Prevention of cytomegalovirus disease in solid organ transplant patients: prophylactic versus preemptive therapy

The advantages and disadvantages of universal prophylaxis and preemptive therapy and current evidence-based recommendations for preventing cytomegalovirus (CMV) disease in solid organ transplant recipients are discussed.

Advantages of universal prophylaxis include the ease of implementation, a reduced incidence of CMV disease, and possibly fewer indirect effects of CMV infection. Disadvantages of universal prophylaxis may include prolonged antiviral drug exposure, resistance, toxicity, the development of late-onset CMV disease, and greater drug costs. Advantages of preemptive therapy may include reduced drug exposure and decreased risk for toxicity and resistance. Disadvantages include the logistic demands of laboratory testing, uncertainty about the impact on the indirect effects of CMV disease, and the costs associated with failure to prevent CMV disease. Evidence-based guidelines call for universal prophylaxis for patients at highest risk for CMV disease. Preemptive therapy may be most appropriate for those at a moderate or low risk of CMV. Antiviral drug regimens used for universal prophylaxis depend on the type of organ transplanted and the donor-recipient CMV serostatus. The optimal preemptive drug regimen and laboratory monitoring strategy are unknown.

Selection of a strategy for preventing CMV disease in solid organ transplant patients requires consideration of patient-specific risk factors as well as practical considerations, such as available resources.