COMBINED ANTIVIRAL AND IMMUNOGLOBULIN THERAPY AS PROPHYLAXIS AGAINST CYTOMEGALOVIRUS-INFECTION AFTER HEART-TRANSPLANTATION

Background: Cytomegalovirus is a frequent cause of infection and morbi dity after heart transplantation, especially in patients treated with antilymphocytic drugs where the incidence may be as high as 50%. Metho ds: To determine the efficacy of combined antiviral and intravenous im mune globulin therapy for prevention of cytomegalovirus disease in tra nsplant recipients receiving OKT3 and to compare two different antivir al drug regimens, we reviewed 115 transplant recipients from December 1988 to December 1993 who survived for more than 30 days. Of these, 29 received oral acyclovir for 3 months (group A) and 86 received intrav enous ganciclovir for 2 weeks followed by oral acyclovir up to 3 month s (group G); all received six infusions of 5% intravenous immune globu lin over 2 months. All patients had OKT3 for 10 to 14 days and triple- drug immunosuppression. Results: Cytomegalovirus disease (pneumonitis, gastroenteritis, or leukopenia with fever) occurred in 10% of patient s (12 of 115 patients) and was confirmed by positive culture, typical microscopic inclusions, or polymerase chain reaction. In 91 seropositi ve recipients, there was a trend to less cytomegalovirus disease in gr oup G (3.0%, 2 of 67 patients) than in group A (12.5%, 3 of 24 patient s) (p = 0.11), which was more apparent in recipients with seropositive donors where the incidence was reduced from 16.7% (group A) to 2.4% ( group G; p = 0.08). In 24 seronegative recipients, cytomegalovirus dis ease incidence was higher overall and not significantly less in group G (26%, 5 of 19 patients) than in group A (40%, two of five patients) (p = Not significant). Conclusions: Prophylaxis with combined antivira l and immune globulin therapy produces a low (10%) incidence of cytome galovirus disease in OKT3 treated heart transplant recipients. In sero positive recipients treated with combined therapy, ganciclovir may be more effective than acyclovir. Larger trials and more aggressive proph ylactic strategies are needed in seronegative patients who receive hea rts from seropositive donors.