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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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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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Freyer CW, Carulli A, Gier S, Ganetsky A, Timlin C, Schuster M, Babushok D, Frey NV, Gill SI, Hexner EO, Luger SM, Mangan JK, Martin ME, McCurdy SR, Perl AE, Porter DL, Pratz K, Smith J, Stadtmauer EA, Loren AW. Letermovir vs. high-dose valacyclovir for cytomegalovirus prophylaxis following haploidentical or mismatched unrelated donor allogeneic hematopoietic cell transplantation receiving post-transplant cyclophosphamide. Leuk Lymphoma 2022; 63:1925-1933. [PMID: 35188052 DOI: 10.1080/10428194.2022.2042686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients undergoing haploidentical or mismatched unrelated donor (haplo/MMUD) allogeneic hematopoietic cell transplantation (alloHCT) receiving post-transplant cyclophosphamide (PTCy) are at high risk of cytomegalovirus (CMV) infection. Experience with letermovir (LET) in this population is limited. This single center retrospective cohort study compared CMV and transplant outcomes between LET and a historical control with high-dose valacyclovir (HDV) prophylaxis in adults undergoing haplo/MMUD alloHCT. Thirty-eight CMV seropositive patients were included, 19 in each arm. LET reduced the incidence of CMV infection (5% vs. 53%, RR 0.01, 95% CI 0.014-0.71, p = .001) and need for CMV treatment by day +100 (5% vs. 37%, RR 0.14, 95% CI 0.18-0.99, p = .017) compared to HDV. Median CMV event-free-survival was improved with LET (not reached vs. 80 days, HR 0.114, 95% CI 0.07-0.61, p = .004). These data support the efficacy of LET in alternative donor transplants.
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Affiliation(s)
- Craig W Freyer
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alison Carulli
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shannon Gier
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Alex Ganetsky
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen Timlin
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mindy Schuster
- Infectious Diseases Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Daria Babushok
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Noelle V Frey
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Saar I Gill
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Elizabeth O Hexner
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Selina M Luger
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - James K Mangan
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Mary Ellen Martin
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Shannon R McCurdy
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Alexander E Perl
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - David L Porter
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Keith Pratz
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Jacqueline Smith
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Edward A Stadtmauer
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Alison W Loren
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
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Gurgel Assis MS, Fernandes Pedrosa TC, de Moraes FS, Caldeira TG, Pereira GR, de Souza J, Ruela ALM. Novel Insights to Enhance Therapeutics With Acyclovir in the Management of Herpes Simplex Encephalitis. J Pharm Sci 2021; 110:1557-1571. [PMID: 33450220 DOI: 10.1016/j.xphs.2021.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 11/17/2022]
Abstract
Acyclovir is an antiviral drug poorly absorbed in the gastrointestinal tract due to its hydrophilicity, with low oral bioavailability (~20%). Although acyclovir is prescribed in the management of herpes simplex encephalitis (HSE), the disease has a poor prognosis, particularly if the treatment is delayed, reaching mortality rates of 70% if left untreated. Thus, high acyclovir doses are administered by intravenous (IV) infusion, usually at a dosage of 10 mg kg-1 8-hourly in adults with normal renal function. However, the mortality related to HSE treated with acyclovir remains high (~20%) and permanent sequelae are commonly reported after 1 year (~50%). This review analyzed clinical trials following IV acyclovir administration. Novel insights aiming to improve drug bioavailability were reviewed, including acyclovir or its prodrugs, leading to the systemic distribution of the drug or drug targeting. Much research effort has been made to improve antiviral therapy, searching for delivery systems increasing acyclovir bioavailability by non-invasive pathways, such as oral and nasal pathways, or parenterally administered nanotechnology-based systems leading to drug targeting. Nanocarriers administered by non-invasive pathways represent feasible alternatives to treat HSE, even though not be industrially manufactured yet.
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Affiliation(s)
- Maria Silvia Gurgel Assis
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
| | | | - Fernanda Segurasse de Moraes
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
| | - Tamires Guedes Caldeira
- Graduate Program in Pharmaceutical Sciences-CiPharma, School of Pharmacy, UFOP, Minas Gerais, Brazil
| | - Gislaine Ribeiro Pereira
- Faculty of Pharmaceutical Sciences, Federal University of Alfenas (UNIFAL-MG), Alfenas, Minas Gerais, Brazil
| | - Jacqueline de Souza
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil
| | - André Luís Morais Ruela
- Department of Pharmacy, School of Pharmacy, Federal University of Ouro Preto (UFOP), Ouro Preto, Minas Gerais, Brazil.
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Clinical features of cytomegalovirus retinitis after solid organ transplantation versus hematopoietic stem cell transplantation. Graefes Arch Clin Exp Ophthalmol 2020; 259:585-591. [PMID: 32761472 DOI: 10.1007/s00417-020-04871-w] [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] [Received: 04/27/2020] [Revised: 07/08/2020] [Accepted: 07/27/2020] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To investigate and compare the clinical features of cytomegalovirus (CMV) retinitis after solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT) and to determine the poor prognostic factors. METHODS Patients consulted to the ophthalmology department for CMV viremia after transplantation between March 2008 and February 2018 and followed for more than 6 months were analyzed. Medical records regarding demographic, serologic, and ocular characteristics were compared between the SOT and HSCT groups. Factors associated with poor visual outcomes were determined with logistic regression. RESULTS CMV retinitis developed in 11.3% of patients with CMV viremia following transplantation. In the SOT group (25 eyes/18 patients) and the HSCT group (33 eyes/21 patients), CMV retinitis occurred at 5.8 months and 3.7 months post-transplantation, respectively. Mortality was significantly higher in the HSCT group (52.4% vs. 5.6%, P < 0.001). During the mean 11.7 months of follow-up, visual acuity tended to be aggravated (P = 0.087) despite antiviral treatment, which was especially notable in the SOT group (P = 0.028). Six eyes (10.3%) underwent vitrectomy due to retinal detachment, most of which (5 eyes) were in the SOT group. Multivariate logistic regression analysis showed that the presence of concurrent CMV disease (OR = 14.11, P = 0.009) and foveal involvement (OR = 114.85, P = 0.001) were poor prognostic factors. CONCLUSION Clinical manifestations of CMV retinitis differed between the HSCT and SOT group. Concurrent CMV diseases and foveal involvement were associated with poor visual outcomes in CMV retinitis following transplantation.
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Lee DH, Zuckerman RA. Herpes simplex virus infections in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13526. [PMID: 30859647 DOI: 10.1111/ctr.13526] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 02/27/2019] [Indexed: 12/19/2022]
Abstract
These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of HSV in the pre- and post-transplant period. A majority of transplant recipients are seropositive for HSV-1 or 2. Compared with immunocompetent persons, SOT recipients shed HSV more frequently, have more severe clinical manifestations, and are slower to respond to therapy. Most HSV infection is diagnosed on clinical grounds, but patients may present with atypical lesions and/or other clinical manifestations. Acquisition from the donor is rare. Polymerase chain reaction is the preferred diagnostic test unless culture is needed for resistance testing. For limited mucocutaneous lesions, oral therapy can be used; however, in severe, disseminated, visceral or CNS involvement, acyclovir doses of up to 10 mg/kg every 8 hours intravenously should be initiated. Acyclovir-resistant HSV is less common in SOT patients than in HSCT and can be treated with foscarnet, though other novel therapies are currently under investigation. HSV-specific prophylaxis should be considered for all HSV-1 and HSV-2-seropositive organ recipients who are not receiving antiviral medication for CMV prevention that has activity against HSV.
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Affiliation(s)
- Dong H Lee
- Division of Infectious Diseases and HIV Medicine, College of Medicine, Drexel University, Philadelphia, Pennsylvania
| | - Richard A Zuckerman
- Infectious Disease Service for Transplant and Immunocompromised Hosts, Section of Infectious Disease and International Health, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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7
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Antiviral prophylaxis for cytomegalovirus infection in allogeneic hematopoietic cell transplantation. Blood Adv 2019; 2:2159-2175. [PMID: 30154125 DOI: 10.1182/bloodadvances.2018016493] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/13/2018] [Indexed: 01/07/2023] Open
Abstract
Patients treated with allogeneic hematopoietic cell transplantation (HCT) are at risk of cytomegalovirus (CMV) reactivation and disease, which results in increased morbidity and mortality. Although universal antiviral prophylaxis against CMV improves outcomes in solid organ transplant recipients, data have been conflicting regarding such prophylaxis in patients undergoing allogeneic HCT. We conducted a systematic review of randomized trials of prophylactic antivirals against CMV after allogeneic HCT to summarize the evolution of the field over the last 35 years and evaluate the prophylactic potential of antiviral agents against CMV after allogeneic HCT. Electronic databases were queried from database inception through 31 December 2017. For included studies, incidence of CMV infection and all-cause mortality were collected as primary outcomes; CMV disease incidence, use of preemptive therapy, and drug toxicities were collected as secondary outcomes. Nineteen clinical trials conducted between 1981 and 2017 involving a total of 4173 patients were included for review. Prophylactic strategies included use of acyclovir, valacyclovir, ganciclovir, maribavir, brincidofovir, and letermovir compared with placebo or a comparator antiviral. Fourteen trials that compared antiviral prophylaxis with placebo demonstrated overall effectiveness in reducing incidence of CMV infection (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.42-0.58), CMV disease (OR, 0.56; 95% CI, 0.40-0.80), and use of preemptive therapy (OR, 0.51; 95% CI, 0.42-0.62; 6 trials); however, none demonstrated reduction in all-cause mortality (OR, 0.96; 95% CI, 0.78-1.18) except the phase 3 trial of letermovir (week-24 OR, 0.59; 95% CI, 0.38-0.98). Additional research is warranted to determine patient groups most likely to benefit from antiviral prophylaxis and its optimal deployment after allogeneic HCT.
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Webb BJ, Harrington R, Schwartz J, Kammerer J, Spalding J, Lee E, Dodds B, Kaufusi S, Goodman BE, Firth SD, Martin G, Sorensen J, Hoda D. The clinical and economic impact of cytomegalovirus infection in recipients of hematopoietic stem cell transplantation. Transpl Infect Dis 2018; 20:e12961. [PMID: 29975816 DOI: 10.1111/tid.12961] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 05/12/2018] [Accepted: 06/19/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND CMV infection (CMV-I) remains an important complication of hematopoietic stem cell transplantation (HSCT). METHODS This was a retrospective, single-center cohort study in HSCT recipients. Primary outcomes were adjusted cost and all-cause mortality. Secondary analyses investigated CMV risk factors and the effect of serostatus. RESULTS Overall, 690 transplant episodes were included (allogeneic [n = 310]; autologous [n = 380]). All received preemptive CMV antiviral therapy at first detectable DNAemia. CMV-I occurred in 34.8% of allogeneic and 2.1% of autologous transplants; median time to onset was 45 days. In allogeneic HSCT recipients, the primary risk factor for CMV-I was CMV donor/recipient (D/R) serostatus. In a Markov multi-state model for allogeneic HSCT recipients, the hazard ratio for CMV-I and relapse was 1.5 (95% CI 0.8-2.8) and for CMV-I and mortality 2.4 (95% CI 0.9-6.5). In a multivariable model for all patients, CMV-I was associated with increased total cost (coefficient = 0.21, estimated incremental daily cost USD $500; P = 0.02). Cost was attenuated in allogeneic HSCT recipients (coefficient = 0.13, USD $699 vs $613, or $24 892 per transplant episode; P = 0.23). CMV disease (CMV-D) complicated 29.6% of CMV-I events in allogeneic HSCT recipients, but was not associated with an incrementally increased adjusted risk of mortality compared with CMV-I alone. CMV-I (56.4%) and CMV-D (19.8%) were significantly overrepresented in D-/R+ serostatus HSCT recipients, and mortality was higher in R+ HSCT recipients. CONCLUSIONS Despite early preemptive antiviral treatment, CMV-I impacts clinical outcomes and cost after HSCT, but the impact on cost is less pronounced in allogeneic HSCT recipients compared with autologous HSCT recipients.
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Affiliation(s)
- Brandon J Webb
- Division of Infectious Disease, Intermountain Healthcare, Salt Lake City, Utah
| | | | - Jason Schwartz
- Astellas Pharma Global Development, Inc., Northbrook, Illinois
| | | | - James Spalding
- Astellas Pharma Global Development, Inc., Northbrook, Illinois
| | - Edward Lee
- Astellas Pharma Global Development, Inc., Northbrook, Illinois
| | - Bart Dodds
- Innovations and Business Development, Intermountain Healthcare, Salt Lake City, Utah
| | - Stephanie Kaufusi
- Innovations and Business Development, Intermountain Healthcare, Salt Lake City, Utah
| | - Bruce E Goodman
- Innovations and Business Development, Intermountain Healthcare, Salt Lake City, Utah
| | - Sean D Firth
- Innovations and Business Development, Intermountain Healthcare, Salt Lake City, Utah
| | - Greta Martin
- Innovations and Business Development, Intermountain Healthcare, Salt Lake City, Utah
| | - Jeffrey Sorensen
- Statistical Data Center, Office of Research, Intermountain Healthcare, Salt Lake City, Utah
| | - Daanish Hoda
- Intermountain Blood and Marrow Transplant/Acute Leukemia Program, Salt Lake City, Utah
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Gagelmann N, Ljungman P, Styczynski J, Kröger N. Comparative Efficacy and Safety of Different Antiviral Agents for Cytomegalovirus Prophylaxis in Allogeneic Hematopoietic Cell Transplantation: A Systematic Review and Meta-Analysis. Biol Blood Marrow Transplant 2018; 24:2101-2109. [PMID: 29777868 DOI: 10.1016/j.bbmt.2018.05.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 05/15/2018] [Indexed: 11/17/2022]
Abstract
Over the past 25 years, several randomized controlled trials have investigated the efficacy of different antiviral agents for cytomegalovirus (CMV) prophylaxis in allogeneic hematopoietic cell transplantation. We performed a systematic literature review, conventional meta-analysis, and network meta-analysis using a random-effects model and risk ratios (RRs) with corresponding 95% confidence intervals (CIs) as effect estimates. Fifteen randomized controlled trials were identified, including 7 different antiviral agents: acyclovir, ganciclovir, maribavir, brincidofovir, letermovir, valacyclovir, and vaccine. Twelve trials used placebo as comparator while 3 trials compared different antiviral agents. We found evidence for CMV disease and infection being significantly reduced by antiviral prophylaxis, with an RR of .66 (95% CI, .48 to .90) and .63 (95% CI, .50 to .79). Across the network, ganciclovir showed the best relative efficacy for CMV disease while letermovir provided first rank of being the best option for CMV infection. The risk for death was not significantly influenced by antiviral prophylaxis in the meta-analysis, with an RR of .92 (95% CI, .78 to 1.08), as well as in the network meta-analysis. In terms of safety, letermovir was at least similar in comparison with placebo and most agents while both letermovir and acyclovir showed significantly reduced risk for serious adverse events compared with ganciclovir, with RRs of .55 (95% CI, .30 to 1.00) for letermovir and .63 (95% CI, .42 to .93) for acyclovir. With a probability of 81%, letermovir appears to be the best option in terms of safety. Future randomized head-to-head comparisons are needed to evaluate the definite efficacy and safety of different prophylactic strategies.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jan Styczynski
- Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Triplett BM, Muller B, Kang G, Li Y, Cross SJ, Moen J, Cunningham L, Janssen W, Mamcarz E, Shook DR, Srinivasan A, Choi J, Hayden RT, Leung W. Selective T-cell depletion targeting CD45RA reduces viremia and enhances early T-cell recovery compared with CD3-targeted T-cell depletion. Transpl Infect Dis 2018; 20. [PMID: 29178554 DOI: 10.1111/tid.12823] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 08/04/2017] [Accepted: 08/29/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND T-cell depletion (TCD) effectively reduces severe graft-versus-host disease in recipients of HLA-mismatched allografts. However, TCD is associated with delayed immune recovery and increased infections. We hypothesized that specific depletion of CD45RA+ naive T cells, rather than broad depletion of CD3+ T cells, can preserve memory-immunity in the allografts and confer protection against important viral infections in the early post-transplant period. METHODS Sixty-seven patients who received TCD haploidentical donor transplantation for hematologic malignancy on 3 consecutive trials were analyzed. RESULTS Patients receiving CD45RA-depleted donor grafts had 2000-fold more donor T cells infused, significantly higher T-cell counts at Day +30 post transplant (550/μL vs 10/μL; P < .001), and higher T-cell diversity by Vbeta spectratyping at Day +100 (P < .001). Importantly, these recipients experienced a significant reduction in both the incidence (P = .002) and duration (P = .02) of any viremia (cytomegalovirus, Epstein-Barr virus, or adenovirus) in the first 6 months post transplant. Specifically, recipients of CD3-depleted grafts were more likely to experience adenovirus viremia (27% vs 4%, P = .02). CONCLUSION CD45RA-depletion provided a large number of donor memory T cells to the recipients and was associated with enhanced early T-cell recovery and protection against viremia.
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Affiliation(s)
- Brandon M Triplett
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Brad Muller
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ying Li
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Shane J Cross
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Joseph Moen
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Lea Cunningham
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - William Janssen
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ewelina Mamcarz
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - David R Shook
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Ashok Srinivasan
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - John Choi
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Randall T Hayden
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wing Leung
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA.,Department of Pediatrics, University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
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11
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Hammerstrom AE, Lombardi LR, Pingali SR, Rondon G, Chen J, Milton DR, Chemaly RF, Champlin RE, Gulbis A, Ciurea SO. Prevention of Cytomegalovirus Reactivation in Haploidentical Stem Cell Transplantation. Biol Blood Marrow Transplant 2017; 24:353-358. [PMID: 28986189 DOI: 10.1016/j.bbmt.2017.09.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 09/28/2017] [Indexed: 12/19/2022]
Abstract
Cytomegalovirus (CMV) infection can increase the morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT). Because of a higher degree of immunosuppression, haploidentical transplant recipients may be at an increased risk of viral infections, particularly CMV. We retrospectively analyzed 86 haploidentical HCT recipients at our institution to determine whether a more intensified antiviral strategy would reduce the incidence of CMV reactivation compared with a traditional antiviral prophylaxis regimen. According to practice changes over time in antiviral prophylaxis at our institution, patients were divided into the following 3 groups: hybrid (n = 15), traditional (n = 26), and intermediate dose (n = 45). The hybrid group received valganciclovir from admission to day -2 followed by standard-dose valacyclovir. The traditional group received standard-dose valacyclovir starting on day -1. The intermediate-dose group received ganciclovir from admission through day -2, followed by intermediate-dose valacyclovir. The hybrid and intermediate-dose groups were combined into an intensified group for further analysis. We found the cumulative incidence (CI) of CMV reactivation within 100 days post-HCT was higher for patients receiving the traditional strategy compared with the hybrid and intermediate-dose strategy groups (81% versus 53% versus 71%, respectively; P = .08) and was significantly higher when the traditional group was compared against the intensified group (81% versus 67%, respectively; P = .032). Median time to CMV reactivation was also shorter in the traditional group versus the intensified group (31 versus 41 days, respectively). Moreover, the CI of CMV disease by day 100 was significantly worse for patients receiving the traditional prophylaxis strategy among the 3 groups (8% traditional versus 0% hybrid versus 0% intermediate dose; P = .032). Renal toxicity did not differ between the traditional and intensified group. In conclusion, an intensified approach to prevention of CMV reactivation was associated with lower incidence of CMV reactivation and less CMV disease without increased toxicity. Because the most benefit was observed in the intensified group, further studies are needed to assess which antiviral intervention is the most beneficial on lowering the rates of CMV viremia and disease.
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Affiliation(s)
- Aimee E Hammerstrom
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Lindsey R Lombardi
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sai Ravi Pingali
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Denái R Milton
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alison Gulbis
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stefan O Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
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12
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Roquelaure D, Harbarth S, Schutz JS, Thumann G, Chronopoulos A. Epstein-Barr-Virus-assoziierte akute retinale Nekrose. Ophthalmologe 2016; 113:864-866. [DOI: 10.1007/s00347-016-0229-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Kim T, Lee YM, Lee SO, Choi SH, Kim YS, Woo JH, Sung H, Jung JH, Shin S, Kim YH, Kang YA, Lee YS, Lee JH, Lee JH, Lee KH, Park SK, Han DJ, Kim SH. Differences of cytomegalovirus diseases between kidney and hematopoietic stem cell transplant recipients during preemptive therapy. Korean J Intern Med 2016; 31:961-70. [PMID: 27055664 PMCID: PMC5016278 DOI: 10.3904/kjim.2015.079] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/22/2015] [Accepted: 06/30/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND/AIMS Cytomegalovirus (CMV) surveillance and preemptive therapy is a widely-used strategy for preventing CMV disease in transplant recipients. However, there are limited data on the incidence and patterns of CMV disease during the preemptive period. Thus, we investigated the incidence and pattern of tissue-invasive CMV disease in CMV seropositive kidney transplantation (KT) and hematopoietic stem cell transplantation (HCT) recipients during preemptive therapy. METHODS We prospectively identified patients with tissue-invasive CMV disease among 664 KT (90%) and 496 HCT (96%) recipients who were D+/R+ (both donor and recipient seropositive) during a 4-year period. RESULTS The incidence rates of CMV disease were 4.1/100 person-years (4%, 27/664) in KT recipients and 5.0/100 person-years (4%, 21/496) in HCT recipients. Twenty-six (96%) of the KT recipients with CMV disease had gastrointestinal CMV, whereas 17 (81%) of the HCT recipients had gastrointestinal CMV and 4 (19%) had CMV retinitis. Thus, CMV retinitis was more common among HCT recipients (p = 0.03). All 27 KT recipients with CMV disease suffered abrupt onset of CMV disease before or during preemptive therapy; 10 (48%) of the 21 HCT recipients with CMV disease were also classified in this way but the other 11 (52%) were classified as CMV disease following successful ganciclovir preemptive therapy (p < 0.001). CONCLUSIONS The incidence of CMV disease was about 4% in both KT and HCT recipients during preemptive therapy. However, CMV retinitis and CMV disease as a relapsed infection were more frequently found among HCT recipients.
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Affiliation(s)
- Tark Kim
- Division of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yu-Mi Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Infectious Diseases, Inje University Busan Paik Hospital, Busan, Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Hee Woo
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heungsup Sung
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Hee Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hoon Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Ah Kang
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Shin Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Hee Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoo-Hyung Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su-Kil Park
- Department of Nephrology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duck Jong Han
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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14
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Ullmann AJ, Schmidt-Hieber M, Bertz H, Heinz WJ, Kiehl M, Krüger W, Mousset S, Neuburger S, Neumann S, Penack O, Silling G, Vehreschild JJ, Einsele H, Maschmeyer G. Infectious diseases in allogeneic haematopoietic stem cell transplantation: prevention and prophylaxis strategy guidelines 2016. Ann Hematol 2016; 95:1435-55. [PMID: 27339055 PMCID: PMC4972852 DOI: 10.1007/s00277-016-2711-1] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/28/2016] [Indexed: 12/13/2022]
Abstract
Infectious complications after allogeneic haematopoietic stem cell transplantation (allo-HCT) remain a clinical challenge. This is a guideline provided by the AGIHO (Infectious Diseases Working Group) of the DGHO (German Society for Hematology and Medical Oncology). A core group of experts prepared a preliminary guideline, which was discussed, reviewed, and approved by the entire working group. The guideline provides clinical recommendations for the preventive management including prophylactic treatment of viral, bacterial, parasitic, and fungal diseases. The guideline focuses on antimicrobial agents but includes recommendations on the use of vaccinations. This is the updated version of the AGHIO guideline in the field of allogeneic haematopoietic stem cell transplantation utilizing methods according to evidence-based medicine criteria.
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Affiliation(s)
- Andrew J Ullmann
- Department of Internal Medicine II, Division of Hematology and Oncology, Division of Infectious Diseases, Universitätsklinikum, Julius Maximilian's University, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| | - Martin Schmidt-Hieber
- Clinic for Hematology, Oncology und Tumor Immunology, Helios Clinic Berlin-Buch, Berlin, Germany
| | - Hartmut Bertz
- Department of Hematology/Oncology, University of Freiburg Medical Center, 79106, Freiburg, Germany
| | - Werner J Heinz
- Department of Internal Medicine II, Division of Hematology and Oncology, Division of Infectious Diseases, Universitätsklinikum, Julius Maximilian's University, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Michael Kiehl
- Medical Clinic I, Klinikum Frankfurt (Oder), Frankfurt (Oder), Germany
| | - William Krüger
- Haematology and Oncology, Stem Cell Transplantation, Palliative Care, University Hospital Greifswald, Greifswald, Germany
| | - Sabine Mousset
- Medizinische Klinik III, Palliativmedizin und interdisziplinäre Onkologie, St. Josefs-Hospital Wiesbaden, Wiesbaden, Germany
| | - Stefan Neuburger
- Sindelfingen-Böblingen Clinical Centre, Medical Department I, Division of Hematology and Oncology, Klinikverbund Südwest, Sindelfingen, Germany
| | | | - Olaf Penack
- Hematology, Oncology and Tumorimmunology, Charité University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Gerda Silling
- Department of Internal Medicine IV, University Hospital RWTH Aachen, Aachen, Germany
| | - Jörg Janne Vehreschild
- Department I of Internal Medicine, German Centre for Infection Research, Partner-site: Bonn-Cologne, University Hospital of Cologne, Cologne, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, Division of Hematology and Oncology, Division of Infectious Diseases, Universitätsklinikum, Julius Maximilian's University, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Georg Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
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15
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Thomasy SM, Maggs DJ. A review of antiviral drugs and other compounds with activity against feline herpesvirus type 1. Vet Ophthalmol 2016; 19 Suppl 1:119-30. [PMID: 27091747 DOI: 10.1111/vop.12375] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Feline herpesvirus type 1 (FHV-1) is a common and important cause of ocular surface disease, dermatitis, respiratory disease, and potentially intraocular disease in cats. Many antiviral drugs developed for the treatment of humans infected with herpesviruses have been used to treat cats infected with FHV-1. Translational use of drugs in this manner ideally requires methodical investigation of their in vitro efficacy against FHV-1 followed by pharmacokinetic and safety trials in normal cats. Subsequently, placebo-controlled efficacy studies in experimentally inoculated animals should be performed followed, finally, by carefully designed and monitored clinical trials in client-owned animals. This review is intended to provide a concise overview of the available literature regarding the efficacy of antiviral drugs and other compounds with proven or putative activity against FHV-1, as well as a discussion of their safety in cats.
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Affiliation(s)
- Sara M Thomasy
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA, 95616, USA
| | - David J Maggs
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, CA, 95616, USA
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16
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Young JAH, Weisdorf DJ. Infections in Recipients of Hematopoietic Stem Cell Transplants. MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7152282 DOI: 10.1016/b978-1-4557-4801-3.00312-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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17
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Emery V, Zuckerman M, Jackson G, Aitken C, Osman H, Pagliuca A, Potter M, Peggs K, Clark A. Management of cytomegalovirus infection in haemopoietic stem cell transplantation. Br J Haematol 2013; 162:25-39. [PMID: 23647436 DOI: 10.1111/bjh.12363] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Vincent Emery
- Department of Virology; University College London School of Life and Medical Sciences; London; UK
| | - Mark Zuckerman
- Department of Virology; King's College Hospital; London; UK
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle; UK
| | - Celia Aitken
- West of Scotland specialist virology centre; Gartnavel General Hospital; Glasgow; UK
| | - Husam Osman
- Birmingham HPA Laboratory; Birmingham Heartlands Hospital; Birmingham; UK
| | | | - Mike Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London; UK
| | - Karl Peggs
- Department of Haematology; University College London Hospitals; London; UK
| | - Andrew Clark
- Blood and Marrow Transplant Unit; Beatson Oncology Centre; Glasgow; UK
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18
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Travi G, Pergam SA. Cytomegalovirus pneumonia in hematopoietic stem cell recipients. J Intensive Care Med 2013; 29:200-12. [PMID: 23753231 DOI: 10.1177/0885066613476454] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 10/23/2012] [Indexed: 01/29/2023]
Abstract
Cytomegalovirus (CMV) is a frequently encountered infection following hematopoietic cell transplantation, and tissue invasive pneumonia is a dreaded complication of the virus in this population. In this review of CMV pneumonia, we address epidemiology, pathogenesis, diagnostics, current therapy, and strategies to prevent the development of CMV. We also review emerging treatment and prevention options for this challenging disease.
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Affiliation(s)
- Giovanna Travi
- Department of Infectious Diseases, AO Ospedale Niguarda Cà Granda, Milan, Italy
| | - Steven A Pergam
- Vaccine and Infectious Diseases and Clinical Research Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, USA Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
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19
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Olson D, Gulley ML, Tang W, Wokocha C, Mechanic O, Hosseinipour M, Gold SH, Nguluwe N, Mwansambo C, Shores C. Phase I clinical trial of valacyclovir and standard of care cyclophosphamide in children with endemic Burkitt lymphoma in Malawi. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2012; 13:112-8. [PMID: 23260601 DOI: 10.1016/j.clml.2012.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 10/12/2012] [Accepted: 11/13/2012] [Indexed: 12/12/2022]
Abstract
UNLABELLED Treatment options for Epstein-Barr virus (EBV)-associated Burkitt lymphoma in Africa are limited because of chemotherapy-associated toxicity. Since other EBV-associated diseases respond to antiviral agents, we investigated adding an antiviral agent, valacyclovir, to the current chemotherapy regimen in Malawi. In this phase I safety study, we showed that cyclophosphamide combined with valacyclovir was safe. Phase II efficacy trials should now be undertaken. BACKGROUND Nucleoside analogues, including acyclovir, ganciclovir, and their precursors, have shown some efficacy against several Epstein-Barr virus (EBV)-associated diseases, including active EBV infection and posttransplantation lymphoproliferative disorder (PTLD). They have also been proposed as a possible treatment for EBV-associated malignancies, including endemic Burkitt lymphoma. The safety of nucleoside analogues in combination with chemotherapy in the developing world has not been studied and is necessary before any large scale efficacy trials are conducted. PATIENTS AND METHODS Children 3-15 years old meeting inclusion criteria were assigned to a 3+3 dose escalation trial of combination valacyclovir (15 and 30 mg/kg, 3 times daily for 40 days) and cyclophosphamide (CPM) (40 mg/kg day 1, 60 mg/kg on days 8, 18, and 28) or CPM monotherapy. Subjects were monitored for clinical and laboratory toxicity and had EBV levels measured regularly. Dose-limiting toxicity (DLT) was our primary outcome. RESULTS We found that the combination of valacyclovir and CPM was safe and did not lead to any DLT compared with CPM monotherapy. The most common side effects were vomiting, abdominal pain, and tumor site pain, which were similar in both arms. Patients with measurable serum EBV showed decreased loads over their treatment course. CONCLUSIONS We recommend a phase II valacyclovir dose of 30 mg/kg 3 times daily for 40 days. We also observed that 6 of our 12 patients with presumed Burkitt lymphoma had measurable EBV viral loads that decreased over the course of their treatment, suggesting that phase II studies should investigate this correlation further. This study paves the way for a phase II efficacy trial of combined valacyclovir and CPM in the treatment of endemic Burkitt lymphoma.
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Affiliation(s)
- Daniel Olson
- University of North Carolina Project, Lilongwe, Malawi.
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20
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Yu ZP, Ding JH, Wu F, Liu J, Wang J, Cheng J, Zhao G. Quality of Life of Patients after Allogeneic Hematopoietic Stem Cell Transplantation with Antihuman Thymocyte Globulin. Biol Blood Marrow Transplant 2012; 18:593-9. [DOI: 10.1016/j.bbmt.2011.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 08/11/2011] [Indexed: 10/17/2022]
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21
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Infections in Leukemia and Hematopoietic Stem Cell Transplantation. LEUKEMIA AND RELATED DISORDERS 2012. [PMCID: PMC7178857 DOI: 10.1007/978-1-60761-565-1_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Infections are one of the most common complications in patients diagnosed with leukemia and serve as a major obstacle to treatment. Through the early 1970s, infections were the most common cause of death in patients diagnosed with acute leukemia, but improvement in treatment and supportive care over the past few decades, coupled with expanded prophylaxis and prevention regimens, have led to reduction in both the frequency and severity of infections. Regardless, due in part to an aging cancer population and the diversity of cancer treatments and procedures, infectious diseases remain a major cause of morbidity and mortality in patients with leukemia.
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22
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Marty FM, Ljungman P, Papanicolaou GA, Winston DJ, Chemaly RF, Strasfeld L, Young JAH, Rodriguez T, Maertens J, Schmitt M, Einsele H, Ferrant A, Lipton JH, Villano SA, Chen H, Boeckh M. Maribavir prophylaxis for prevention of cytomegalovirus disease in recipients of allogeneic stem-cell transplants: a phase 3, double-blind, placebo-controlled, randomised trial. THE LANCET. INFECTIOUS DISEASES 2011; 11:284-92. [PMID: 21414843 DOI: 10.1016/s1473-3099(11)70024-x] [Citation(s) in RCA: 256] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Available drugs against cytomegalovirus have adverse effects that compromise their prophylactic use in recipients of allogeneic stem-cell transplants. We assessed the safety, tolerability, and antiviral activity of oral maribavir in such patients. METHODS In this placebo-controlled, randomised, double-blind, multicentre phase 3 study, we enrolled adult patients recipient-seropositive or donor-seropositive for cytomegalovirus who had undergone allogeneic stem-cell transplantation. Patients were recruited from 90 centres in Canada, Europe, and the USA. After engraftment, patients were stratified by recipient cytomegalovirus serostatus and conditioning regimen (myeloablative or reduced-intensity) and assigned (2:1) by masked computer-generated randomisation sequence to receive maribavir 100 mg twice daily or placebo for up to 12 weeks, with weekly blood cytomegalovirus surveillance. If the virus was detected, administration of study drug was stopped and pre-emptive anticytomegalovirus treatment started. The primary endpoint was cytomegalovirus disease within 6 months of transplantation. Analysis was by intention-to-treat. This study is registered with ClinicalTrials.gov, NCT00411645. FINDINGS Between December, 2006, and May, 2008, 681 patients were enrolled and assigned to receive maribavir (454) or placebo (227). The incidence of cytomegalovirus disease within 6 months was 20 of 454 (4%) for the maribavir group and 11 of 227 (5%) for the placebo group (OR 0.90; 95% CI 0.42-1.92). During the 100 days following transplantation, cytomegalovirus infection rates as measured by pp65 antigenaemia were lower in the maribavir group (26.4%) than in the placebo group (34.8%; OR 0.67; 0.47-0.95), but not when measured by plasma cytomegalovirus DNA PCR (27.8%vs 30.4%; OR 0·88; 0.62-1.25), nor by initiation of treatment against cytomegalovirus (30.6%vs 37.4%; OR 0.73, 0.52-1.03). Maribavir was well tolerated: most adverse events, including incident acute graft-versus-host disease and neutropenia, affected both groups equally, except for taste disturbance (15% maribavir, 6% placebo). INTERPRETATION Compared with placebo, maribavir prophylaxis did not prevent cytomegalovirus disease when started after engraftment. Cytomegalovirus disease as a primary endpoint might not be sufficient to show improvements in cytomegalovirus prevention in recipients of allogeneic stem-cell transplants in the setting of pre-emptive antiviral treatment. Clinical and virological composite endpoints should be used in future trials. FUNDING ViroPharma Incorporated.
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Affiliation(s)
- Francisco M Marty
- Brigham & Women's Hospital and Dana-Farber Cancer Institute, Boston, MA 02115, USA.
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23
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Kang HJ, Yoo KH, Lee JW, Kim H, Lee SH, Sung KW, Park KD, Koo HH, Shin HY, Ahn HS. Double umbilical cord blood transplantation for children and adolescents. Ann Hematol 2010; 89:1035-44. [PMID: 20508938 PMCID: PMC7101701 DOI: 10.1007/s00277-010-0985-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Accepted: 05/04/2010] [Indexed: 12/01/2022]
Abstract
Umbilical cord blood transplantation (UCBT) with two units has been conducted with promising results in adults to overcome the limitation of low cell numbers. In an attempt to improve the outcomes, double UCBT was performed in children and adolescents. Sixty-one patients, including 44 acute leukemia, and 17 other hematologic diseases, received double UCBT. Donor-type engraftment achieved in 82% of patients. Except one patient with persistent mixed chimerism of two units, other 49 patients showed dominancy of one unit and only the CFU-GM was significant factor influencing dominancy. The event-free survival (EFS) of leukemia and other hematologic disease were 59% and 53%, respectively, and the EFS of acute leukemia patients who received transplant in first or second CR (68.6%) was significantly better than in those with advanced disease (22.2%) (P = 0.007). Among the factors influencing outcomes, low cell dose difference between two units (TNC difference/TNC of large unit <15%) were associated with higher TRM, relapse, and lower EFS. Double UCBT was a promising modality of transplant in children and adolescence. However, engraftment and other results were not so satisfactory yet. To improve the outcomes, development of new selection guideline, probably including cell dose difference between two units and technology to enhance engraftment and reduce transplantation-related mortality are warranted.
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Affiliation(s)
- Hyoung Jin Kang
- Department of Pediatrics, Cancer Research Institute, Seoul National University College of Medicine, Daehangno, Chongno-gu, Republic of Korea
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24
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Schönberger S, Meisel R, Adams O, Pufal Y, Laws HJ, Enczmann J, Dilloo D. Prospective, comprehensive, and effective viral monitoring in children undergoing allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2010; 16:1428-35. [PMID: 20399877 DOI: 10.1016/j.bbmt.2010.04.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 04/08/2010] [Indexed: 01/19/2023]
Abstract
Major advances in the monitoring and treatment of viral infections after hematopoietic stem cell transplantation (HSCT) have been achieved over the last decade. The appropriate extent of viral monitoring and antiviral therapy remains controversial, and reports in pediatric patients receiving allogeneic unmanipulated hematopoietic stem cells (HSCs) are sparse. A total of 40 pediatric patients who underwent HSCT with either peripheral blood stem cells (PBSCs, n = 30) or bone marrow (BM; n = 10) were prospectively monitored every week for viral DNAemia (VDNA) by simultaneous detection of cytomegalovirus (CMV), Epstein-Barr virus (EBV), human herpesvirus 6 (HHV6), human adenovirus (ADV), and polyoma BK virus (BKV) using real-time TaqMan polymerase chain reaction (PCR). All patients received prophylactic acyclovir and preemptive ganciclovir (GCV) when 500 copies/microg DNA (EBV/HHV6) or >1 copy/microg DNA (CMV) were detected on 2 consecutive measurements. VDNA occurred in 25 of 40 recipients (CMV, 11/40 patients [28%]; EBV, 19/40 [48%]; HHV6, 2/40 [5%]; ADV/BKV, 1/40) and was found exclusively after neutrophil engraftment and in most cases up to day +100. Recurrent VDNA (P = .028) and (readily treatable) viral disease (P = .003) were observed predominantly in patients suffering from nonmalignant diseases, a cohort characterized by delayed lymphocyte engraftment. VDNA occurred more frequently in HLA-mismatched HSCT and in the 24 of 40 patients receiving antithymocyte globulin (ATG). The incidence of EBV, but not that of CMV, was increased in the ATG group. Yet, in these patients, viral loads of both EBV and CMV were higher, but with prompt initiation of preemptive GCV, no posttransplantation lymphoproliferative disorder or other life-threatening morbidities occurred. HHV6 was typically detected at low viral loads (<10(2) copies/microg DNA), with only 5% of HSC recipients fulfilling our HHV6 criteria for triggering GCV treatment. In multivariate analysis, ATG treatment, HLA mismatch, recipient CMV seropositivity, and stem cell source, but not severe acute graft-versus-host disease were identified as independent risk factors for VDNA. This comprehensive viral monitoring program with defined thresholds for initiation of preemptive GCV effectively prevents the development of critical viral disease, even in high-risk patients receiving ATG.
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Affiliation(s)
- S Schönberger
- Department of Pediatric Oncology, Hematology and Clinical Immunology, University Children's Hospital, Heinrich-Heine-University, Düsseldorf, Germany.
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Antiviral prophylaxis in haematological patients: Systematic review and meta-analysis. Eur J Cancer 2009; 45:3131-48. [DOI: 10.1016/j.ejca.2009.08.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Revised: 08/05/2009] [Accepted: 08/19/2009] [Indexed: 11/23/2022]
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Beck JC, Wagner JE, DeFor TE, Brunstein CG, Schleiss MR, Young JA, Weisdorf DH, Cooley S, Miller JS, Verneris MR. Impact of cytomegalovirus (CMV) reactivation after umbilical cord blood transplantation. Biol Blood Marrow Transplant 2009; 16:215-22. [PMID: 19786112 DOI: 10.1016/j.bbmt.2009.09.019] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 09/24/2009] [Indexed: 02/08/2023]
Abstract
This study investigated the impact of pretransplant cytomegalovirus (CMV) serostatus and posttransplant CMV reactivation and disease on umbilical cord blood transplant (UCBT) outcomes. Between 1994 and 2007, 332 patients with hematologic malignancies underwent UCBT and 54% were CMV seropositive. Pretransplant recipient CMV serostatus had no impact on acute or chronic graft-versus-host disease (aGVHD, cGVHD), relapse, disease-free survival (DFS), or overall survival (OS). There was a trend toward greater day 100 treatment-related mortality (TRM) in CMV-seropositive recipients (P=.07). CMV reactivation occurred in 51% (92/180) of patients with no difference in myeloablative (MA) versus reduced-intensity conditioning (RIC) recipients (P=.33). Similarly, reactivation was not influenced by the number of UCB units transplanted, the degree of HLA disparity, the CD34(+) or CD3(+) cell dose, or donor killer cell immunoglobulin-like receptor (KIR) gene haplotype. Rapid lymphocyte recovery was associated with CMV reactivation (P=.02). CMV reactivation was not associated with aGVHD (P=.97) or cGVHD (P=.65), nor did it impact TRM (P=.88), relapse (P=.62), or survival (P=.78). CMV disease occurred in 13.8% of the CMV-seropositive patients, resulting in higher TRM (P=.01) and lower OS (P=.02). Thus, although recipient CMV serostatus and CMV reactivation have little demonstrable impact on UCB transplant outcomes, the development of CMV disease remains a risk, associated with inferior outcomes.
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Affiliation(s)
- Jill C Beck
- Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Management of the Bone Marrow Transplant Patient. Oncology 2007. [DOI: 10.1007/0-387-31056-8_88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Walker CM, van Burik JAH, De For TE, Weisdorf DJ. Cytomegalovirus infection after allogeneic transplantation: comparison of cord blood with peripheral blood and marrow graft sources. Biol Blood Marrow Transplant 2007; 13:1106-15. [PMID: 17697973 DOI: 10.1016/j.bbmt.2007.06.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 06/13/2007] [Indexed: 11/21/2022]
Abstract
Cytomegalovirus (CMV) infection is an important complication following allogeneic hematopoietic stem cell transplant (HSCT), but the natural history in the cord blood setting has not been well studied. We assessed CMV infection episodes in 753 consecutive allogeneic HSCT recipients at the University of Minnesota between January 1, 1998 and December 31, 2003. The 6-month cumulative incidence of viremia/antigenemia was 22% by day +182: 21% (95% confidence interval 16%-26%) in cord blood recipients (UCB), 24% (20%-28%) in marrow (BM), and 22% (16%-28%) using peripheral blood grafts (PBSC). CMV disease incidence was 6% (2%-10%) in UCB, 8% (5%-11%) in BM, and 9% (6%-12%) in PBSC. In multivariate analysis, CMV infection (viremia/antigenemia and disease) was significantly more likely in patients who were seropositive to CMV, in those with acute graft versus host disease, and in those receiving T cell-depleted grafts. Graft source did not independently contribute to the risk of CMV infection and did not impact survival after CMV infection. These data confirm that recipient CMV serostatus remains the dominant risk factor for CMV infection. Recipients of UCB have similar risks of CMV infection, responses to antiviral therapy, and survival following CMV infection as recipients of either marrow or PBSC.
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Affiliation(s)
- Christopher M Walker
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, Minnesota 55455-0250, USA
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Abstract
OBJECTIVE To review the available clinical data on the critical care complications of hematopoietic stem cell transplantation (HSCT). DATA SOURCE The MEDLINE database and references from the identified articles related to the critical care in HSCT. CONCLUSION HSCT is an important treatment for a variety of malignant and nonmalignant conditions. The procedure is, however, limited by significant complications that may involve every organ of the body. Up to 40% of HSCT recipients are admitted to the intensive care unit as a result of severe complications related to the transplantation. The outcome of those critically ill patients has been traditionally poor. However, recent advances in the transplantation procedure, diagnostic studies, antimicrobial prophylaxis and therapy, and intensive care unit care have improved the outcome of these patients. The increasing number of HSCTs performed annually, the unique complications that develop in these patients, and the improvement in the intensive care unit outcome make knowledge about the critical care aspect of HSCT an essential part of the current practice of critical care medicine.
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Affiliation(s)
- Ayman O Soubani
- Division of Pulmonary, Critical Care, and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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Barker JN, Hough RE, van Burik JAH, DeFor TE, MacMillan ML, O'Brien MR, Wagner JE. Serious infections after unrelated donor transplantation in 136 children: impact of stem cell source. Biol Blood Marrow Transplant 2005; 11:362-70. [PMID: 15846290 DOI: 10.1016/j.bbmt.2005.02.004] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
How the infection risks compare after umbilical cord blood (UCB) and bone marrow (BM) transplantation is not known. Therefore, we compared serious infections in the 2 years after pediatric myeloablative unrelated donor transplantation with unmanipulated BM (n = 52), T cell-depleted (TCD) BM (n = 24), or UCB (n = 60) for the treatment of hematologic malignancy. Overall, the cumulative incidence of 1 or more serious infections was comparable between groups (BM, 81%; TCD, 83%; UCB, 90%; P = .12). Furthermore, by taking all serious infections into account and using multivariate techniques with unmanipulated BM as the reference, there were also no significant differences between groups (TCD relative risk [RR], 1.6; P = .10; UCB RR, 1.0; P = .84). Within the time periods days 0 to 42, days 43 to 100, and days 101 to 180, the only difference was a greater risk of viral infections from days 0 to 42 in TCD recipients (RR, 3.5; P = .02). Notably, after day 180, TCD recipients had a significantly increased infection risk (RR, 3.1; P = .03), whereas the risk in UCB recipients (RR, 0.5; P = .23) was comparable to that in BM recipients. Other factors associated with an increased infection risk in the 2 years after transplantation were age > or = 8 years, graft failure, and severe acute graft-versus-host disease. These data suggest that the risk of serious infection after pediatric UCB transplantation is comparable to that with unmanipulated BM.
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Affiliation(s)
- Juliet N Barker
- Division of Medical Hematology, Oncology, and Transplantation, University of Minnesota Blood and Marrow Transplant Program, Minneapolis, Minnesota, USA.
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Meyer-Koenig U, Hufert FT, Duffner U, Neumann-Haefelin D, Henschen M. G-CSF-mobilised granulocyte transfusion to an ALL patient complicated by cytomegalovirus transmission. Bone Marrow Transplant 2005; 34:1095-6. [PMID: 15502855 DOI: 10.1038/sj.bmt.1704644] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kaneko M, Watanabe T, Watanabe H, Kimura M, Suzuya H, Okamoto Y, Nakagawa R, Kuroda Y. Successful unrelated cord blood transplantation in an infant with Wiskott-Aldrich syndrome following recurrent cytomegalovirus disease. Int J Hematol 2004; 78:457-60. [PMID: 14704041 DOI: 10.1007/bf02983821] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We describe successful unrelated cord blood transplantation in a 14-month-old boy with Wiskott-Aldrich syndrome. He had been suffering from recurrent cytomegalovirus (CMV) pneumonia. Ganciclovir was given pretransplantation and posttransplantation, and CMV antigenemia was monitored as a marker of reactivation. The conditioning regimen was cyclophosphamide, busulfan, and antithymocyte globulin. The patient received an HLA 1-locus-mismatched cord blood unit, and the total number of infused nucleated cells was 9.0 x 10(7)/kg. Neutrophil engraftment was achieved on day +20, and a platelet count greater than 50 x 10(9)/L was achieved on day +51. A normal lymphoproliferative response to phytohemagglutinin mitogen was detectable 7 months posttransplantation. Long-term use of ganciclovir prevented CMV reactivation and did not compromise engraftment.
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Affiliation(s)
- Michiya Kaneko
- Department of Pediatrics, University of Tokushima School of Medicine, Tokushima, Japan
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