What is the treatment for Disseminated Cytomegalovirus (CMV) infection?

Treatment of Disseminated Cytomegalovirus (CMV) Infection

Intravenous ganciclovir (5 mg/kg twice daily) for 2-3 weeks is the first-line treatment for disseminated CMV infection, with potential transition to oral valganciclovir (900 mg twice daily) after 3-5 days if clinically improving. 1

Initial Treatment Approach

• For disseminated CMV causing systemic disease (meningo-encephalitis, pneumonitis, hepatitis, esophagitis, or colitis), prompt initiation of antiviral therapy is critical for optimal clinical response 1
• Intravenous ganciclovir at 5 mg/kg twice daily for 2-3 weeks is the therapy of choice for disseminated CMV infections 1
• After 3-5 days of IV therapy, if clinical improvement is observed and oral absorption is adequate, transition to oral valganciclovir 900 mg twice daily for the remainder of the 2-3 week course may be considered 1, 2
• For neurological CMV disease, combination therapy with ganciclovir and foscarnet might be preferred as initial therapy to maximize response, despite higher rates of adverse effects 1

Alternative Treatment Options

• In cases of ganciclovir resistance or intolerance (e.g., myelotoxicity), foscarnet for 2-3 weeks is the recommended alternative 1
• Cidofovir can be considered as a third-line agent, though it carries substantial risk of nephrotoxicity 1
• For CMV pneumonitis, adjunctive intravenous immunoglobulin (IVIG) can be administered, typically every other day for 3 to 5 doses 1

Monitoring During Treatment

• Weekly monitoring of CMV viral load by PCR is recommended to assess treatment response 1
• Complete blood count should be monitored regularly due to the high risk of neutropenia, thrombocytopenia, and anemia with ganciclovir/valganciclovir 2, 3
• Renal function should be closely monitored, especially with foscarnet or cidofovir therapy 1, 2
• For patients with CMV retinitis, dilated indirect ophthalmoscopy should be performed at diagnosis, after completion of induction therapy, 1 month after initiation, and monthly thereafter 1

Treatment Duration and Special Considerations

• Treatment should continue for at least 2-3 weeks and until CMV is no longer detected in blood 1
• In immunocompromised patients, discontinuation of immunosuppressive agents is associated with clinical improvement and decreased mortality 1
• For HIV-infected patients with CMV disease, antiretroviral therapy (ART) should be initiated or optimized concurrently with CMV treatment 1
• For neurological CMV disease in HIV patients, a brief delay in ART initiation until clinical improvement occurs might be prudent to avoid inflammatory reactions 1

Common Adverse Effects and Management

• Ganciclovir and valganciclovir: neutropenia, thrombocytopenia, anemia, nausea, diarrhea, and renal dysfunction 1, 2
• Foscarnet: nephrotoxicity, electrolyte abnormalities (particularly calcium and phosphate), and neurologic dysfunction 1
• Cidofovir: substantial nephrotoxicity and potential ocular toxicity 1
• Dose reduction may be necessary in up to 40% of patients due to hematologic toxicity 2

Treatment Success and Recurrence

• In transplant recipients, successful treatment with valganciclovir has been reported in approximately 84% of cases 4
• Treatment failure may occur due to persistent viremia, clinical deterioration, or recurrent disease 4
• Recurrence rates are higher in patients with risk factors for persistence of viremia, such as high-intensity immunosuppression 5

Early consultation with an infectious disease specialist is recommended for severe or disseminated CMV infection to optimize treatment approach and management of potential complications 2.