CMV Treatment According to IDSA Guidelines
For HIV-infected patients with CMV disease, lifelong chronic maintenance therapy (secondary prophylaxis) is required following induction treatment, using ganciclovir (IV or oral), foscarnet, cidofovir, or for retinitis specifically, ganciclovir intraocular implant plus oral ganciclovir. 1
Treatment Approach for Active CMV Disease
Induction Therapy
- CMV disease requires initial high-dose induction therapy with ganciclovir, foscarnet, or cidofovir, as CMV disease is not cured with currently available antiviral agents 1
- For CMV anal ulcers specifically, IV ganciclovir 5 mg/kg twice daily for 3-5 days is recommended, followed by oral valganciclovir 900 mg twice daily for 2-3 weeks until symptoms resolve 2
- Consultation with an infectious disease specialist is strongly recommended for treatment decisions, particularly for retinitis cases where ophthalmology consultation is essential 1, 2
Maintenance (Secondary Prophylaxis)
Following induction, lifelong chronic maintenance therapy is mandatory with one of these regimens 1:
- Parenteral or oral ganciclovir
- Parenteral foscarnet
- Combined parenteral ganciclovir and foscarnet
- Parenteral cidofovir
- For retinitis only: Ganciclovir intraocular implant plus oral ganciclovir (the implant alone does not protect the contralateral eye or other organs) 1
Discontinuation of Maintenance Therapy (HAART Era)
Maintenance therapy may be discontinued in patients with CMV retinitis when 1:
- CD4+ count has increased to >100-150 cells/µL
- Sustained increase for >3-6 months on HAART
- HIV plasma RNA levels are suppressed
- Decision made in consultation with ophthalmologist considering anatomic location of lesion, vision in contralateral eye, and feasibility of regular monitoring
Restart maintenance therapy when CD4+ count decreases to <50-100 cells/µL 1
Primary Prophylaxis (Prevention of First Episode)
For HIV-Infected Adults and Adolescents
- Oral ganciclovir prophylaxis may be considered for CMV-seropositive patients with CD4+ count <50 cells/µL, though this is a weak recommendation (CI) 1
- Important considerations against routine prophylaxis include: ganciclovir-induced neutropenia, anemia, conflicting efficacy reports, lack of proven survival benefit, risk of ganciclovir-resistant CMV, and cost 1
- Acyclovir is NOT effective for preventing CMV disease (EI) 1
- Valacyclovir is NOT recommended due to unexplained trend toward increased deaths in AIDS patients receiving it for CMV prophylaxis (EI) 1, 3
Critical Prevention Strategy: Early Recognition
The most important method for preventing severe CMV disease is early recognition 1:
- Educate patients about increased floaters in the eye as a warning sign 1
- Advise regular self-assessment of visual acuity using simple techniques like reading newsprint 1
- Regular funduscopic examinations by ophthalmologist are recommended by some experts for patients with CD4+ count <50 cells/µL 1
Exposure Prevention Measures
For HIV-Infected Persons
- Test for CMV antibody in patients from risk groups with low seropositivity rates (those without male homosexual contact or injection drug use history) 1
- Always use latex condoms during sexual contact, as CMV is shed in semen, cervical secretions, and saliva 1
- Practice good hand hygiene for child-care providers or parents of children in child-care facilities, as they are at increased risk 1
- Use CMV antibody-negative or leukocyte-reduced blood products for CMV-seronegative patients requiring transfusion in nonemergency situations 1
Special Populations
Pediatric Patients
- Obtain CMV urine culture at birth or early postnatal visit for all HIV-infected/exposed infants to identify congenital CMV infection 1
- Annual CMV antibody testing starting at age 1 year for CMV-seronegative, severely immunosuppressed children 1
- Dilated retinal examination every 4-6 months by ophthalmologist for CMV-infected, severely immunosuppressed children 1
- Oral ganciclovir may be considered for primary prophylaxis in CMV-infected children with CD4+ count <50 cells/µL 1
Pregnant Women
- Ganciclovir is NOT recommended for primary prophylaxis during pregnancy due to lack of routine use recommendation in nonpregnant adults and lack of pregnancy experience 1
- Discontinue ganciclovir if patient conceives while on primary prophylaxis 1
- Prophylaxis against recurrent CMV disease IS indicated during pregnancy due to maternal health risks, with agent choice individualized after expert consultation 1
- Valacyclovir should NOT be used for CMV prophylaxis in HIV-infected pregnant women due to increased mortality trend 3
Transplant Recipients
FDA-Approved Indications
Valganciclovir is FDA-approved for prevention of CMV disease in kidney, heart, and kidney-pancreas transplant patients at high risk (D+/R-), and for pediatric heart transplant patients ages 4 months to 16 years 4
Treatment Considerations
- Oral valganciclovir or IV ganciclovir are standard first-line treatments for CMV disease in transplant recipients 5
- Severe or life-threatening CMV disease requires initial IV therapy (ganciclovir or foscarnet), particularly with very high viral load or impaired GI absorption 5
- Transition to oral therapy is appropriate after clinical improvement and satisfactory viral load decline 5
- Reduce immunosuppression when treating CMV disease in immunocompromised patients 2
Common Pitfalls and Caveats
Drug Toxicity Monitoring
- Monitor for neutropenia, anemia, and thrombocytopenia with ganciclovir/valganciclovir therapy 6
- Monitor renal function carefully, especially with concomitant nephrotoxic agents like cyclosporine 6
- Ganciclovir and valganciclovir can cause seizures in rare cases 2
Resistance Risk
- Extended use of ganciclovir increases risk of developing drug-resistant CMV 1
- Foscarnet is an alternative for ganciclovir-resistant CMV 2
- Cidofovir may be considered as third-line agent 2