New trends in the management of cytomegalovirus infection after allogeneic hematopoietic cell transplantation: a survey of the Infectious Diseases Working Pary of EBMT

Abstract

The management of cytomegalovirus (CMV) infection was assessed with a survey performed in 2020 by the Infectious Diseases Working Party of European Society for Blood and Marrow Transplantation (EBMT). One-hundred-eighty of the 579 EBMT centres (31%) responded. CMV monitoring with quantitative PCR for CMV-DNAemia was used by 97% of centres while the duration of monitoring was variable according to the patient immune recovery and the ongoing immunosuppressive therapy. CMV prophylaxis for high-risk patients was used in 101 (56%) of centres: letermovir in 62 centres (61%), aciclovir/valaciclovir in 19 centres (19%), ganciclovir/valganciclovir in 17 centres (17%), foscarnet in 3 (3%). The most used trigger for pre-emptive therapy was a threshold of >10 3 copies/ml or >10 3 IU/ml. Ganciclovir/valganciclovir confirmed the preferred first line treatment both for pre-emptive and CMV disease therapy. CMV-cytotoxic T-cells were used mainly in the setting of relapsing/refractory CMV disease. Forty-eight centres reported CMV refractory/resistant infection due to mutated CMV strain.This survey showed that letermovir prophylaxis is adopted by more than half of centres using a prophylaxis approach for CMV infection. How letermovir prophylaxis will modify other important pillars of daily CMV management, such as frequency of CMV-DNAemia monitoring and preemptive therapy, remain a matter of investigation.

Challenges and Opportunities in Antimicrobial Stewardship among Hematopoietic Stem Cell Transplant and Oncology Patients

“…In 2017, letermovir was approved by the FDA for CMV prophylaxis through day 100 post-HSCT in CMV-seropositive patients, later becoming a Grade A-1 recommendation by the ASTCT [ 24 , 65 ]. Cesaro et al surveyed treatment approaches to CMV infection in a 2020 survey among European BMT centers, highlighting that up to 62% of centers are adopting a prophylaxis-based approach with letermovir [ 66 ]. Different strategies and the impact of letermovir prophylaxis on CMV reactivation are being studied [ 63 , 67 , 68 ].…”

Conference Report 33rd European Congress on Clinical Microbiology and Infectious Diseases (ECCMID): New developments in pediatric oncology infectious disease supportive care

“…Other topics that were not represented but are challenging for all infectious disease specialists involved in pediatric cancer and HCT patients include the non-pharmacological approaches to infection prevention, antibacterial prophylaxis, hospital epidemiology and control of resistant bacterial and fungal pathogens, the impact of alterations in the intestinal microbiome, the complex issue of respiratory viral infections in this population, new approaches to prevention and treatment of systemic viral infections, potential consequences of climate changes on the spectrum of potential pathogens, and the impact of replacements of conventional cancer chemotherapies by immunologically based approaches. [31][32][33][34][35][36][37][38][39] International societies provide an appropriate platform to address these challenges and move the field forward. The ESCMID with its diverse study groups, in particular the Study Group for Immunocompromised Hosts and the Fungal Infection Study Group, are called to enhance the inclusion of pediatric infectious disease specialists and to foster the collaboration with other players in this field.…”

“…Contributions at this year's ECCMID centered around two important topics: the radiographic presentation, the epidemiology, and the prevention of IFDs and reports on the approaches of individual centers to the de‐escalation of antibacterial therapy of fever of unknown origin in neutropenic patients. Other topics that were not represented but are challenging for all infectious disease specialists involved in pediatric cancer and HCT patients include the non‐pharmacological approaches to infection prevention, antibacterial prophylaxis, hospital epidemiology and control of resistant bacterial and fungal pathogens, the impact of alterations in the intestinal microbiome, the complex issue of respiratory viral infections in this population, new approaches to prevention and treatment of systemic viral infections, potential consequences of climate changes on the spectrum of potential pathogens, and the impact of replacements of conventional cancer chemotherapies by immunologically based approaches 31–39 …”

Expanding the scope of the infectious diseases pharmacist in HCT: Beyond antimicrobial stewardship

“…With the estimated global seroprevalence of CMV at 86% identifying the recipient's risk prior is critical as activation/reactivation in the recipient can result in multiorgan infection and mortality 12,22 . With the recent availability of anti‐CMV agent letermovir, decisions to provide prophylaxis, or opt for monitoring with pre‐emptive therapy can be made based on CMV reactivation risk, age and financial factors 23–26 . Likewise, the use of T cell depleting agents such as ATG or posttransplant cyclophosphamide (PTCy) to prevent GVHD is one of the highest risk factors for CMV and EBV reactivation; therefore more stringent, regular monitoring (see below) may be necessary.…”