CMV Colitis Treatment
Initiate intravenous ganciclovir 5 mg/kg every 12 hours immediately upon diagnosis of CMV colitis, then transition to oral valganciclovir 900 mg twice daily after 3-5 days to complete a total 2-3 week course. 1, 2
Initial Antiviral Therapy
Start IV ganciclovir 5 mg/kg every 12 hours as first-line therapy for all patients with CMV colitis, regardless of immune status 1, 2, 3
After 3-5 days of IV therapy, switch to oral valganciclovir 900 mg twice daily to complete the full 2-3 week treatment course in adult patients 1, 2, 3
In pediatric patients, maintain parenteral ganciclovir for the full 14-21 day course rather than switching to oral therapy, as early transition to oral treatment in children may promote CMV reactivation 4, 3
Begin ganciclovir immediately when CMV colitis is suspected clinically or on endoscopy, even before histopathologic confirmation, due to high mortality risk 4, 3
Management of Immunosuppression
Do not abruptly discontinue immunosuppressive therapy in inflammatory bowel disease (IBD) patients with CMV colitis 2
Taper steroids gradually rather than stopping them abruptly in IBD patients 2
Discontinue immunosuppressive agents promptly in cases of systemic CMV reactivation causing severe disease (meningo-encephalitis, pneumonitis, hepatitis, or severe colitis), as this is associated with clinical improvement and decreased mortality 1
The approach differs based on disease severity: mild CMV colitis in IBD patients can be treated without stopping immunosuppression, while severe systemic CMV disease requires immediate cessation 1, 2
Monitoring Requirements
Check complete blood count at least twice weekly during ganciclovir therapy, as severe neutropenia occurs in approximately 11% of treated patients 4, 2
Obtain weekly CMV viral load by PCR to assess treatment response, and continue antiviral therapy until CMV is no longer detected in blood 4, 2
Monitor serum creatinine and electrolytes closely, particularly if foscarnet is used, due to risk of nephrotoxicity and electrolyte abnormalities 4
Alternative Agents for Resistance or Intolerance
Foscarnet 90 mg/kg IV every 12 hours for 14-21 days is the primary alternative when ganciclovir resistance is documented or suspected, or when myelotoxicity occurs 1, 2
Cidofovir is reserved as a third-line agent due to substantial nephrotoxicity risk, and should only be considered when both ganciclovir and foscarnet have failed or are contraindicated 4
High-dose valganciclovir (1800 mg twice daily based on creatinine clearance) along with immunosuppression reduction may be considered for ganciclovir-resistant CMV colitis with dual UL97 and UL54 gene mutations 5
Adjunctive Measures
Add broad-spectrum antibiotics to the antiviral regimen, as bacterial translocation and secondary infection are common complications in CMV colitis with bowel wall necrosis 4, 2, 3
Obtain early surgical consultation on admission given the extremely high mortality risk (approaching or exceeding 70% even with treatment) 4, 3
Consider infectious disease consultation early in the treatment course 2
Surgical Intervention Criteria
Proceed urgently to subtotal or partial colectomy if the patient develops any of the following despite antiviral therapy: 4, 2, 3
- Toxic megacolon
- Fulminant colitis
- Colonic perforation
- Bowel ischemia
These complications represent surgical emergencies requiring immediate intervention, as medical therapy alone carries prohibitively high mortality 4, 3
Critical Pitfalls to Avoid
Do not delay ganciclovir initiation waiting for histopathologic confirmation in severely ill patients, as untreated CMV disease in immunodeficient patients carries extremely high morbidity and mortality 4, 3
Do not switch to oral therapy prematurely in children, as this may promote CMV reactivation 4, 3
Do not screen for subclinical CMV infection in IBD patients unless they are steroid-resistant, as only a minority of CMV infections lead to clinical disease 1
Recognize that in-hospital mortality of immunocompromised patients with severe CMV colitis approaches or exceeds 70% even with treatment, emphasizing the need for aggressive early management 4, 3