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Aguado JM, Navarro D, Montoto C, Yébenes M, de Castro-Orós I. Incidence of refractory CMV infection with or without antiviral resistance in Spain: A systematic literature review. Transplant Rev (Orlando) 2024; 38:100804. [PMID: 37949797 DOI: 10.1016/j.trre.2023.100804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT) recipients are susceptible to cytomegalovirus (CMV) infection. The incidence of refractoriness to antivirals, with or without resistance, is unclear. The purpose of this review was to describe the epidemiology of refractory CMV infection in Spain to understand the current unmet needs. METHODS PubMed, EMBASE, Cochrane and MEDES were searched systematically for relevant articles. We included randomized controlled trials and observational studies published during the period from January 1990 to June 2021. RESULTS From 212 screened records, we selected 19 papers including 1973 transplant recipients. Refractory infection ranged from 3 to 10% in studies with SOT recipients. The incidence of CMV resistance ranged from 1% to 36% in these patients. The incidence of CMV refractory infection in HSCT recipients ranged from 11 to 50%, while values for resistant infection ranged from 0% to 21%. CONCLUSION The wide range of definitions and values observed does not allow us to establish the true incidence of refractory CMV infection with or without resistances in SOT and HSCT patients in Spain. This review highlights the gap between clinical practice and clinical trials' definitions which needed to be updated to be easier followed in current clinical practice.
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Affiliation(s)
- J M Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre", Universidad Complutense, Calle del Dr. Tolosa Latour, s/n, 28041 Madrid, Spain
| | - D Navarro
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Research Institute, Valencia, Spain; Department of Microbiology, School of Medicine, University of Valencia, Av. De Blasco Ibáñez, 17, 46010, Valencia, Spain
| | - C Montoto
- Takeda Pharmaceutical Company Limited, P° Castellana 95, 22(nd) floor, 28046 Madrid, Spain
| | - M Yébenes
- Pharmacoeconomics & Outcomes Research Iberia (PORIB), P° Joaquin Rodrigo, 4 I, 28224 Pozuelo de Alarcón, Madrid, Spain.
| | - I de Castro-Orós
- Takeda Pharmaceutical Company Limited, P° Castellana 95, 22(nd) floor, 28046 Madrid, Spain
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Camargo JF, Kimble E, Rosa R, Shimose LA, Bueno MX, Jeyakumar N, Morris MI, Abbo LM, Simkins J, Alencar MC, Benjamin C, Wieder E, Jimenez A, Beitinjaneh A, Goodman M, Byrnes JJ, Lekakis LJ, Pereira D, Komanduri KV. Impact of Cytomegalovirus Viral Load on Probability of Spontaneous Clearance and Response to Preemptive Therapy in Allogeneic Stem Cell Transplantation Recipients. Biol Blood Marrow Transplant 2017; 24:806-814. [PMID: 29217388 DOI: 10.1016/j.bbmt.2017.11.038] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
Abstract
The optimal viral load threshold at which to initiate preemptive cytomegalovirus (CMV) therapy in hematopoietic cell transplantation (HCT) recipients remains to be defined. In an effort to address this question, we conducted a retrospective study of 174 allogeneic HCT recipients who underwent transplantation at a single center between August 2012 and April 2016. During this period, preemptive therapy was initiated at the discretion of the treating clinician. A total of 109 patients (63%) developed CMV viremia. The median time to reactivation was 17 days (interquartile range, IQR, 7-30 days) post-HCT. A peak viremia ≥150 IU/mL was strongly associated with a reduced probability of spontaneous clearance (relative risk, .16; 95% confidence interval, .1-.27), independent of established clinical risk factors, including CMV donor serostatus, exposure to antithymocyte globulin, and underlying lymphoid malignancy. The median time to clearance of viremia was significantly shorter in those who started therapy at CMV <350 IU/mL (19 days; IQR, 11-35 days) compared with those who started antiviral therapy at higher viremia thresholds (33 days; IQR, 21-42 days; P = .02). The occurrence of treatment-associated cytopenias was frequent but similar in patients who started preemptive therapy at CMV <350 IU/mL and those who started at CMV >350 IU/mL (44% versus 57%; P = .42). Unresolved CMV viremia by treatment day 35 was associated with increased risk of therapeutic failure (32% versus 0%; P = .001). Achieving eradication of CMV viremia by treatment day 35 was associated with a 74% reduction in 1-year nonrelapse mortality (NRM) (adjusted hazard ratio [HR], .26; 95% confidence interval [CI], .1-.8; P = .02), whereas therapeutic failure was associated with a significant increase in the probability of 1-year NRM (adjusted HR, 26; 95% CI, 8-87; P <.0001). We conclude that among allogeneic HCT patients, a peak CMV viremia ≥150 IU/mL is associated with a >80% reduction in the probability of spontaneous clearance independent of ATG administration, CMV donor serostatus, and lymphoid malignancy, and is a reasonable cutoff for preemptive therapy. Delaying initiation of therapy until a CMV value ≥350 IU/mL is associated with more protracted CMV viremia, and unresolved viremia by treatment day 35 is associated with a significant increase in NRM.
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Affiliation(s)
- Jose F Camargo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida.
| | - Erik Kimble
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Rossana Rosa
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Luis A Shimose
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Maria X Bueno
- Department of Medicine, Jackson Memorial Hospital, Miami, Florida
| | - Nikeshan Jeyakumar
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Michele I Morris
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Lilian M Abbo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Jacques Simkins
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida
| | - Maritza C Alencar
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Cara Benjamin
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Eric Wieder
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Antonio Jimenez
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Amer Beitinjaneh
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Mark Goodman
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - John J Byrnes
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Lazaros J Lekakis
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Denise Pereira
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Krishna V Komanduri
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida; Adult Stem Cell Transplant Program, Sylvester Comprehensive Cancer Center, Miami, Florida
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Abstract
Despite the refinements in molecular methods for the detection of cytomegalovirus (CMV) and the advent of highly effective preemptive strategies, CMV remains a leading cause of morbidity and mortality in hematopoietic cell transplant (HCT) recipients. CMV can cause tissue-invasive disease including pneumonia, hepatitis, colitis, retinitis, and encephalitis. Mortality in HCT recipients with CMV disease can be as high as 60%. CMV infection has been associated with increased risk of secondary bacterial and fungal infections, increased risk of graft-versus-host disease, and high rates of non-relapse mortality following HCT. The risk of CMV is highly dependent on the donor (D) and the recipient (R) serostatus (D-/R+>D+/R+>D+/R->D-/R-). Among allogeneic HCT recipients, high-dose corticosteroids, T-cell depletion, graft-versus-host disease, and mismatched or unrelated donors constitute the main predisposing factors. However, not all seropositive individuals with these risk factors develop CMV, which strongly suggests that host factors, such as those regulating CMV-specific T-cell responses, play a major role in predisposition to CMV in HCT recipients. Here, we discuss emerging concepts in CMV infection in HCT with emphasis on immunological factors that govern CMV reactivation and the applicability of immune monitoring to understand correlates of pathogenesis and its potential to guide clinical decision making.
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Affiliation(s)
- Jose F Camargo
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Krishna V Komanduri
- Departments of Medicine, Microbiology and Immunology and Adult Stem Cell Transplant Program, Sylvester Cancer Center, University of Miami, Miami, FL, USA.
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Janoly-Dumenil A, Rouvet I, Bleyzac N, Morfin F, Zabot MT, Tod M. A pharmacodynamic model of ganciclovir antiviral effect and toxicity for lymphoblastoid cells suggests a new dosing regimen to treat cytomegalovirus infection. Antimicrob Agents Chemother 2012; 56:3732-8. [PMID: 22526305 DOI: 10.1128/AAC.06423-11] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
In bone marrow transplantation, the efficacy of ganciclovir in cytomegalovirus (CMV) disease treatment or prophylaxis remains partial. Because its hematological toxicity is dose limiting, optimization of the dosing schedule is required to increase its therapeutic index. The goal of our study was to describe the influence of the ganciclovir concentration and duration of exposure on cell survival and antiviral efficacy. The study was carried out in vitro on cultures of lymphoblastoid cells infected or not with the CMV AD169 reference strain and exposed to ganciclovir at different concentrations for 1, 2, 7, or 14 days. The data were analyzed by a mathematical model that allowed a quantitative characterization of ganciclovir pharmacodynamics and its variability. Simulations of the model were undertaken to determine the optimal concentration profile for maximizing the ganciclovir therapeutic index. Ganciclovir had very little toxic and antiviral effect, even at 20 mg liter(-1), when the duration of exposure was ≤ 7 days. A biologically significant effect was observed only with a 14-day exposure. Complete inhibition of viral replication was obtained at 20 mg liter(-1). The utility function, assuming equal weights for antiviral effect and toxicity, showed that maximal utility was reached around 10 mg liter(-1). The optimal ganciclovir concentration profile consisted of maintaining the concentration at 20 mg liter(-1) at the intervals 0 to 2 days and 7.58 to 9.58 days and a null concentration at other times. This optimal profile could be obtained by intravenous (i.v.) ganciclovir at 10 mg/kg of body weight twice daily (b.i.d.) at days 1, 2, 8.5, and 9.5 in stem cell transplant patients with normal renal function.
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Atkinson C, Emery VC. Cytomegalovirus quantification: where to next in optimising patient management? J Clin Virol 2011; 51:223-8. [PMID: 21620764 DOI: 10.1016/j.jcv.2011.04.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 04/11/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Over the years quantification of cytomegalovirus (HCMV) load in blood has become a mainstay of clinical management helping direct deployment of antiviral therapy, assess response to therapy and highlight cases of drug resistance. AIMS The review focuses on a brief historical perspective of HCMV quantification and the ways in which viral load is being used to improve patient management. METHODS A review of the published literature and also personal experience at the Royal Free Hospital. RESULTS Quantification of HCMV is essential for efficient patient management. The ability to use real time quantitative PCR to drive pre-emptive therapy has improved patient management after transplantation although the threshold viral loads for deployment differ between laboratories. The field would benefit from access to a universal standard for quantification. CONCLUSIONS We see that HCMV quantification will continue to be central to delivering individualised patient management and facilitating multicentre trials of new antiviral agents and vaccines in a variety of clinical settings.
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Affiliation(s)
- Claire Atkinson
- Centre for Virology, Department of Infection, UCL London, United Kingdom
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