What is the recommended treatment for Cytomegalovirus (CMV) pneumonia?

Treatment of CMV Pneumonia

For CMV pneumonia, first-line treatment is ganciclovir (IV) or foscarnet (IV), with valganciclovir (oral) as an alternative when absorption is adequate; adjunctive IVIG can be considered but is not routinely recommended. 1

First-Line Antiviral Therapy

The cornerstone of treatment involves antiviral agents targeting CMV replication:

• Ganciclovir (IV) or Foscarnet (IV) are the first-choice antiviral options 1
• Valganciclovir (oral) is typically initiated when absorption is not a concern, though some centers prefer IV ganciclovir 1
• Treatment duration is at least 2 weeks and should continue until CMV is no longer detected by PCR 1

Choosing Between Agents

The selection between ganciclovir and foscarnet depends on the patient's clinical profile:

• Foscarnet causes less myelosuppression, making it preferable in patients with baseline cytopenias 1
• Ganciclovir avoids the reversible nephrotoxicity and electrolyte abnormalities associated with foscarnet 1
• Choice may depend on institutional preference and concern for specific toxicities (myelosuppression vs nephrotoxicity) 1

Adjunctive Immunoglobulin Therapy

IVIG can be administered adjunctively for CMV pneumonitis, but is not routinely recommended due to cost and limited evidence of benefit 1:

• When used, IVIG is commonly administered every other day for 3 to 5 doses 1
• CMV-specific IVIG has not proven more efficacious than standard IVIG 1
• A large retrospective study found that adding IVIG to antiviral treatment did not improve overall or attributable mortality in hematopoietic cell transplant recipients 2

Treatment Outcomes and Prognosis

CMV pneumonia remains challenging despite antiviral therapy:

• In immunocompromised patients, treatment benefits 10%-72% of patients, making it more difficult to treat than CMV retinitis or gastrointestinal disease 3
• Among hematopoietic cell transplant recipients, 6-month survival improved to approximately 30% in recent years 2
• Improvements appear due to antiviral treatment and changes in transplant practices rather than immunoglobulin-based treatments 2
• In immunocompetent hosts with severe CMV pneumonia, prognosis is generally good with antiviral treatment 4

Risk Factors for Poor Outcome

Independent predictors of mortality include:

• High APACHE II score (>16) at onset of CMV pneumonia 5
• Development of antiviral toxicity 5
• Lymphopenia and mechanical ventilation 2
• Female sex and elevated bilirubin 2

Special Populations

Immunocompetent Patients

While CMV pneumonia is rare in immunocompetent individuals, antiviral treatment should be considered in severe cases:

• Ganciclovir treatment may positively shorten the course of CMV pneumonia 6
• Consider CMV pneumonia in patients with atypical lymphocytes and mildly elevated transaminases 4
• Treatment with ganciclovir 6 mg/kg/day IV divided twice daily has shown dramatic response 6

Patients with Lymphoma

CMV pneumonia incidence is increasing in lymphoma patients:

• Most patients (92%) had received chemotherapy and corticosteroids (89%) before onset 5
• CMV-attributed mortality rate was 30% 5
• Coinfections were present in 31% of cases at onset of CMV pneumonia 5

Monitoring and Resistance

• Consider testing for drug resistance if clinically significant breakthrough infection is detected 1
• For refractory or resistant infections, infectious disease consultation is recommended 1
• CMV surveillance consists of weekly monitoring by PCR, though thresholds for treatment vary by institution 1

Common Pitfalls

• Do not use acyclovir or valacyclovir for CMV pneumonia treatment—they are only weakly active against CMV 1
• Ensure adequate diagnostic sampling: CMV detection in bronchoalveolar lavage specimens is better with culture methods than cytologic or immunohistochemical methods 5
• Avoid delaying treatment while awaiting confirmatory testing in high-risk patients with compatible clinical presentation 1