Strategy to prevent late CMV disease (FHCRC approach)
| Patients at risk for disease, start and discontinuation of virologic surveillance, and preemptive therapy . |
|---|
| Risk factors for late CMV disease (CMV-seropositive allograft recipients or -seronegative recipients with a positive donor) |
| Virologic criteria (one required) |
| CMV infection or disease before day 100 or |
| Prophylaxis with ganciclovir/valganciclovir/foscarnet plus |
| Immunologic criteria (one required) |
| Undetectable CMV-specific T-cell responses or |
| GVHD requiring systemic treatment or |
| High-dose steroids for reasons other than GVHD or |
| T-cell depletion or |
| Cord blood transplantation or |
| Donor lymphocyte infusion or |
| CD4 T-cell count less than 50/mm3 |
| CMV surveillance* |
| Continue PCR weekly surveillance after day 100 if risk factors for late CMV disease are present |
| Discontinue CMV surveillance if |
| No or minimal immunosuppression (< 0.5 mg prednisone/kg/day) and |
| No anti–T-cell agents and |
| At least 3 negative weekly tests |
| Preemptive therapy |
| Start preemptive therapy with valganciclovir (900 mg twice daily) if CMV DNA is more than 1000 copies/mL |
| Continue induction dosing until viral load declines, at least 1 week |
| Treat with maintenance dose (900 mg/day) until viral load is undetectable |
| Patients at risk for disease, start and discontinuation of virologic surveillance, and preemptive therapy . |
|---|
| Risk factors for late CMV disease (CMV-seropositive allograft recipients or -seronegative recipients with a positive donor) |
| Virologic criteria (one required) |
| CMV infection or disease before day 100 or |
| Prophylaxis with ganciclovir/valganciclovir/foscarnet plus |
| Immunologic criteria (one required) |
| Undetectable CMV-specific T-cell responses or |
| GVHD requiring systemic treatment or |
| High-dose steroids for reasons other than GVHD or |
| T-cell depletion or |
| Cord blood transplantation or |
| Donor lymphocyte infusion or |
| CD4 T-cell count less than 50/mm3 |
| CMV surveillance* |
| Continue PCR weekly surveillance after day 100 if risk factors for late CMV disease are present |
| Discontinue CMV surveillance if |
| No or minimal immunosuppression (< 0.5 mg prednisone/kg/day) and |
| No anti–T-cell agents and |
| At least 3 negative weekly tests |
| Preemptive therapy |
| Start preemptive therapy with valganciclovir (900 mg twice daily) if CMV DNA is more than 1000 copies/mL |
| Continue induction dosing until viral load declines, at least 1 week |
| Treat with maintenance dose (900 mg/day) until viral load is undetectable |
Consider valganciclovir prophylaxis if virologic surveillance is not feasible (see “Secondary prophylaxis to prevent late CMV disease”).