What is the treatment for a patient with CMV (Cytomegalovirus) infection?

Treatment of Cytomegalovirus (CMV) Infection

For patients with CMV infection, the first-line treatment is intravenous ganciclovir (5 mg/kg twice daily) or oral valganciclovir (900 mg twice daily for induction, then 900 mg once daily for maintenance) for 2-3 weeks, followed by maintenance therapy based on the clinical context and immune status of the patient. 1, 2

Treatment Approach Based on Clinical Presentation

CMV Retinitis

• Induction therapy: Valganciclovir 900 mg PO twice daily for 21 days 2
• Maintenance therapy: Valganciclovir 900 mg PO once daily 2
• For severe cases or those with absorption issues: IV ganciclovir 5 mg/kg twice daily for 21 days 1
• Alternative for ganciclovir-resistant cases: Foscarnet 90 mg/kg twice daily 1

CMV Disease in Transplant Recipients

• Intravenous ganciclovir: 5 mg/kg twice daily 1
• Oral valganciclovir: 900 mg twice daily (for non-severe disease in adults) 1
• Continue therapy until CMV is no longer detectable by plasma nucleic acid testing (NAT) or pp65 antigenemia 1
• Consider reducing immunosuppressive medications in life-threatening CMV disease 1

CMV Pneumonitis

• Intravenous ganciclovir 5 mg/kg twice daily 1
• For severe cases: Consider adjunctive intravenous immunoglobulin (IVIG) 1
• Duration: 15-21 days followed by valganciclovir (15 mg/kg every 12 hours for 6 weeks) 1

Monitoring During Treatment

• Weekly CMV viral load monitoring by PCR or pp65 antigenemia 1
• Monitor for drug toxicities:
  • Complete blood count (neutropenia is common with ganciclovir/valganciclovir) 2
  • Renal function tests (especially with foscarnet or cidofovir) 1
  • Liver function tests twice weekly initially, then weekly 3

Alternative Therapies for Resistant Cases

• Foscarnet: 90 mg/kg IV twice daily for 2-3 weeks 1, 3
• Cidofovir: Consider in refractory cases, though limited by nephrotoxicity 1, 3
• Combined therapy: Ganciclovir and foscarnet for severe or resistant cases 1

Special Considerations

Immunocompromised Patients

• Higher risk for severe disease and complications 3
• May require longer treatment courses and careful monitoring 1
• Consider prophylaxis in high-risk patients (e.g., transplant recipients) 1

Pediatric Patients

• All CMV disease in pediatric kidney transplant recipients should be treated with IV ganciclovir 1
• Dosing is weight-based: 5 mg/kg IV every 12 hours for induction 1

Pregnant Patients

• Valaciclovir (valacyclovir) may reduce risk of fetal infection if started early in pregnancy 4
• Valganciclovir and ganciclovir have potential for fetal toxicity 2

Prevention Strategies

• Prophylaxis: Valganciclovir for high-risk transplant recipients (e.g., D+/R-) 1, 2
• Preemptive therapy: Initiate treatment based on CMV viral load monitoring 1
• Duration: Typically 3-6 months post-transplant, or 6 weeks after T-cell depleting antibody treatment 1

Common Pitfalls to Avoid

1. Delayed diagnosis: CMV can present with nonspecific symptoms; maintain high index of suspicion in immunocompromised patients
2. Inadequate monitoring: Regular viral load testing is essential to assess treatment response
3. Premature discontinuation: Continue therapy until viral clearance is documented
4. Overlooking drug resistance: Consider resistance testing if breakthrough infection occurs during treatment
5. Neglecting drug toxicities: Monitor for myelosuppression with ganciclovir/valganciclovir and nephrotoxicity with foscarnet/cidofovir

Remember that early diagnosis and prompt initiation of appropriate antiviral therapy are crucial for improving outcomes and reducing mortality in patients with CMV infection, particularly those who are immunocompromised 3.