Antiviral drugs for cytomegalovirus in transplant recipients: advantages of preemptive therapy

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Abstract
Currently available, potent antiviral agents have proven highly effective for the prevention of CMV disease during the time that prophylaxis is employed. However, late‐onset CMV disease, occurring in 5–18% of the patients, has emerged as a significant complication in organ transplant recipients receiving prophylaxis. Complete suppression of the virus with long‐term use of a potent antiviral agent may be less conducive to antigen‐induced priming of host responses, which may explain why there is a greater likelihood of late‐onset CMV disease. On the other hand, allowing controlled low‐level viral replication, implicit in the strategy of preemptive therapy, may facilitate CMV‐specific immune reconstitution and have a mitigating effect on the risk of late‐onset CMV disease. Preemptive therapy with valganciclovir appears less likely to be associated with CMV disease, largely due to a lower incidence of late‐onset CMV disease. Emerging data, documenting that CMV disease in the era of prophylaxis with potent antiviral agents is an independent contributor to mortality, particularly infection‐associated mortality, stands to challenge the notion that prophylaxis is more likely to have a beneficial effect on CMV‐related secondary outcomes. Preemptive therapy is a more logical and theoretically more appealing approach for the prevention of CMV disease in transplant recipients. Published in 2006 by John Wiley & Sons, Ltd.

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