Impact of standardized protocols for cytomegalovirus disease prevention in pediatric solid organ transplant recipients

Abstract

End‐organ disease caused by CMV is a significant cause of morbidity and mortality in pediatric SOT recipients. Pediatric transplant centers have adopted various approaches for CMV disease prevention in this patient population. We observed significant practice variation in CMV testing, prophylaxis, and surveillance across SOT groups in our center. To address this, we implemented evidence‐based standardized protocols and measured outcomes pre‐ and post‐implementation of these protocols. We performed retrospective chart review for SOT recipients from 2009 to 2014 at Boston Children's Hospital. Using descriptive statistics, we measured practice improvement in provision of appropriate prophylaxis, occurrence of neutropenia and associated complications, and occurrence of CMV DNAemia and CMV disease pre‐ and post‐intervention. The pre‐ and post‐intervention periods included 141 and 109 patients, respectively. With the exception of kidney transplant recipients, provision of appropriate valganciclovir prophylaxis improved across SOT groups post‐intervention (P < .01). Occurrence of >1 episode of neutropenia was greater in the preintervention period (30% vs 10%, P < .001). In both periods, neutropenia was associated with few episodes of invasive infections. The occurrence of CMV disease did not differ and was overall low. However, due to routine surveillance a significantly greater number of asymptomatic CMV DNAemia episodes were identified and treated in the post‐intervention period. Implementation of standardized prevention protocols helped to improve the provision of appropriate prophylaxis to patients at risk for CMV acquisition, increased the diagnosis and treatment of asymptomatic CMV DNAemia, and decreased episodes of recurrent neutropenia in patients receiving prophylaxis.

Evaluation of a change in cytomegalovirus prevention strategy following pediatric solid organ transplantation

“…No increase in CMV invasive disease was identified after modification of a local CMV prevention protocol which included earlier transition to oral valganciclovir, increased surveillance testing, and decreased use of CMVIG among high‐risk heart recipients. This is consistent with the findings from a recent study at another pediatric center …”

“…In addition, the post‐intervention group's CMV infection rate was similar to that observed in previous pediatric studies . One recent study showed no increase in the CMV infection rate when comparing pre‐ and post‐standardized prophylaxis followed by surveillance . However, the current study introduces surveillance on prophylaxis with the presence of CMV infections occurring while on prophylaxis.…”

“…This is consistent with the findings from a recent study at another pediatric center. 9 Increased surveillance was one of the major changes in the 2013 local guideline updates, which could have multiple consequences. This increase in the frequency of surveillance testing among heart and liver recipients reflected adherence to the updated guidelines and was independently associated with an increase in the detection of CMV events for all organ recipients, of which most were asymptomatic infections.…”

“…22,26 One recent study showed no increase in the CMV infection rate when comparing pre-and post-standardized prophylaxis followed by surveillance. 9 However,…”

“…7,8 There are pediatric studies showing efficacy for all three prevention strategies, although there are currently no comparative trials and the optimal prevention strategy for each organ type is uncertain. 1 Standardization of local prevention strategies can allow for the evaluation of effectiveness, 9 while modification can allow for comparison of effectiveness of the strategy's components. A standardized protocol for the prevention of CMV among solid organ transplant recipients at our center was developed in 2007 10 and revised in 2013.…”