Monitoring
Patients with cytomegalovirus (CMV) disease should undergo regular monitoring with CMV quantitative nucleic acid testing (NAT), typically once weekly. This helps to track the clearance of CMV from the blood and determine the duration of treatment. Regular CMV monitoring is generally not clinically indicated during routine antiviral prophylaxis in solid organ transplant recipients or for AIDS patients (see below for consideration of AIDS patients with CD4 T-cell count of <50 cells/microlitre). Monitoring is commonly used as part of a pre-emptive strategy in solid organ transplant recipients or allogeneic haematopoietic stem cell transplant recipients who are not receiving antiviral prophylaxis. Monitoring may also be used occasionally in solid organ transplant recipients after completion of a course of prophylaxis (hybrid strategy).
Patients with detectable CMV in their blood or showing clinical signs consistent with active or persistent CMV disease should continue antiviral therapy.
CMV NAT for transplant recipients and AIDS patients: Solid organ and allogeneic haematopoietic stem cell transplant recipients are monitored at least once weekly with CMV NAT to detect asymptomatic CMV replication, enabling administration of pre-emptive antiviral therapy to prevent disease progression. AIDS patients with CD4 T-cell counts of <50 cells/microlitre are monitored regularly with CMV NAT to determine whether to initiate antiviral therapy for the prevention of CMV retinitis and organ-invasive disease.[42]
CMV serology in prospective transplant recipients and their donors: CMV serology is conducted in all prospective transplant recipients and donors to assess the risk of CMV disease post-transplantation.[42] Blood transfusions can result in false-positive CMV serology results in allogeneic haematopoietic stem cell transplant recipients. Thus, a two-step serology evaluation protocol is recommended to improve the accuracy of CMV risk assessment before transplantation.[77]
Patients on long-term maintenance treatment should be monitored for potential side effects of the medications, including bone marrow suppression, renal toxicity, or electrolyte disturbance.
Patients with CMV retinitis require close monitoring by an experienced ophthalmologist and the primary clinician. Dilated indirect ophthalmoscopy should be performed at various stages of treatment, including diagnosis of CMV retinitis, completion of induction therapy, 1 month after initiating therapy, and monthly thereafter while on anti-CMV treatment. Monthly fundus photographs using a standardised photographic technique that documents the appearance of the retina, help detect early relapse. Children with HIV aged <5 years who are CMV infected and severely immunosuppressed (CD4 count <50 cells/microlitre or CD4 percentage <5%) should have a dilated retinal examination performed by an ophthalmologist every six months. As CMV retinitis can occur in patients with higher CD4 counts, ophthalmologic screening can also be considered for young children with lesser degrees of immunosuppression who are unable to report visual symptoms.[32]
Infants with confirmed congenital CMV infection should be evaluated regularly for early detection of hearing loss.[32]
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