ANZTCT cytomegalovirus practice survey for allogeneic haemopoietic stem cell transplant and cellular therapy recipients in Australia and New Zealand

Abstract

BACKGROUND: Despite pre-emptive treatment (PeT), cytomegalovirus (CMV) disease and reactivation remain a clinical concern. In Australia and New Zealand (ANZ), variability exists in the management of CMV for haematopoietic stem cell transplantation (HSCT) recipients. AIMS AND METHODS: To understand the state of practice in Australia, a survey captured insights on detection, monitoring, prophylaxis and treatment from 21 sites, including 11 chimeric antigen receptor T-cell (CAR-T) therapy sites. RESULTS: Respondents reported 26 cases of CMV disease after HSCT and four cases after CAR-T in 2024. All HSCT sites and four CAR-T sites had CMV protocols. Commonly, CMV nucleic acid viral load (VL) testing was employed weekly. Sites utilised plasma (66%) or whole blood (33%). VL was reported as IU/mL (66%), copies/mL (29%) or not specified (5%). One third of respondents tested CMV DNAemia before HSCT. All recipients were monitored regardless of CMV serostatus. Half the sites employed post-HSCT CMV prophylaxis using letermovir (nine sites), (val)aciclovir (eight) and (val)ganciclovir (three). VL thresholds for PeT ranged from 100 to 5000 IU/mL. Most sites used (val)ganciclovir for PeT, with foscarnet second line. At 76% of HSCT sites, PeT continued until two consecutive negative results. Frontline therapy for CMV disease is ganciclovir; 86% of ANZ sites used (val)ganciclovir while three paediatric sites used foscarnet. For resistant or refractory CMV, guidelines recommend foscarnet or maribavir, although maribavir was not funded or used during the survey period. CMV-specific immunotherapy can be considered. CONCLUSIONS: Institutional preferences and medicine funding drives variability in ANZ practice. This leaves potential for healthcare inequity since newer antiviral agents are inconsistently used, contrasting with international guidelines.