Sandbox parminder

• Cytomegalovirus treatment

• 1. Immunocompetent patients

• 1.1 Mononucleosis syndrome

• Preferred regimen: supportive therapy

• 1.2 CMV in pregnancy

• Preferred regimen: Hyperimmune 200 IU/kg of maternal weight as single-dose during pregnancy

• 2. Immunocompromised patients

• 2.1 Retinitis

• Preferred regimen (1): Ganciclovir intraocular implant PLUS Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900mg PO qq for maintenance therapy - for immediate sight-threatening lesions
• Preferred regimen (2): Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900 mg PO qq for maintenance therapy - for peripheral lesions
• Alternative regimen (1): Foscarnet 60 mg/kg IV q8h OR Foscarnet 90 mg/kg IV q12h for 14-21 days THEN Foscarnet 90-120 mg/kg IV q24h
• Alternative regimen (2): Cidofovir 5 mg/kg IV for 2 weeks THEN Cidofovir 5 mg/kg IV every other week - each dose should be admnistered with IV saline hydration and probenecid
• Alternative regimen (3): Ganciclovir 5 mg/kg IV q12h for 14-21 days THEN Valganciclovir 900 mg PO bid
• Alternative regimen (4): Fomivirsen intravitreal injection - for relapses
• Note: keep a maintenance dose of Valganciclovir 900 mg PO qd until CD4 >100/mm³

• 2.2 Transplant patients

• Preferred regimen: Valganciclovir 900 mg PO bid OR Ganciclovir 5 mg/kg IV q12h for at least 2-3 weeek
• Note: Use Valganciclovir 900 mg PO qd for 1-3 months if high dose of immunosuppression.

• 2.3 Colitis, esophagitis, gastritis

• Preferred regimen: Ganciclovir 5 mg/kg/dose IV q12h for 3-6 weeks weeks for induction. There is no agreement on the use of maintenance.
• Alternative regimen: Cidofovir 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
• Note: Switch to oral Valganciclovir when PO tolerated & when symptoms not severe enough to interfere with absorption.

• 2.4 Pneumonia

• Preferred regimen: Valganciclovir 900 mg PO bid for 14–21 days, then 900 mg PO qd for maintenance therapy
• Alternative regimen for retinitis: Ganciclovir 5 mg/kg IV q12h for 14–21 days, then Valganciclovir 900 mg PO qd
• Note: In bone marrow transplant patients, combine therapy with CMV immune globulin.

• 2.5 Encephalitis, ventriculitis

• Note: Treatment not defined, but should be considered the same as retinitis. Disease may develop while taking Ganciclovir as suppressive therapy.

• 2.6 Lumbosacral polyradiculopathy

• Preferred regimen: Ganciclovir, as with retinitis
• Alternative regimen: Foscarnet 40 mg/kg IV q12h another option
• Alternative regimen: Cidofovir 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
• Note (1): Switch to Valganciclovir when possible.
• Note (2): Suppression continued until CD4 remains >100/mm³ for 6 months.

• 2.7 Peri/postnatal severe CMV infection in very low birth weight infants

• Preferred regimen: Ganciclovir 6 mg/kg/dose IV q12h for 3 weeks

Antibiotic Regimen

In case of serious skin, soft tissues, and bones infection, a combination of antibiotics need to be administered:

• Macrolide: clarithromycin OR azithromycin

PLUS

• Parenteral antibiotics: amikacin, cefoxitin OR imipenem

Note that, during the initial therapy, amikacin should be administered with cefoxitin up to two weeks or until the patient improves clinically.

Antibiotic Dosage

Antibiotic	Dosage
Clarithromycin	1,000 mg/day
Azithromycin	250 mg/day
Amikacin	Once a day regimen - Adults <50 years and normal renal function: 10-15 mg/kg - Age >50 years and/or anticipated long term therapy for more than 3 weeks: 10 mg/kg Three times per week regimen - 25 mg/kg
Cefoxitin	High dose, up to 12 g/day, divided dose
Imipenem	500 mg, 2-4 times/day

Antibiotic Duration of Therapy

• Skin or soft tissue infection: At least 4 months
• Bone infection: 6 months

Antibiotic Regimen

There is no optimal multidrug regimen for the treatment of pulmonary M. abscessus infection. A successful treatment is defined by 12 months of negative sputum culture. In the majority of cases, pulmonary M. abscessus infection is chronic and incurable.

The suggested combination of antibiotics to be administered is:

• Macrolide: clarithromycin OR azithromycin

PLUS

• Amikacin

PLUS

• Cefoxitin OR imipenem

Note that, in case of macrolide resistance, the antibiotic therapy should be chosen based on the suscepibility profile of M. abscessus.

Duration of the Antibiotic Regimen

2-4 months