days (range, 14-109 days) after letermovir discontinuation. In four (7%) of these patients, CMV DNAemia resolved without PET, and nine (15%) received PET. No patient developed CMV disease. Patients who developed CMV reactivation during prophylaxis did so shortly after initiation of letermovir, and most patients who developed CMV reactivation post-prophylaxis did so within 60 days after discontinuation of letermovir. Letermovir prophylaxis has changed the presentation of CMV infection in high-risk HCT patients.
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Affiliation(s)
- Kaiwen Chen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Esther Arbona-Haddad
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew P Cheng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne M McDonnell
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Mahasweta Gooptu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jose L Orejas
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kaitlyn Timblin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily Silverman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rama Al-Hamed
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sarah P Hammond
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Francisco M Marty
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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40
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Li PH, Lin CH, Lin YH, Chen TC, Hsu CY, Teng CLJ. Cytomegalovirus prophylaxis using low-dose valganciclovir in patients with acute leukemia undergoing allogeneic hematopoietic stem-cell transplantation. Ther Adv Hematol 2021; 12:2040620721998124. [PMID: 33747424 PMCID: PMC7940724 DOI: 10.1177/2040620721998124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/03/2021] [Indexed: 11/16/2022] Open
Abstract
Background Letermovir prophylaxis is currently the standard of care for the prevention of cytomegalovirus (CMV) infections in allogeneic hematopoietic stem-cell transplantation (allo-HSCT). However, drug-drug interactions between letermovir and azoles or calcineurin inhibitors and the high financial burden of letermovir remain problematic, especially in resource-limited countries. It has not been clarified whether a lower dose of valganciclovir would constitute an effective strategy for CMV prevention in patients with acute leukemia undergoing allo-HSCT. Methods We retrospectively assessed 84 consecutive adult patients with acute leukemia who underwent allo-HSCT. These 84 patients were stratified into a valganciclovir prophylaxis group (n = 20) and a non-valganciclovir prophylaxis group (n = 64). Results Patients in the valganciclovir prophylaxis group had a lower possibility of CMV DNAemia at week 14 after allo-HSCT than those in the non-valganciclovir prophylaxis group (15.0% versus 50.0%; p = 0.012). The cumulative incidence of CMV DNAemia at week 14 was also lower in patients with valganciclovir CMV prophylaxis than in those without (15.0% versus 50.4%; p = 0.006). Multivariate analysis validated these data, showing that a low dose of valganciclovir significantly reduced the risk of CMV DNAemia at week 14 by 88% (hazard ratio: 0.12; 95% confidence interval: 0.04-0.42; p = 0.001). However, these two groups had similar overall survival rates at week 48 (75.0% versus 76.6%; p = 0.805). Four of 20 (20%) patients discontinued valganciclovir prophylaxis because of adverse events. Conclusion Low-dose valganciclovir prophylaxis could be an alternative to letermovir to prevent CMV infection in allo-HSCT, especially in resource-limited countries.
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Affiliation(s)
- Po-Hsien Li
- Division of Hematology/Medical Oncology, Department of Medicine, Taichung Veterans General Hospital, Taichung
| | - Cheng-Hsien Lin
- Division of Hematology/Medical Oncology, Department of Medicine, Taichung Veterans General Hospital, Taichung
| | - Yu-Hui Lin
- Division of Infectious Diseases, Department of Medicine, Taichung Veterans General Hospital, Taichung
| | - Tsung-Chih Chen
- Division of Hematology/Medical Oncology, Department of Medicine, Taichung Veterans General Hospital, Taichung
| | - Chiann-Yi Hsu
- Biostatistics Task Force, Taichung Veterans General Hospital, Taichung
| | - Chieh-Lin Jerry Teng
- Division of Hematology/Medical Oncology, Department of Medicine, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd., Taichung, 40705
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41
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Gilioli A, Messerotti A, Bresciani P, Cuoghi A, Pioli V, Colasante C, Bettelli F, Giusti D, Forghieri F, Potenza L, Donatelli F, Giubbolini R, Galassi L, Marasca R, Banchelli F, D'Amico R, Pecorari M, Gennari W, Trenti T, Comoli P, Luppi M, Narni F. Cytomegalovirus reactivation after hematopoietic stem cell transplant with CMV-IG prophylaxis: A monocentric retrospective analysis. J Med Virol 2021; 93:6292-6300. [PMID: 33580523 DOI: 10.1002/jmv.26861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/03/2021] [Indexed: 01/19/2023]
Abstract
Human cytomegalovirus (CMV) represents the most common viral infection after hematopoietic stem cell transplant (HSCT), mainly occurring as reactivation from latency in seropositive patients, with a different prevalence based on the extent and timing of seroconversion in a specific population. Here, we retrospectively analyzed a cohort of patients who underwent HSCT at our Institution between 2013 and 2018, all of whom were prophylactically treated with CMV-IG (Megalotect Biotest®), to define the incidence and clinical outcomes of CMV reactivation and clinically significant infection. CMV infection occurred in 69% of our patient series, mainly resulting from reactivation, and CMV clinically significant infection (CS-CMVi) occurred in 48% of prophylactically treated patients. CMV infection and CS-CMVi impacted neither on relapse incidence nor on overall survival nor on relapse-free survival. Moreover, a very low incidence of CMV end-organ disease was documented. CMV-IG used alone as prophylactic therapy after HSCT does not effectively prevent CMV reactivation.
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Affiliation(s)
- Andrea Gilioli
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Messerotti
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Paola Bresciani
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Angela Cuoghi
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Valeria Pioli
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Corrado Colasante
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Bettelli
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Davide Giusti
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Forghieri
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Leonardo Potenza
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Donatelli
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Rachele Giubbolini
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Galassi
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Marasca
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Banchelli
- Section of Medical Statistics, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto D'Amico
- Section of Medical Statistics, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Monica Pecorari
- Molecular Microbiology and Virology Unit, Department of Laboratory Medicine and Pathological Anatomy, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - William Gennari
- Molecular Microbiology and Virology Unit, Department of Laboratory Medicine and Pathological Anatomy, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Tommaso Trenti
- Molecular Microbiology and Virology Unit, Department of Laboratory Medicine and Pathological Anatomy, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Patrizia Comoli
- Pediatric Hematology/Oncology Unit and Cell Factory, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Mario Luppi
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Franco Narni
- Section of Hematology, Department of Medical and Surgical Sciences, Azienda Ospedaliero-Universitaria di Modena, University of Modena and Reggio Emilia, Modena, Italy
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42
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Ferdjallah A, Young JAH, MacMillan ML. A Review of Infections After Hematopoietic Cell Transplantation Requiring PICU Care: Transplant Timeline Is Key. Front Pediatr 2021; 9:634449. [PMID: 34386464 PMCID: PMC8353083 DOI: 10.3389/fped.2021.634449] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 07/01/2021] [Indexed: 12/16/2022] Open
Abstract
Despite major advances in antimicrobial prophylaxis and therapy, opportunistic infections remain a major cause of morbidity and mortality after pediatric hematopoietic cell transplant (HCT). Risk factors associated with the development of opportunistic infections include the patient's underlying disease, previous infection history, co-morbidities, source of the donor graft, preparative therapy prior to the graft infusion, immunosuppressive agents, early and late toxicities after transplant, and graft-vs.-host disease (GVHD). Additionally, the risk for and type of infection changes throughout the HCT course and is greatly influenced by the degree and duration of immunosuppression of the HCT recipient. Hematopoietic cell transplant recipients are at high risk for rapid clinical decompensation from infections. The pediatric intensivist must remain abreast of the status of the timeline from HCT to understand the risk for different infections. This review will serve to highlight the infection risks over the year-long course of the HCT process and to provide key clinical considerations for the pediatric intensivist by presenting a series of hypothetical HCT cases.
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Affiliation(s)
- Asmaa Ferdjallah
- Department of Pediatrics, Division of Blood and Marrow Transplantation and Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
| | - Jo-Anne H Young
- Department of Medicine, Division of Infectious Disease and International Medicine, Program in Transplant Infectious Disease, University of Minnesota, Minneapolis, MN, United States
| | - Margaret L MacMillan
- Department of Pediatrics, Division of Blood and Marrow Transplantation and Cellular Therapy, University of Minnesota, Minneapolis, MN, United States
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43
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How I treat CMV reactivation after allogeneic hematopoietic stem cell transplantation. Blood 2020; 135:1619-1629. [PMID: 32202631 DOI: 10.1182/blood.2019000956] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/04/2020] [Indexed: 12/12/2022] Open
Abstract
Cytomegalovirus (CMV) reactivation remains one of the most common and life-threatening infectious complications following allogeneic hematopoietic stem cell transplantation, despite novel diagnostic technologies, several novel prophylactic agents, and further improvements in preemptive therapy and treatment of established CMV disease. Treatment decisions for CMV reactivation are becoming increasingly difficult and must take into account whether the patient has received antiviral prophylaxis, the patient's individual risk profile for CMV disease, CMV-specific T-cell reconstitution, CMV viral load, and the potential drug resistance detected at the time of initiation of antiviral therapy. Thus, we increasingly use personalized treatment strategies for the recipient of an allograft with CMV reactivation based on prior use of anti-CMV prophylaxis, viral load, the assessment of CMV-specific T-cell immunity, and the molecular assessment of resistance to antiviral drugs.
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44
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Akahoshi Y, Kimura SI, Inamoto Y, Seo S, Muranushi H, Shimizu H, Ozawa Y, Tanaka M, Uchida N, Kanda Y, Katayama Y, Shiratori S, Ota S, Matsuoka KI, Onizuka M, Fukuda T, Atsuta Y, Murata M, Terakura S, Nakasone H. Effect of Cytomegalovirus Reactivation With or Without Acute Graft-Versus-Host Disease on the Risk of Nonrelapse Mortality. Clin Infect Dis 2020; 73:e620-e628. [DOI: 10.1093/cid/ciaa1871] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/16/2020] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Despite a strong association between acute graft-versus-host disease (GVHD) and cytomegalovirus reactivation (CMVR), the joint effect of acute GVHD and CMVR on nonrelapse mortality (NRM) has not been well studied.
Methods
We evaluated the impact of CMVR on NRM stratified according to the development of acute GVHD using a landmark method. This study included 6078 patients who received their first allogeneic hematopoietic cell transplantation (HCT) with a preemptive strategy for CMVR between 2008 and 2017.
Results
The cumulative incidences of grade 2-4 acute GVHD (G24GVHD), CMVR by day 100, and CMV disease by day 365 were 37.3%, 52.1%, and 2.9%, respectively. Patients with G24GVHD were associated with the subsequent development of CMVR, and the presence of CMVR also increased the risk of G24GVHD. In a landmark analysis at day 65, the cumulative incidence of NRM at 1 year was 5.4%, 10.0%, 13.9%, and 19.7% in patients with G24GVHD–/CMVR–, G24GVHD–/CMVR+, G24GVHD+/CMVR–, and G24GVHD+/CMVR+, respectively. In a multivariate analysis, CMVR was respectively associated with an increased risk of NRM by day 365 in patients without G24GVHD (hazard ratio [HR], 1.59; 95% confidence interval [CI], 1.24–2.05; P < .001) and with G24GVHD (HR, 1.34; 95% CI, 1.06–1.70; P = .014), but the interaction between G24GVHD and CMVR was not significant (P = .326). Subgroup analyses suggested that the joint effect of acute GVHD and CMVR might vary according to the baseline characteristics.
Conclusions
These data regarding the close relationship between acute GVHD and CMVR should provide important implications for the treatment strategy after HCT.
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Affiliation(s)
- Yu Akahoshi
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Sachiko Seo
- Department of Haematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Hiroyuki Muranushi
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroaki Shimizu
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yuta Katayama
- Department of Hematology, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan
| | - Souichi Shiratori
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Shuichi Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Ken-ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Takahiro Fukuda
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Makoto Murata
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Seitaro Terakura
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
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45
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Ho SA, Slavin M, Roberts JA, Yong M. Optimization of Ganciclovir use in allogeneic hematopoietic cell transplant recipients - the role of therapeutic drug monitoring. Expert Rev Anti Infect Ther 2020; 19:707-718. [PMID: 33201745 DOI: 10.1080/14787210.2021.1851193] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: Cytomegalovirus (CMV) is an opportunistic infectious complication that can occur after allogeneic hematopoietic cell transplantation (HCT). The mainstay of treatment and prevention of this infection is ganciclovir and its ester prodrug valganciclovir. There is conflicting evidence on the clinical utility of routine ganciclovir therapeutic drug monitoring (TDM) as a means to optimize treatment.Areas covered: This review aims to describe the current knowledge of the pharmacokinetic and pharmacodynamic characteristics of ganciclovir and valganciclovir, and to explore the evidence and challenges surrounding ganciclovir TDM within the allogeneic HCT cohort.Expert opinion: Ganciclovir TDM is important to optimize efficacy in selected patient groups where there are variable pharmacokinetic factors or inadequate response to treatment. However, defined pharmacokinetic exposures which correlate with treatment efficacy and toxicity remain elusive. Prospective clinical studies in specific patient groups are required to clarify this issue. Alternative TDM targets such as the intracellular ganciclovir triphosphate should be explored as they may prove to have better correlation with clinical outcomes and adverse effects. With recent advances in CMV immune monitoring, novel approaches integrating TDM with specific CMV immune phenotyping in a predictive model will be advantageous in optimizing ganciclovir dosing by combining TDM with a risk stratification approach.
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Affiliation(s)
- Su Ann Ho
- Departments of Infectious Diseases, The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne, Australia
| | - Monica Slavin
- Departments of Infectious Diseases, The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Victorian Infectious Diseases Services Department, Royal Melbourne Hospital, Parkville VIC, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Michelle Yong
- Departments of Infectious Diseases, The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Victorian Infectious Diseases Services Department, Royal Melbourne Hospital, Parkville VIC, Australia
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Limaye AP, Babu TM, Boeckh M. Progress and Challenges in the Prevention, Diagnosis, and Management of Cytomegalovirus Infection in Transplantation. Clin Microbiol Rev 2020; 34:34/1/e00043-19. [PMID: 33115722 PMCID: PMC7920732 DOI: 10.1128/cmr.00043-19] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hosts with compromised or naive immune systems, such as individuals living with HIV/AIDS, transplant recipients, and fetuses, are at the highest risk for complications from cytomegalovirus (CMV) infection. Despite substantial progress in prevention, diagnostics, and treatment, CMV continues to negatively impact both solid-organ transplant (SOT) and hematologic cell transplant (HCT) recipients. In this article, we summarize important developments in the field over the past 10 years and highlight new approaches and remaining challenges to the optimal control of CMV infection and disease in transplant settings.
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Affiliation(s)
- Ajit P Limaye
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Tara M Babu
- Division of Infectious Diseases, University of Rochester Medical Center, Rochester, New York, USA
- Department of Infectious Diseases, Overlake Medical Center, Bellevue, Washington, USA
| | - Michael Boeckh
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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47
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Derigs P, Radujkovic A, Schubert ML, Schnitzler P, Schöning T, Müller-Tidow C, Hegenbart U, Schönland SO, Luft T, Dreger P, Schmitt M. Letermovir prophylaxis is effective in preventing cytomegalovirus reactivation after allogeneic hematopoietic cell transplantation: single-center real-world data. Ann Hematol 2020; 100:2087-2093. [PMID: 33270162 PMCID: PMC8285358 DOI: 10.1007/s00277-020-04362-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 11/23/2020] [Indexed: 11/28/2022]
Abstract
Morbidity and mortality after allogeneic hematopoietic cell transplantation (alloHCT) are still essentially affected by reactivation of cytomegalovirus (CMV). We evaluated 80 seropositive patients transplanted consecutively between March 2018 and March 2019 who received letermovir (LET) prophylaxis from engraftment until day +100 and retrospectively compared them with 80 patients without LET allografted between January 2017 and March 2018. The primary endpoint of this study was the cumulative incidence (CI) of clinically significant CMV infection (CS-CMVi) defined as CMV reactivation demanding preemptive treatment or CMV disease. With 14% CI of CS-CMVi at day +100 (11 events) was significantly lower in the LET cohort when compared to the control group (33 events, 41%; HR 0.29; p < 0.001). Whereas therapy with foscarnet could be completely avoided in the LET group, 7 out of 80 patients in the control cohort received foscarnet, resulting in 151 extra in-patient days for foscarnet administration (p = 0.002). One-year overall survival was 72% in the control arm vs 84% in the LET arm (HR 0.75 [95%CI 0.43–1.30]; p < 0.306). This study confirms efficacy and safety of LET for prophylaxis of CS-CMVi after alloHCT in a real-world setting, resulting in a significant patient benefit by reducing hospitalization needs and exposure to potentially toxic antiviral drugs for treatment of CMV reactivation.
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Affiliation(s)
- Patrick Derigs
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Aleksandar Radujkovic
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Maria-Luisa Schubert
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Paul Schnitzler
- Center for Infectious Diseases, Virology, Heidelberg University Hospital, Heidelberg, Germany
| | - Tilman Schöning
- Department of Pharmacy, Heidelberg University Hospital, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Ute Hegenbart
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Stefan O Schönland
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Thomas Luft
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Peter Dreger
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Michael Schmitt
- Department of Internal Medicine V (Hematology/Oncology/Rheumatology), Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
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48
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Chan TSY, Cheng SSY, Chen WT, Hsu DC, Chau RWY, Kang SH, Alsumali A, Kwong YL. Cost-effectiveness of letermovir as cytomegalovirus prophylaxis in adult recipients of allogeneic hematopoietic stem cell transplantation in Hong Kong. J Med Econ 2020; 23:1485-1492. [PMID: 33155494 DOI: 10.1080/13696998.2020.1843321] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The cost-effectiveness of letermovir as cytomegalovirus (CMV) prophylaxis in adult seropositive patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT), compared with the conventional strategy of preemptive treatment, has not been evaluated in Asia. METHODS A decision analytical model, simulating the clinical progression of CMV infection on a lifetime horizon, was developed to compare prophylactic strategy with letermovir with preemptive therapy alone as anti-CMV strategies. Prophylaxis comprised administering letermovir for 14 weeks, with clinical outcomes measured at 24 weeks, followed by preemptive therapy if CMV infection occurred. This approach was modeled on outcomes of the letermovir phase 3 clinical study. The model enumerated the cost of letermovir prophylaxis, quality-adjusted life years (QALYs), and incremental cost per QALYs gained with prophylaxis. The opposite arm involved regular monitoring and preemptive therapy for CMV reactivation. Real-world costs from the adult HSCT center at Queen Mary Hospital, Hong Kong, were adopted for analysis. Costs and clinical benefits, expressed as QALYs, were discounted at 3% per year. RESULTS Letermovir prophylaxis compared with preemptive therapy only would lead to an increase of life-year and QALYs at increased costs. Incremental cost-effectiveness analysis showed that letermovir prophylaxis had an associated cost of HKD 193,580 for each life-year gained, and HKD 234,675 for each QALY gained. Probabilistic sensitivity analysis showed that the majority of incremental cost-effectiveness ratio fell below the cost-effectiveness threshold of HKD 382,046 (one gross domestic product per capita) per QALY gained. CONCLUSIONS Letermovir prophylaxis would be cost-effective for preventing CMV infection in adult seropositive allogeneic HSCT recipients in Hong Kong.
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Affiliation(s)
| | | | - Wei-Ting Chen
- Global Medical & Scientific Affairs, MSD, Taipei, Taiwan
| | - Danny Chung Hsu
- Global Medical & Scientific Affairs, MSD, Hong Kong, Hong Kong
| | | | - Suk Hyun Kang
- Centre for Observational and Real-world Evidence, MSD, Seoul, Korea
| | | | - Yok-Lam Kwong
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
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49
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Bacigalupo A, Metafuni E, Amato V, Marquez Algaba E, Pagano L. Reducing infectious complications after allogeneic stem cell transplant. Expert Rev Hematol 2020; 13:1235-1251. [PMID: 32996342 DOI: 10.1080/17474086.2020.1831382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Infections remain a significant problem, in patients undergoing an allogeneic hematopoietic stem-cell transplant (HSCT) and efforts have been made over the years, to reduce the incidence, morbidity and mortality of infectious complications. AREAS COVERED This manuscript is focused on the epidemiology, risk factors and prevention of infections after allogeneic HSCT. A systematic literature review was performed using the PubMed database, between November 2019 and January 2020, with the following MeSH terms: stem-cell transplantation, infection, fungal, bacterial, viral, prophylaxis, vaccines, prevention. The authors reviewed all the publications, and following a common revision, a summary report was made and results were divided in three sections: bacterial, fungal and viral infections. EXPERT OPINION Different infections occur in the early, intermediate and late post-transplant period, due to distinct risk factors. Improved diagnostic techniques, pre-emtive therapy and better prophylaxis of immunologic complications, have reduced the morbidity and mortality of infections. The role of the gut microbiota is under careful scrutiny and may further help us to identify high-risk patients.
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Affiliation(s)
- Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy
| | - Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy
| | - Viviana Amato
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy
| | - Ester Marquez Algaba
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona , Barcelona, Spain
| | - Livio Pagano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica Del Sacro Cuore , Rome, Italy
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50
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Efficacy of prophylactic letermovir for cytomegalovirus reactivation in hematopoietic cell transplantation: a multicenter real-world data. Bone Marrow Transplant 2020; 56:853-862. [DOI: 10.1038/s41409-020-01082-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/20/2020] [Accepted: 09/29/2020] [Indexed: 12/19/2022]
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