Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV

The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.

Cytomegalovirus Disease

Last Updated: November 4, 2015; Last Reviewed: June 26, 2019

Recommendations for Treating Cytomegalovirus Infections
Preventing CMV Disease
  • CMV end-organ disease is best prevented by using ART to maintain CD4 count >100 cells/mm3.
Managing CMV Retinitis
  • The choice of initial therapy for CMV retinitis should be individualized, based on location and severity of the lesion(s), the level of immunosuppression, and other factors (e.g., concomitant medications, ability to adhere to treatment) (AIII).
  • Given the evident benefits of systemic therapy in preventing contralateral eye involvement, reduce CMV visceral disease and improve survival,whenever feasible, treatment should include systemic therapy.
  • The ganciclovir ocular implant, which is effective for treatment of CMV retinitis, is no longer available.
Initial Therapy Followed by Chronic Maintenance Therapy—For Immediate Sight Threatening Lesions (within 1500 microns of the fovea)
Preferred Therapy:
  • Intravitreal injections of ganciclovir (2 mg/injection) or foscarnet (2.4 mg/injection) for 1–4 doses over a period of 7–10 days to provide higher intraocular levels of drug and faster control of the infection until steady state intraocular ganciclovir concentrations are achieved (AIII); plus
  • Valganciclovir 900 mg PO BID for 14–21 days, then 900 mg once daily (AI)
Alternative Therapy:
  • Intravitreal injections as listed above (AIII); plus one of the following systemic therapy:
    • Ganciclovir 5 mg/kg IV q12h for 14–21 days, then 5 mg/kg IV daily (AI), or
    • Ganciclovir 5 mg/kg IV q12h for 14–21 days, then valganciclovir 900 mg PO daily (AI), or
    • Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h (AI), or
    • Cidofovir 5 mg/kg/week IV for 2 weeks, then 5 mg/kg every other week with saline hydration before and after therapy and probenecid 2 g PO 3 hours before the dose followed by 1 g PO 2 hours after the dose, and 1 g PO 8 hours after the dose (total of 4 g) (BI).
      Note: This regimen should be avoided in patients with sulfa allergy because of cross hypersensitivity with probenecid.
For Peripheral Lesions:
  • Administer one of the systemic antiviral therapy listed above for the first 3–6 months until ART induced immune recovery (AII).
  • Minimizing lesion size by treating all CMV retinitis lesions until there is immune recovery may reduce the incidence of IRU (BII).
  • IRU might develop in the setting of immune reconstitution.
Treatment of IRU:
  • Periocular corticosteroid or a short course of systemic steroid (BIII).
Stopping Chronic Maintenance Therapy for CMV Retinitis:
  • CMV treatment for at least 3–6 months, and lesions are inactive, and with CD4 count >100 cells/mm3 for 3 to 6 months in response to ART (AII).
  • Therapy should be discontinued only after consultation with an ophthalmologist, taking into account magnitude and duration of CD4 count increase, anatomic location of the lesions, vision in the contralateral eye, and the feasibility of regular ophthalmologic monitoring.
  • Routine (i.e., every 3 months) ophthalmologic follow-up is recommended after stopping chronic maintenance therapy for early detection of relapse or IRU, and then periodically after sustained immune reconstitution (AIII).
Reinstituting Chronic Maintenance for CMV Retinitis:
  • CD4 count <100 cells/mm3 (AIII).
Managing of CMV Esophagitis or Colitis
  • Doses are the same as for CMV retinitis.
Preferred Therapy:
  • Ganciclovir 5 mg/kg IV q12h, may switch to valganciclovir 900 mg PO q12h once the patient can absorb and tolerate PO therapy (BI).
Alternative Therapy:
  • Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h (BIII)—for patients with treatment limiting toxicities to ganciclovir or with ganciclovir resistance; or
  • Oral valganciclovir may be used if symptoms are not severe enough to interfere with oral absorption (BIII); or
  • For mild cases: If ART can be initiated or optimized without delay, withholding CMV therapy may be considered (CIII).
Duration of Anti-CMV Therapy:
  • 21–42 days or until signs and symptoms have resolved (CII).
Note: Maintenance therapy is usually not necessary, but should be considered after relapses (BII)
Managing Well-Documented CMV Pneumonitis
  • Doses are the same as for CMV retinitis.
  • Treatment experience for CMV pneumonitis in HIV patients is limited. Use of IV ganciclovir or IV foscarnet is reasonable (CIII).
  • The role of oral valganciclovir has not been established.
  • The optimal duration of therapy has not been established.
Managing CMV Neurological Disease
  • Doses are the same as for CMV retinitis.
  • Treatment should be initiated promptly.
  • Combination of ganciclovir IV plus foscarnet IV to stabilize disease and maximize response (CIII).
  • Optimal duration of therapy has not been established.
  • The role of oral valganciclovir has not been established.
  • Optimize ART to achieve viral suppression and immune reconstitution (BIII).
Key to Acronyms: ART = antiretroviral therapy; BID = twice a day; CMV = Cytomegalovirus; IRU = immune recovery uveitis; PO = orally; IV = intraveneously; q(n)h = every “n” hours

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