Department of Pharmacy, West Virginia University Hospital, WV, USA.
Department of Pharmacy, West Virginia University Hospital, WV, USA; Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, WV, USA.
J Infect Chemother. 2024 Dec;30(12):1233-1236. doi: 10.1016/j.jiac.2024.05.010. Epub 2024 May 28.
Cytomegalovirus (CMV) can be a serious complication after allogeneic hematopoietic cell transplant (HCT). CMV viral load is routinely monitored, and pre-emptive therapy is initiated to prevent CMV viremia from developing into CMV organ disease based on institutional thresholds. There is no established universal threshold for pre-emptive therapy and many centers utilize different strategies.
Allogeneic HCT recipients at WVU Medicine from 2009 to 2021 were routinely initiated on pre-emptive CMV treatment for a PCR viral threshold above 4000 IU/mL. Adult patients with quantifiable values below this threshold, were analyzed to evaluate the rate of spontaneous clearance without initiation of CMV-directed therapy, during their first episode of CMV reactivation. This study excluded any patients that received letermovir prophylaxis.
Sixty patients were included in the analysis. The spontaneous clearance rate was 60 %. The risk factors that were associated with a lower spontaneous clearance rate were reactivation within thirty days after transplant (p = 0.031), presence of graft-versus-host-disease (p = 0.031), and CMV PCR values of 2500-4000 IU/mL (p = 0.02). Although these patients had lower rates of spontaneous clearance, they still spontaneously cleared in 42 %, 42 %, and 43 % of the cases, respectively.
Delaying pre-emptive treatment until a CMV PCR value of 4000 IU/mL is reached appears appropriate and decreases unnecessary treatment toxicity and resistance.
巨细胞病毒（CMV）可成为异基因造血细胞移植（HCT）后的严重并发症。常规监测 CMV 病毒载量，并根据机构阈值启动抢先治疗，以防止 CMV 血症发展为 CMV 器官疾病。目前尚无确定的抢先治疗通用阈值，许多中心采用不同的策略。
2009 年至 2021 年，西弗吉尼亚大学医学中心的所有接受 HCT 的患者，在 PCR 病毒载量超过 4000 IU/ml 时，常规开始进行抢先 CMV 治疗。对低于该阈值的可量化值的成年患者进行分析，以评估在首次 CMV 再激活期间，不启动 CMV 定向治疗而自发清除的比率。本研究排除了接受来特莫韦预防的任何患者。
60 例患者纳入分析。自发清除率为 60%。与自发清除率较低相关的危险因素包括移植后 30 天内再激活（p=0.031）、移植物抗宿主病（p=0.031）和 CMV PCR 值为 2500-4000 IU/ml（p=0.02）。尽管这些患者自发清除率较低，但他们分别有 42%、42%和 43%的病例仍能自发清除。
将抢先治疗推迟到 CMV PCR 值达到 4000 IU/ml 似乎是合适的，可减少不必要的治疗毒性和耐药性。
