Cytomegalovirus Organism-Specific Therapy 

Updated: Dec 02, 2015
  • Author: Kauser Akhter, MD; Chief Editor: Thomas E Herchline, MD  more...
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Organism-Specific Therapeutic Regimens

Organism-specific therapeutic and prophylactic regimens for cytomegalovirus (CMV) infection are provided below, including those for patients with HIV-associated CMV retinitis; those with pneumonia, hepatitis, and gastrointestinal (GI) CMV infection; and those who have undergone transplant procedures. [1, 2, 3]

Retinitis in patients with HIV infection

See the list below:

  • Initial induction therapy followed by maintenance therapy
  • Therapy is continued until immune reconstitution occurs

Preferred regimen:

Alternative regimens:

  • Ganciclovir 5 mg/kg IV q12h for 14d, then ganciclovir (5 mg/kg IV once daily or 6 mg/kg IV once daily for 5d/wk) or valganciclovir 900 mg/day PO or
  • Foscarnet 90 mg/kg IV q12h for 14d, then 90 mg/kg IV daily or
  • Cidofovir 5 mg/kg IV once weekly for 2wk, then 5 mg/kg IV once weekly

Pneumonia, hepatitis, GI CMV infection

Preferred regimens:

  • Valganciclovir 900 mg PO BID for 14-28d or
  • Ganciclovir 5 mg/kg IV q12h for 14-28d
  • In transplant patients, therapy is continued until clearance of viremia is documented

Alternative regimens:

  • Foscarnet 90 mg/kg IV q12h for 14-28d or
  • Cidofovir 5 mg/kg IV once weekly for 2wk, then 5 mg/kg IV once every 2wk or
  • Leflunomide 100 mg/day PO (not approved by the US Food and Drug Administration [FDA] for this indication) [4] or
  • CMV IV immune globulin (150 mg/kg twice weekly for 2 wk, then weekly for 4wk) should also be given for pneumonitis in hematopoietic cell transplant (HCT) recipients or for refractory CMV infection in any setting

Posttransplant prophylaxis

Solid-organ transplant:

  • Valganciclovir 900 mg/day PO for 3-6mo after transplant or
  • Ganciclovir 5 mg/kg IV daily for 3-6mo after transplant

HCT:

  • Ganciclovir 5 mg/kg IV q12h for 5-7d beginning at engraftment, then 5 mg/kg IV once daily until 100d after transplant or
  • Foscarnet 60 mg/kg IV q12h for 7d, then 90-120 mg/kg IV once daily until 100d after transplant or
  • Valganciclovir 2 g PO TID until 100d after transplant

Posttransplant preemptive treatment

See the list below:

  • Preemptive treatment is an alternative to prophylaxis
  • Preemptive treatment requires frequent (once- or twice weekly) monitoring for evidence of CMV replication on antigen assay or quantitative polymerase chain reaction (PCR)
  • If viremia is detected, begin induction treatment; various centers use different protocols once viremia is suppressed

Additional considerations

See the list below:

  • Ganciclovir dosing must be adjusted in renal failure – For a creatinine clearance (CrCl) of 50-79 mL/min, the daily dose is reduced by 50%; for CrCl 25-49 mL/min, by 75%; for CrCl 10-24 mL/min, by 87.5%
  • Valganciclovir dosing must be adjusted in renal failure – For CrCl 40-59 mL/min, the daily dose is reduced by 50%; for CrCl 25-39 mL/min, by 75%; for CrCl 10-24 mL/min, by 87.5%
  • Foscarnet dosing must be adjusted in renal failure – For CrCl 72-98 mL/min, the daily dose is reduced by 22%; for CrCl 58-71 mL/min, by 45%; for CrCl 43-57 mL/min, by 56%; for CrCl 36-42 mL/min, by 67%; for CrCl 29-35 mL/min, by 72%; for CrCl < 29mL/min, foscarnet is not recommended
  • Cidofovir dosing is complicated; refer to manufacturer’s package insert
  • Toxicity may be the limiting factor for the administration of ganciclovir (neutropenia), valganciclovir (neutropenia), foscarnet (nephrotoxicity), and cidofovir (nephrotoxicity)
  • Diagnostic modalities include quantitative CMV DNA PCR (preferred in transplant settings), antigen assay, viral culture, and histopathology (intranuclear inclusions)
  • CMV resistance mutations should be suspected in patients who initially respond to anti-CMV treatment and subsequently develop an increasing viral load despite compliance with drug therapy; they should also be suspected if the patient’s condition deteriorates on ganciclovir therapy [5]