Costs and outcomes of prolonged cytomegalovirus prophylaxis to cover the enhanced immunosuppression phase following lung transplantation

Background: Cytomegalovirus (CMV) disease is one of the major challenges of lung transplantation that may determine outcome, The benefits of ganciclov ir prophylaxis seem indisputable, but no consensus has been reached on the optimal duration of therapy. Results with different protocols suggest that efficacy is related to the duration of treatment, Materials ana methods: To evaluate the additional effect of a prolonged reg imen throughout the maximal immunosuppression phase; we conceived a protoco l administering ganciclovir, 5 mg/kg/d for 20 weeks from the first postoper ative day, to all CMV-seropositive patients undergoing lung transplantation or receiving the lung from a seropositive donor. Virus shedding was routin ely measured in body fluids including through BAL, Costs and outcomes are c ompared with those in shorter prophylaxis protocols from previous reported studies. Results: Of 30 lung transplant recipients, 22 patients at risk for CMV reac tivations were observed for (mean SD) 22.9 +/- 13.2 months. CMV infections were detected in eight patients 8.6 +/- 5.1 months after transplantation. C MV pneumonitis developed in one patient 9 months following the transplant e vent. Prolonged IV ganciclovir prophylaxis was, in general, well tolerated. However, five patients had bacteremia and one had a local thrombosis, with no long-term consequences, A prescription for 8 additional weeks of prophy laxis to cover the whole period of enhanced immunosuppression decreased the cumulative incidence of first CMV infections by 29% 1 year after transplan tation compared to 12-week regimens reported in other studies that indicate d a 50% reduction in the incidence of first CMV infection, The total cost o f 20 weeks of IV ganciclovir prophylaxis was $6,010 (US dollars) per patien t more expensive than 12 weeks of IV ganciclovir therapy, This was not offs et by the reduced requirement for treatment of infections. Indeed, extrapol ating to our cohort of patients, the additional cost per patient was seven times greater than the treatment for the infections that were reported afte r the le-week prophylaxis protocol. Conclusion: Prolonging ganciclovir prophylaxis to 20 weeks decreased by hal f the rates of CMV infection when compared to reports from centers using a shorter protocol of 12 weeks for ganciclovir prophylaxis. Additionally, a d elay in the onset of the first infection was observed. Nevertheless, the in crease in costs and the discomfort of long-term use of venous catheters are important factors that may favor a shorter regimen of 12 weeks followed by preemptive therapies each time CMV infections occur.