Table II.. Summary of recommendations
| Bone marrow transplantation |
|
| (a) HSV |
| Treatment |
| Intravenous acyclovir (250 mg/m2 or 5 mg/kg q 8h) should be used for treatment of severe localized HSV in allogeneic BMT patients (Category 2). For less severe mucocutaneous disease, oral acyclovir (400 mg five times daily) is recommended (Category 2). Intravenous acyclovir is recommended for visceral or disseminated HSV infection (Category 3). |
| Prophylaxis |
| Acyclovir prophylaxis (iv or oral) is recommended from the start of conditioning for a period of 4 weeks for HSV seropositive recipients who are not receiving prophylactic ganciclovir (Category 1). Patients who are receiving ganciclovir prophylaxis against CMV disease are also protected against HSV reactivation (Category 1). Acyclovir should be stopped as ganciclovir commences. |
| (b) CMV |
| Treatment |
| Ganciclovir plus normal immunoglobulin should be used for treatment of CMV pneumonitis (Category 3). |
| Prophylaxis |
| CMV seronegative blood or leucodepleted blood should be used for CMV seronegative allogeneic BMT patients regardless of donor marrow CMV serostatus and also for autologous transplants (Category 1). |
| Prophylactic high-dose acyclovir improves survival following allogeneic BMT (Category 2) although this may be rendered unnecessary in the context of pre-emptive or prophylactic ganciclovir (Category 3). |
| Prophylactic ganciclovir reduces CMV infection and disease following allogeneic BMT in CMV-seropositive patients although overall survival is not improved (Category 1). Consider as an alternative to CMV antigenaemia-guided therapy (see pre-emptive therapy below) for patients at especially high risk of CMV disease, e.g. CMV-seropositive patients receiving grafts from unrelated or HLA-mismatched donors. |
| Pre-emptive therapy |
| Pre-emptive therapy with ganciclovir, guided by rapid culture reduces CMV infection and disease after allogeneic BMT (Category 1). This has now been superseded by CMV infection-guided treatment based on antigenaemia or PCR for CMV DNA and resulting in shorter courses of ganciclovir (Category 2). With both strategies overall survival may not be improved. |
| All patients at risk of CMV disease by virtue of CMV seropositivity in either donor or recipient should be monitored at least weekly with either the antigenaemia assay or PCR. Monitoring should be for at least 100 days. Longer monitoring is recommended in patients who have received an unrelated or HLA-mismatched transplant, or for whom at least one course of pre-emptive therapy has been administered. Implementation of CMV infection-guided treatment is highly dependent on the availability of local clinical virology laboratories providing suitable assays. |
| (c) VZV |
| Treatment |
| Intravenous acyclovir is the treatment of choice for VZV infection, occurring within the 9–12 months following BMT and later if the patient is still receiving immunosuppressive therapy for GVHD (Category 1). More delayed VZV infections can be treated with oral acyclovir (Category 3). |
| Prophylaxis |
| No specific prophylactic antiviral is recommended for VZV infection in BMT (Category 3). |
| (d) EBV |
| EBV-associated PTLD should be managed by a reduction in immunosuppressive therapy, if possible (Category 3). There is no evidence that antiviral therapy is beneficial in treatment of PTLD (Category 3). |
|
| Liver/renal transplantation |
|
| (a) HSV |
| Treatment |
| For mucocutaneous HSV infections in renal transplant patients oral acyclovir, famciclovir or valaciclovir is recommended (Category 3). For more severe disease in renal transplant and for all forms of disease in other solid organ transplant recipients iv acyclovir is recommended (Category 3). |
| Prophylaxis |
| If acyclovir or ganciclovir is used for CMV prophylaxis this will obviate the need for additional prophylaxis directed at HSV (Category 3). Oral acyclovir is recommended for all HSV-seropositive patients not receiving CMV prophylaxis (Category 1). |
| (b) CMV |
| Treatment |
| CMV disease should be treated with ganciclovir with (for pneumonitis) or without normal immunoglobulin (Category 3). |
| Prophylaxis |
| Ganciclovir (iv or oral) or acyclovir, given for at least 3 months following transplantation, reduces the incidence of symptomatic CMV infection, and its use should be considered for recipients other than seronegative recipients of organs from seronegative donors (Category 1). Ganciclovir provides greater protection than acyclovir (Category 2) |
| Pre-emptive therapy |
| Pre-emptive administration of ganciclovir can reduce the incidence of symptomatic CMV infection (Category 1). |
| (c) VZV |
| Treatment |
| Intravenous acyclovir is recommended for varicella in solid organ transplant recipients of all ages (Category 2). For herpes zoster either iv or oral acyclovir, iv penciclovir, oral famciclovir or oral valaciclovir may be used (Category 3). |
| Prophylaxis |
| No antiviral prophylaxis specifically directed at VZV infection is recommended (Category 3). Vaccination of seronegative children before transplant with live attenuated vaccine can reduce the risk of post-transplant primary VZV infection (Category 3). |
| (d) EBV |
| EBV-associated PTLD should be managed by a reduction in immunosuppressive therapy, if possible (Category 3). There is no evidence that antiviral therapy is beneficial in treatment of PTLD (Category 3). |
|
| Thoracic transplantation |
|
| (a) HSV |
| Treatment |
| For all HSV infections iv acyclovir is recommended (Category 3). |
| Prophylaxis |
| If acyclovir or ganciclovir are used for CMV prophylaxis this will obviate the need for additional prophylaxis directed at HSV (Category 3). Oral acyclovir is recommended for all HSV-seropositive patients not receiving CMV prophylaxis (Category 1). |
| (b) CMV |
| Treatment |
| CMV disease in thoracic transplant recipients should be treated with ganciclovir with (for pneumonitis) or without normal immunoglobulin (Category 3). |
| Prophylaxis |
| Ganciclovir prophylaxis should be used for heart and lung transplant recipients who are CMV seropositive, or who are recipients of seropositive organs (Category 1). |
| Pre-emptive therapy |
| Ganciclovir pre-emptive therapy based on the CMV viraemia assay should be considered where rapid techniques are locally available (Category 2). |
| (c) VZV |
| Treatment |
| Intravenous acyclovir is recommended for varicella in solid organ transplant recipients of all ages (Category 2). For herpes zoster either iv or oral acyclovir, iv penciclovir, oral famciclovir or oral valaciclovir may be used (Category 3). |
| Prophylaxis |
| No antiviral prophylaxis specifically directed at VZV infection is recommended (Category 3). Vaccination of seronegative children before transplant with live attenuated vaccine can reduce the risk of post-transplant primary VZV infection (Category 3). |
| (d) EBV |
| EBV-associated PTLD should be managed by a reduction in immunosuppressive therapy, if possible (Category 3). There is no evidence that antiviral therapy is beneficial in treatment of PTLD (Category 3). |
| |
