Meta-analysis: the efficacy of strategies to prevent organ disease by cytomegalovirus in solid organ transplant recipients.

BACKGROUND Cytomegalovirus (CMV), the most common opportunistic viral infection in solid organ transplant recipients, is associated with substantial morbidity and mortality. PURPOSE To assess the efficacy of universal prophylaxis and preemptive approaches in preventing CMV organ disease and other complications in solid organ transplant recipients. DATA SOURCES Using no language restrictions, the authors searched the following databases from their inception through May 2005: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Evidence-Based Medicine. The authors also reviewed abstracts from scientific meetings and contacted experts and pharmaceutical companies. STUDY SELECTION Randomized, controlled trials that evaluated antiviral strategies for preventing CMV and associated complications in solid organ transplant recipients were selected. DATA EXTRACTION Two reviewers independently extracted and assessed the data. DATA SYNTHESIS The authors found 17 trials involving 1980 patients. Compared with placebo or no therapy, both universal prophylaxis (odds ratio [OR], 0.20 [95% CI, 0.13 to 0.31]) and preemptive strategies (OR, 0.28 [CI, 0.11 to 0.69]) reduced CMV organ disease. However, only universal prophylaxis seemingly reduced CMV organ disease in subgroups of patients at highest risk (donors with positive CMV serostatus and recipients with negative CMV serostatus and induction with antibodies). Both strategies reduced the rate of allograft rejection. Only universal prophylaxis statistically significantly reduced bacterial and fungal infections (OR, 0.49 [CI, 0.36 to 0.67]) and death (OR, 0.62 [CI, 0.40 to 0.96]). Both acyclovir and ganciclovir statistically significantly prevented CMV organ disease in the universal prophylaxis trials. LIMITATIONS Studies were of modest size, and few studies assessed all outcomes. Studies did not always provide data that discriminated between CMV organ disease and CMV syndrome or data about the timing of CMV organ disease. CONCLUSIONS Universal prophylaxis and preemptive strategies are beneficial in preventing CMV organ disease in solid organ transplant recipients. Both strategies are associated with a reduction in allograft rejection, but current data suggest that only universal prophylaxis reduces bacterial and fungal infections and death. Acyclovir and ganciclovir are both effective for universal prophylaxis.