Cytomegalovirus Disease
Prevention of Exposure
HIV-infected persons who belong to risk groups with relatively low
rates of seropositivity for cytomegalovirus (CMV) and who anticipate possible
exposure to CMV (e.g., through blood transfusion or employment in a child-care
facility) should be tested for antibody to CMV. These groups include
patients who have not had male homosexual contact and those who are not
injecting-drug users.
HIV-infected adolescents and adults should be advised that CMV is shed in se-men, cervical secretions, and saliva and that latex condoms must always be used during sexual contact to reduce the risk of exposure to CMV and to other sexually transmitted pathogens.
HIV-infected adults and adolescents who are child-care providers or parents of children in child-care facilities should be informed that theylike all children at these facilitiesare at increased risk of acquiring CMV infection. Parents and other care-takers of HIV-infected children should be advised of the increased risk to children at these centers. The risk of acquiring CMV infection can be diminished by good hygienic practices such as hand washing.
HIV-exposed infants and HIV-infected children, adolescents, and adults who are seronegative for CMV and require blood transfusion should be administered only CMV antibody-negative or leukocyte-reduced cellular blood products in non-emergency situations.
Prevention of Disease
Prophylaxis with oral ganciclovir may be considered for HIV-infected
adults and adolescents who are CMV seropositive and who have a CD4+ T-lymphocyte
count of <50 cells/µL. Neutropenia, anemia, limited efficacy,
lack of improvement in survival, and cost are among the issues that should
be considered in decisions about whether to institute prophylaxis in individual
patients. Acyclovir is not effective in preventing CMV disease, and valaciclovir
is not recommended because of an unexplained trend toward increased mortality
observed in persons who have AIDS and who were administered this drug for
CMV prophylaxis. Therefore, neither acyclovir nor valaciclovir should be
used for this purpose. The most important method for preventing severe
CMV disease is recognition of the early manifestations of the disease. Early
recognition of CMV retinitis is most likely when the patient has been educated
on this topic. Patients should be made aware of the significance of increased
"floaters" in the eye and should be advised to assess their visual acuity
regularly by simple techniques such as reading newsprint. Regular
funduscopic examinations performed by a health-care provider or specifically
by an ophthalmologist are recommended by some experts for patients with low
(e.g., <100 cells/µL) CD4+ T-lymphocyte counts.
Prevention of Recurrence
CMV disease is not cured with courses of the currently available antiviral
agents (i.e., ganciclovir, foscarnet, or cidofovir). Chronic suppressive
or maintenance therapy is indicated. Effective regimens include parenteral
or oral ganciclovir, parenteral foscarnet, combined parenteral ganciclovir
and foscarnet, parenteral cidofovir, and (for retinitis only) ganciclovir
administration via intraocular implant. The intraocular implant does
not provide protection to the contralateral eye or to other organ systems.
In spite of maintenance therapy, recurrences develop routinely and require
reinstitution of high-dose induction therapy or replacement of the implant.
Notes:
Pediatric Note
Some experts recommend obtaining a CMV urine culture on all HIV-infected
(or exposed) infants at birth or at an early postnatal visit to identify
those infants with congenital CMV infection. In addition, beginning
at 1 year of age, CMV antibody testing on an annual basis may be considered
for CMV-seronegative (and culture-negative) HIV-infected infants and children
who are severely immunosuppressed (Table 1). Annual testing will allow
identification of children who have acquired CMV infection and might benefit
from screening for retinitis.
HIV-infected children who are CMV-infected and severely immunosuppressed may benefit from a dilated retinal examination performed by an ophthalmologist every 46 months. In addition, older children should be counseled to be aware of "floaters" in the eye, similar to the recommendation for adults (BIII).
Oral ganciclovir is currently under investigation in CMV-infected children, and no recommendation about its use can be made at this time.
Because of the lack of recommendation for its routine use in nonpregnant adults and the lack of experience with this drug during pregnancy, ganciclovir is not recommended for primary prophylaxis against CMV disease during pregnancy. Ganciclovir should be discontinued for patients who conceive while being administered primary prophylaxis. Because of the risks to maternal health, prophylaxis against recurrent CMV disease is indicated during pregnancy. The choice of agents to be used in pregnancy should be individualized after consultation with experts.
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