Cytomegalovirus infection medical therapy

• 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