Cytomegalovirus (CMV)

Cytomegalovirus infections

Treatment

Diagnosis of retinitis: clinical appearance of typical retinal lesions AND response to therapy. PCR of aqueous and vitreous humor optional

Diagnosis of esophagitis / colitis: endoscopic presence of ulcerations AND typical histopathological picture (cellular / nuclear inclusion bodies)

Diagnosis of encephalitis / myelitis: clinical appearance AND positive PCR in CSF AND other pathology excluded. Antibody testing and PCR in blood not useful for diagnosis of end-organ disease

During treatment: monitor renal function, adjust drug dose in renal impairment

	Drug / Dose	Comments
Retinitis, Immediate sight-threatening lesions	ganciclovir 5 mg/kg bid iv	3 weeks, then secondary prophylaxis
OR foscarnet 90 mg/kg bid iv	Foscarnet used as alternative therapy if toxicity or resistance to ganciclovir. Most experts would add intravitreal injections of ganciclovir (2 mg) or foscarnet (2.4 mg) for 1-4 doses over 7-10 days in combination with systemic CMV treatment
Retinitis, small peripheral retinal lesions	valganciclovir 900 mg bid po (with food)	2-3 weeks, then secondary prophylaxis
OR foscarnet 90 mg/kg bid iv
Oesophagitis/Colitis	ganciclovir 5 mg/kg bid iv	3-6 weeks, until symptoms resolved, then secondary prophylaxis (switch to oral valganciclovir once tolerated)
OR foscarnet 90 mg/kg bid iv
OR valganciclovir 900 mg bid po (with food)	In milder disease if oral treatment tolerated
Encephalitis/Myelitis	ganciclovir 5 mg/kg bid iv foscarnet 90 mg/kg bid iv	Treat until symptoms resolved and CMV replication in CSF has cleared (negative PCR DNA-CMV in CSF) Treatment is individualised according to clinical symptoms and response to treatment. Some guidelines recommend ganciclovir combined with foscarnet especially in relapse

Drug / Dose

Comments

Retinitis, Immediate sight-threatening lesions

ganciclovir
5 mg/kg bid iv

3 weeks, then secondary prophylaxis

OR foscarnet
90 mg/kg bid iv

Foscarnet used as alternative therapy if toxicity or resistance to ganciclovir. Most experts would add intravitreal injections of ganciclovir (2 mg) or foscarnet (2.4 mg) for 1-4 doses over 7-10 days in combination with systemic CMV treatment

Retinitis, small peripheral retinal lesions

valganciclovir
900 mg bid po (with food)

2-3 weeks, then secondary prophylaxis

OR foscarnet
90 mg/kg bid iv

Oesophagitis/Colitis

ganciclovir
5 mg/kg bid iv

3-6 weeks, until symptoms resolved, then secondary prophylaxis (switch to oral valganciclovir once tolerated)

OR foscarnet
90 mg/kg bid iv

OR valganciclovir
900 mg bid po (with food)

In milder disease if oral treatment tolerated

Encephalitis/Myelitis

ganciclovir
5 mg/kg bid iv
foscarnet
90 mg/kg bid iv

Treat until symptoms resolved and CMV replication in CSF has cleared (negative PCR DNA-CMV in CSF) Treatment is individualised according to clinical symptoms and response to treatment.
Some guidelines recommend ganciclovir combined with foscarnet especially in relapse

Secondary Prophylaxis/ Maintenance Therapy

Cytomegalovirus (CMV) Retinitis

Stop: Inactive lesions treated for at least 3 months and CD4 count > 100 cells/μL and HIV-VL undetectable over 3 months

Regimens listed are alternatives

Drug / Dose
valganciclovir (preferred regimen) 900 mg qd po (with food)
OR ganciclovir 6 mg/kg qd (x 5 days/week) iv
OR foscarnet 90-120 mg/kg qd (x 5 days/week) iv

Drug / Dose

valganciclovir (preferred regimen)
900 mg qd po (with food)

OR ganciclovir
6 mg/kg qd (x 5 days/week) iv

OR foscarnet
90-120 mg/kg qd (x 5 days/week) iv