Prophylaxis with Acyclovir after stem cell transplantation

Both allogeneic(from another human) and autologous9from the self) hematopoietic cell transplant (HCT) recipients are at increased risk for a variety of infections based upon their past history and exposures, more so the allogeneic transplant recipients.
The types of infections to which these hosts are most vulnerable can be roughly divided based upon their temporal relation to the transplantation:

?Preengraftment — less than three weeks
?Immediate postengraftment — three weeks to three months
?Late postengraftment — more than three months

Unfortunately, infection is reported as the primary cause of death in 8% of autologous HCT patients and 17% to 20% of allogeneic HCT recipients. Many of these are CMV or varicelaa-zoster viral infections and may be prevented with drugs such as Acyclovir. High-dose intravenous acyclovir (500 mg/m2 3 times daily, from day < 5 until day > 30) followed by oral acyclovir (800 mg 4 times daily for 6 months) has been found to effectively reduce the incidence of CMV disease (52%–59% vs. 61%–75%) and increase overall patient survival. However, it is expensive and has side effects. The Infectious Diseases Society of America (IDSA) issued clinical practice guidelines for preventing opportunistic infections among HCT recipients, published in Biol Blood Marrow Transpant ; 2009 ; 15 : 1143 -1238. IDSA does not recommend open ended acyclovir prophylaxis. It says: “Acyclovir prophylaxis should be offered to all HSV-seropositive allogeneic recipients to prevent HSV reactivation during the early posttransplant
period (AI). The standard approach is to begin acyclovir prophylaxis at the start of the conditioning therapy and continue until engraftment occurs or until mucositis resolves, whichever is longer, or approximately 30 days after HCT.” It does appears from its discussion in this section that there may be a benefit for a longer patients who are seronegative positive for CMV or VZV but the guideline does not define how long and does not specifically recommend it.  NCCN does recommend a year of prophylaxis in CMV or VZV infected patients but otherwise only for 30 days.  The American Society of Bone Marrow Transplantation and CDC take the same position in an identical language to the ISDA.  

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