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Pascal R.-A. Meylan, Manuel Pascual, Preemptive versus Prophylactic Approaches in the Management of Cytomegalovirus Disease in Solid Organ Transplant Recipients: What We Know and What We Do Not Know, Clinical Infectious Diseases, Volume 43, Issue 7, 1 October 2006, Pages 881–883, https://doi.org/10.1086/507338
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Different approaches have been used to mitigate the morbidity and mortality associated with cytomegalovirus (CMV) infection after solid organ transplantation [1]. Agents such as CMV hyperimmune globulins, acyclovir, valaciclovir, ganciclovir, and valganciclovir have been used preemptively or prophylactically in numerous clinical studies. However, a majority of these studies were neither designed nor powered adequately to answer the most important questions they were supposed to have addressed. In fact, a few large prophylactic studies [2–4] have helped promote prophylaxis, but there is still a significant debate between supporters of the preemptive and of the prophylactic methods [5–7], resulting in somewhat complex guidelines for the management of CMV infection [8, 9]. In addition, over the years, it has been recognized that, aside from direct effects (i.e., morbidity directly attributable to CMV infection), CMV as an immunoregulatory virus is also responsible for indirect effects (i.e., acute and perhaps chronic allograft rejection and secondary fungal and bacterial infections) [10]. Finally, it has been realized that prophylaxis against CMV disease modifies the time course of the viral infection, causing late-onset disease, which typically occurs after prophylaxis discontinuation [3, 11]. This has led to the definition of new end points and to an increase in the duration of follow-up as necessary parts of any study evaluating the management of CMV infection after transplantation. In view of the paucity of evidence and the lack of consensus regarding the optimal method for preventing CMV infection, it was tempting to try to make the best use of data by meta-analysis of existing studies.
