Comparison of the efficacy and cost effectiveness of pre-emptive therapy as directed by CMV antigenemia and prophylaxis with ganciclovir in lung transplant recipients

Background: CMV disease remains a major complication of lung transplantatio n and attempts to prevent it have met with marginal success. In a previous study we documented that universal prophylaxis did not prevent CMV disease but merely delayed it, and was very costly. Methods: We compared the efficacy and cost of pre-emptive therapy with ganc iclovir, guided by CMV antigenemia, to that of historic controls that recei ved universal prophylaxis with ganciclovir. CMV antigenemia assay was done routinely and preemptive therapy was initiated if greater than 25 CMV posit ive cells per 100,000 polymorphonuclear cells were found. Results: Nineteen patients were enrolled; 6 of whom received 12 courses of preemptive therapy. The incidence of CMV disease was 26% compared to 38% fo r the historical controls (p = 0.51). None of the patients that received pr e-emptive therapy developed CMV disease following that therapy. Antigenemia failed to predict disease in 5 patients that developed it, and thus it is unknown if pre-emptive therapy could have prevented it. There was no mortal ity in either the study patients or historic controls directly related to C MV. The net savings with pre-emptive therapy was $2569 per patient. Conclusion: We conclude that pre-emptive therapy with ganciclovir is as saf e and effective as universal prophylaxis in preventing CMV disease in lung transplant recipients, and is less expensive. The appropriate surveillance technique and timing remain to be determine to optimize the efficacy of pre -emptive therapy.