An International Survey of CMV Preventive Strategies after Intestinal Transplantation. Where do we go from here?
Diana F Florescu1, Kareem Abu-Elmagd2, David F Mercer1, Fang Qiu1, Andre C Kalil1
1University of Nebraska Medical Center, Omaha, NE, United States; 2Cleveland Clinic, Cleveland, OH, United States
Background. Cytomegalovirus (CMV) infections remain the most common post-transplant viral infections. Practice variation regarding CMV prevention across intestinal transplantation is unknown.
Methods. An electronic survey regarding CMV preventive strategies was sent to all intestinal transplant programs registered with the Intestinal Transplant Association. Proportions were computed for categorical variables; means and standard deviations were calculated for continuous variables.
Results. Twenty-seven of the 35 active intestinal transplant programs (77%) responded to the survey. Preventive strategies used: 46.2% universal prophylaxis, 23.1% preemptive strategy, and 30.8% both. If preemptive strategy was used, frequency of monitoring was: weekly in 71.4% of programs, every 2 weeks in 21.4% and monthly in 7.1%. The length of preemptive strategy was: 2 months in 7.1% of the programs, 3 months in 14.3%, 6 months in 64.3% and 12 months in 14.3%.
For CMV D+/R- recipients: 80.8% programs used for prophylaxis with ganciclovir followed by valganciclovir; 7.7% ganciclovir followed by valacyclovir; 3.9% ganciclovir and 3.9% valganciclovir. The length of universal prophylaxis for D+/R- was: 3 months in 32% of programs; 6 months in 44%; and 12 months in 24%.
For CMV R+ recipients:76.9% programs used for prophylaxis with ganciclovir followed by valganciclovir; 3.9% ganciclovir followed by valacyclovir; 11.5% ganciclovir and 3.9% valganciclovir. The length of universal prophylaxis for R+ was: one month in 3.9% of programs; 2 months in 3.9%; 3 months in 34.6%; 6 months in 26.9%; 12 months in 26.9%; and no prophylaxis 3.9%.
For CMV D-/R- recipients: 50.0% programs used for prophylaxis ganciclovir followed by valganciclovir; 11.5% ganciclovir followed by acyclovir; 3.9% ganciclovir followed by valacyclovir; 11.5% ganciclovir; 7.7% acyclovir; and 15.4% no prophylaxis. The length of universal prophylaxis for D-/R- was: one month in 16% of programs; 3 months 36%; 6 months in 20%; 12 months in 16%; and no prophylaxis in 12%.
Conclusions. Prophylaxis was the most commonly used preventive strategy, but significant variation from program-to-program was noted regarding the regimen and duration of prophylaxis. Our findings suggest that international CMV guidelines would benefit from addressing prevention specifically for intestinal transplantation.