The case for cytomegalovirus prophylaxis in solid organ transplantation.

Cytomegalovirus prevention strategies have been debated for the past decade. This review argues in favour of the prophylaxis strategy. Clinical trials comparing prophylaxis to pre-emptive therapy have, thus far, had insufficient power to differentiate strategies, especially with regard to the indirect effects of CMV. From meta-analyses, prospective trials, observational studies, and case control studies, there is evidence that prophylaxis prevents cytomegalovirus infection and disease, reduces the indirect effects of cytomegalovirus, including organ rejection and transplant associated, all cause mortality as well as opportunistic infection, and even bacteremia as well as post transplant lymphoproliferative disease. Prophylaxis has also been shown to be cost effective. One must recognise that with the current prophylaxis regimens employed for 3 months post-transplantation, late onset cases of cytomegalovirus disease may occur. Cytomegalovirus replication monitoring may be necessary after cessation of prophylaxis, especially in the high risk cytomegalovirus seropositive donor to cytomegalovirus seronegative recipient. Future trials with longer periods of prophylaxis are being undertaken.