Management of cytomegalovirus infection in haemopoietic stem cell transplantation

Abstract

● Cytomegalovirus (CMV) infection and CMV diseaseshould be diagnosed according to established, interna-tionally accepted, standardized criteria (Grade 1C).● Risk-adapted patient assessment should inform clinicalmanagement (Grade 1B).● All potential haemopoietic stem cell transplantation(HSCT) recipients should be tested for the presence ofCMV IgG antibody at diagnosis (Grade 1C).● Once optimum human leucocyte antigen (HLA) match-ing has been performed, a CMV IgG-negative donorshould be chosen for a CMV IgG-negative recipient anda CMV IgG-positive donor should be chosen for a CMVIgG-positive recipient when possible (Grade 1A).● Donors or recipients who are initially found to be CMVIgG-negative should be retested pre-transplant toexclude primary CMV infection (Grade 1C).● Apparent CMV seroconversion in potential allograftrecipients who have received unscreened blood productsshould be actively investigated to exclude passive acqui-sition of antibody (Grade 1C)● Any CMV IgG-negative HSCT recipient transplantedfrom a CMV IgG-negative donor who develops CMVinfection post-transplant must be reported to the SeriousHazards of Transfusion (SHOT) scheme (Grade 1C).● Primary prophylaxis with ganciclovir is not generallyrecommended as toxicity outweighs efficacy in HSCTpatients (Grade 1B).● Primary prophylaxis with aciclovir or valaciclovir canbe deployed but only in conjunction with appropriatemonitoring of CMV in blood (Grade 1B).● Valaciclovir or valganciclovir are valid treatmentoptions for secondary prophylaxis with appropriatemonitoring of CMV in blood (Grade 1C).● Intravenous immunoglobulin is not recommended forprophylaxis of CMV infection (Grade 1A).● Real time quantitative polymerase chain reaction (PCR)is the preferred choice for monitoring CMV DNA levelsin HSCT patients (Grade 1B).● All diagnostic laboratories should deploy the CMVinternational standard to allow viral loads to becompared between centres (Grade 1C).● Monitoring of CMV load should be undertaken atleast weekly for the first 3 months post-HSCT (Grade2C).● CMV viral load monitoring should continue for 6-12 months if the patient has chronic graft-versus-hostdisease (GvHD) or prolonged T-cell immunodeficiency(Grade 1B).● Each transplant centre should have a risk-adapted policydetailing threshold values for treatment of CMV infec-tion, taking into account patient factors and PCR meth-odology (Grade 2C).● Ganciclovir is recommended as first line pre-emptivetherapy for CMV in HSCT patients (Grade 1A).● Oral valganciclovir is a valid alternative when gastroin-testinal absorption is normal or only minimallyimpaired (Grade 1A).● Foscarnet is recommended as an alternative first-lineagent if neutropenia is present or for ganciclovir treat-ment failure (Grade 1A).