CMV Resistance Testing and Novel Antivirals

Transcription

1 CMV Resistance Testing and Novel Antivirals Prof William Rawlinson October 2018

2 OUTLINE 1 CMV in the Transplant Population 2 CMV epidemiology Australia and International At-risk populations 3 Diagnosis and Clinical Consequences Methods 4 Antiviral Resistance 5 Novel Antivirals 6 Summary

3 Net State of Immune Suppression All factors contributing to infection risk Immune defects Immunosuppressive therapy: type/temporal sequence/intensity Duration and rate of development of neutropaenia, lymphopaenia, hypogammaglobulinaemia Underlying immune deficiencies Toxicities of prior chemotherapy Mucocutaneous barrier integrity (catheters, wounds) Metabolic conditions (uremia, malnutrition, diabetes, alcohol, cirrhosis) Viral infections (CMV, HBV, HCV, RSV) Prior infection and prior antimicrobials

4 CMV Infection Reactivation the most common form of infection Virus release from latency Role of regulatory T cells, cf gamma-delta T cells role in survival post burns (Schwacha 2000) Reactivation usually systemic Role of cytokine Th1 bias in reactivation, acute infection Role of Th1 bias (increased IL6 TNFalpha) in reduced vaccine responsiveness (Trzonkowski 2003)

5 CMV Mortality and VL post HSCT in PET treated patiens Green 2016

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7 OUTLINE 1 CMV in the Transplant Population 2 CMV epidemiology Australia and International At-risk populations 3 Diagnosis and Clinical Consequences Methods 4 Antiviral Resistance 5 Novel Antivirals 6 Summary

8 Global Activity of Solid Organ Transplants ,873 SOT 41.6% renal 19.8% liver Number of organs transplanted per million population Data not available Not applicable Global Observatory on Donation and Transplantation. Organ donation and transplantation activities: Accessed March 2,

9 Number of transplants in Australia SOT 2015, OTA HSCT 2012, ABMTDR Organ Number Kidneys 703 Livers 264 Hearts 95 Lungs 193 Pancreas 47 Total 1,303

10 CMV Seroprevalence Prevalence >95% 81% 95% 66% 80% 51% 65% 35% 50% <35% No data Adland E et al. Front Microbiol. 2015;6:1016. doi: /fmicb

11 CMV seroprevalence Australia CMV IgG seropositivity in 1,018 de-identified blood donors <20 yrs 34.9% Steady increase 2 50 yrs Plateau at 50 yrs age 72% [Munro 2005, Seale 2006]

12 Epidemiology of CMV Influenced by Changing tx practice Donor/Recipient population changes Immunosuppressives Antivirals Prophylaxis Pre emptive Treatment regimens Monitoring and diagnosis Shifts in infection and disease Late onset Clinical risk factors Multiple Virus factors Antiviral resistance Antiviral under dosing

13 CMV Seropositivity Associated With Increased All-Cause Mortality n=14153 Survival probability CMV serostatus CMV seronegative CMV seropositive Follow-up time (months from exam) HR=1.19; 95% CI, Adjusted for age, gender, race/ethnicity, country of origin, education level, BMI, smoking status, diabetes Simanek AM et al. PLoS One. 2011;6(2):e doi: /journal.pone

14 Increased Risk of Overall Mortality With CMV Viremia in HSCT Patients Viral load as a risk factor for overall mortality Adapted from Green ML et al. A viral load above the given study threshold carried a significantly higher risk of death and this held true for the lowest threshold, 20 IU/mL (any positive viremia vs negative viremia), determined by the lower limit of detection for the assay. 14

15 OUTLINE 1 CMV in the Transplant Population 2 CMV epidemiology Australia and International At-risk populations 3 Diagnosis and Clinical Consequences Methods 4 Antiviral Resistance 5 Novel Antivirals 6 Summary

16 CMV Clinical Risk factors in Tx Serostatus D+/R- (30% HSCT) R+ in HSCT Level of immunosuppression Transplant type Immunosuppressive therapy with ALG, ATG, Steroids Immunosuppression plus additional factors Kidney-pancreas lung Graft rejection SOT recipients HSCT Allogeneic > autologous GVHD Myeloablative > non Viral factors Higher VL Concomitant HHV6 ICU admission CARS

17 CMV Risk factors in Tx Serostatus D+/R- R+ in HSCT recipients HSCT Allogeneic > autologous GVHD Level of immunosuppression Transplant type Immunosuppressive therapy with ALG, ATG, Steroids Immunosuppression plus additional factors Kidney-pancreas Lung Intermediate liver, heart, small bowel Graft rejection SOT Viral factors Higher VL Concomitant HHV6 ICU admission CARS Host factors Increased donor age TLR polymorphisms Immunosuppressives with CyA>sirolimus>everolimus, Alemtuzumab > Daclizumab Rejection > None

18 CMV in HSCT recipients Highly immunosuppressed Late onset disease occurs [Boeckh 2003] Higher risk of mortality [Ozdemir 2007] Myeloablative > non, but risk same after 12 months post HSCT [Nakamae 2009] Late CMV reactivation associated with GVHD Lymphoid diagnosis More episodes early CMV reactivation >2 D100 lymphopaenia D- graft [Ozdemir 2007] Prolonged GCV CMV T cell deficiency HHV6 concurrent infection

19 CMV Clinical Risk factors in Tx Serostatus D+/R- (30% HSCT) R+ in HSCT Level of immunosuppression Transplant type Immunosuppressive therapy with ALG, ATG, Steroids Immunosuppression plus additional factors Kidney-pancreas lung Graft rejection SOT recipients HSCT Allogeneic > autologous GVHD Myeloablative > non Viral factors Higher VL Concomitant HHV6 ICU admission CARS

20 CMV in HSCT recipients Higher Viral Load [Howden 2003, Green 2016] Concomitant HHV6 Antiviral resistance Higher if D+/R- Higher persisting VL Multiple CMV disease episodes High level of immunosuppression include OKT3 Lung, kidney-pancreas Prolonged antiviral administration, with Prophylaxis>Pre emptive Low antiviral concentrations with ValGCV 450 > 900 [Stevens 2015] [Green 2016]

21 Diagnostic considerations Viral load now available to HSCT population Measurement at least weekly?twice weekly pp65 Ag assay low sensitivity in reactivation in HSCT if viraemic before bone marrow grafting localized disease incl GIT Higher VL 250 IU/ml associated with increased early death independent of PET [Green 2016] [Kotton 2013, Hill 2017]

22 Q-NAT use in transplant recipients Initiation of therapy in SCT o High risk allogeneic SCT 10,000 c/ml whole blood o Alternative 418 cp/104 PBL [Peres 2010] o Pre emptive therapy with GCV 5mg/kg/dy o Dose escalation of GCV if no VL response Initiation of therapy in renal transplants o Lower risk SOT 30,000 c/ml plasma Initiation of therapy in liver transplants o Moderate risk SOT 1,000 c/ml plasma, PPV 47%, NPV 83% o Moderate risk SOT 5,000 c/5x106 cells, PPV 40%, NPV 90% [Li 2003; Martin-Davila 2005; Rayes 2005; Verkruyse 2006, Peres 2010]

23 CMV Risk factors in Tx Serostatus D+/R- R+ in HSCT Level of immunosuppression Transplant type Immunosuppressive therapy with ALG, ATG, Steroids Immunosuppression plus additional factors Kidney-pancreas lung Graft rejection SOT recipients HSCT Allogeneic > autologous GVHD Viral factors Higher VL Concomitant HHV6 ICU admission CARS

24 CCC Pathogenesis of CMV Reactivation Usual reactivation <1% Reactivation pregnancy 5 15% Reactivation with immunosuppression dependent on net state 1/3 of patients in ICU reactivate ICU Systemic inflammatory response syndrome (SIRS) Compensatory anti-inflammatory response (CARS) [Bone 1996, Ward 2008]

25 CCC CARS characteristics Cutaneous anergy Reduction of lymphocytes via apoptosis Decreased Cytokine response of monocytes to stimulation Blastogenesis to mitogens Altered lymphocyte activation receptors (reduced CD28, increased inhibitory PD-1, CTLA4) Decreased HLA antigen-presenting receptors on monocytes Expression of cytokines (IL-10) that suppress TNF expression

26 Effect of antiviral treatment on CCC GCV prophylaxis for 5 dys IVI then GCV or ValGCV until discharge Case 84 : Control 76 Primary outcomes IL6 no different in cases and controls to D14 Secondary outcomes no different Secondary bacteraemia or fungaemia ICU length of stay Mortality Secondary outcomes improved with antiviral treatment CMV reactivation in plasma Mechanical ventilation days Concludes no support for routine prophylaxis in ICU [Limaye 2017]

27 OUTLINE 1 CMV in the Transplant Population 2 CMV epidemiology Australia and International At-risk populations 3 Diagnosis and Clinical Consequences Methods 4 Antiviral Resistance 5 Novel Antivirals 6 Summary

28 Overview of Current Management of Transplant Patients Advantages Disadvantages Universal prophylaxis Easy administration Decrease in early asymptomatic CMV viremia Potential efficacy in prevention of CMV indirect effects Prevention of other herpes viruses Late-onset CMV disease and viremia Increased risk of ganciclovir resistance Drug toxicity and cost Preemptive therapy Low incidence of late-onset CMV disease May facilitate the recovery of CMV-specific T-cell immunity Decreased drug cost Requires frequent monitoring of CMV activity Efficacy failure in the case of noncompliance with surveillance monitoring protocol and/or rapid viral doubling time No prevention of asymptomatic CMV viremia 1. Reischig T. Expert Rev Anti Infect Ther. 2010;8(8): Boeckh M, Ljungman P. Blood. 2009;113(23):

29 Causes of treatment failure Wrong drug Drug-resistance Inadequate drug exposure Dosing Renal/Liver function Inadequate immune control Alternative causes for deterioration Multiple infection Local tissue damage incl surgery

30 Causes of treatment failure Wrong drug Drug-resistance Inadequate drug exposure Dosing Renal/Liver function Inadequate immune control Alternative causes for deterioration Multiple infection Local tissue damage incl surgery

31 RECOMMENDATIONS - Prophylaxis Oral ValGCV 900 mg od [Kotton 2013, 2017] Duration Oral ValACV 2g qid most useful in high risk D+/R- (3% vs 10dys, 16% vs 180 dys) [Lowance, 1999] Economic benefits on chronic complications Oral GCV - 3g/d [Squifflet, 2002] morbidity no effect on mortality [Kletzmayr, 2000]

32 Causes of treatment failure Wrong drug Drug-resistance Inadequate drug exposure Dosing Renal/Liver function Inadequate immune control Alternative causes for deterioration Multiple infection Local tissue damage incl surgery

33 Prolonged Pre-Exposure and Persistent CMV Reactivation Can Lead to Drug Resistance Prolonged drug administration (before and/or after transplant) + Low antiviral drug levels Low immune status Drug induced T cell depletion (eg, haploidentical donor transplants) Cord blood transplantation + + Subclinical CMV load + Resistance Drug resistance suspected in patients on antiviral drugs and have had CMV load increases for >2 weeks. Boeckh M, Ljungman P. Blood. 2009;113(23):

34 Some SOT still develop CMV infection and disease during prophylaxis OR after discontinuation of prophylaxis

35 Ganciclovir (GCV) Aciclovir (ACV) Cidofovir (CDV) UL97 protein kinase GCV-p Cellular kinases inhibition inhibition GCV-ppp Foscarnet (FOS) DNA polymerase CDV-pp

36 CMV antiviral resistance 13% 15% 13% 45% 44% 15% 47% 3% 26% 23% Specimens Patients CMV antiviral sensitive CMV antiviral resistance UL97 CMV antiviral resistance UL54 CMV antiviral resistance UL97 + UL54 CMV PCR negative 42% (specimens) or 38% (patients) contain antiviral resistant CMV sequences 13% (specimens) or 15% (patients) have dual UL97+UL54 mutations Confers multidrug resistance

37 Antiviral Mechanism CDV GCV ACV UL97 protein kinase GCV ACV P P P P cellular enzymes GCV ACV CDV UL54 FOS DNA polymerase

38 Antiviral Resistance CDV GCV ACV UL97 protein kinase GCV ACV P P P P cellular enzymes GCV ACV CDV UL54 FOS DNA polymerase

39 Antiviral resistance ACV GCV PCV CMV UL97 kinase NA monophosphate CDV ADV Cellular kinases NA triphosphate PFA Viral DNA polymerase Chain termination

40 Detection of mutations UL54 PCR1 HCMV UL54 (DNApol) NH 2 COOH IV -C II VI III I VII V HCMV UL97 (PK) UL54 PCR2 NH 2 COOH I II III VI VII VIII IX XI UL97 PCR

41 CMV antiviral resistance Overall resistance in liver tx receiving valgcv = 8.9% (4/45) Common mutations detected Gene Mutation Resistance UL97 A594V GCV UL97 L595W GCV UL54 T503I GCV, CDV [Scott 2011 JCV]

42 Evolution of resistance Lung transplant recipient Heart transplant recipient

43 In Vitro Maribavir Resistance So far, no MBV-resistant isolates from treated subjects UL97 MBV resistance mutations selected in cell culture: - moderate (10-15x): V353A, H411N, H411Y - high (50-100x): H411L, T409M - very high (>100x): L397R, V353A+H411Y - unrelated to ganciclovir resistance Various UL27 mutations confer low-grade resistance UL97 mutations [Chou 2008]

44 Causes of treatment failure Wrong drug Drug-resistance Inadequate drug exposure Dosing Renal/Liver function Inadequate immune control Alternative causes for deterioration Multiple infection Local tissue damage incl surgery

45 Valganciclovir absorption and biotransformation Perrottet et al. Clin Pharmacokinet. 2009;48(6):

46 ValGCV prophylaxis 100d Incidence of viraemia very low (2.5% ValGCV,10.4% GCV) Risk of CMV viraemia high at >100 d prophylaxis, ~50% pts develop viraemia 1 yr post, usu shortly after termination of prophylaxis Need to match prophylaxis with risk for infection; if immune suppression is not substantially reduced 100dy, risk for CMV activation will persist, most notably in seronegative Time to first detectable CMV VL [Paya 2004]

47 LCMSMS method development GCV in plasma Population Modelling GCV in peripheral blood mononuclear cells (PBMC) Research and development

48 Inadequate exposure to ganciclovir: key studies Wiltshire (2005): 240 SOT (D+/R-) 12% viremia during prophylaxis viremia suppression during prophylaxis and following month when exposure 40 to 50 μg h/ml. Perrottet (2009): 65 SOT (D+/R-, D+/R+, D-/R+) 14% viremia during prophylaxis (D+/R- only) No significant association between GCV exposure or trough concentration and breakthrough viremia during prophylaxis or following 3 months. Wiltshire (2005) Clin Pharmacokinet. Perrottet (2009) Antimicrob Agents Chemother.

49 22 year old woman ESRF secondary to IgA nephropathy: Hypertension Impaired glucose tolerance Pre-emptive ABO-I living donor Renal Transplant Donor A- to recipient O+, 3/6 HLA mismatch, T and B cell cross-match negative, no DSAs CMV donor IgG positive, recipient IgG negative Immunosuppression: 4 x immunoadsorption sessions Induction: IVIG, Basiliximab, Methylprednisolone Maintenance: Prednisolone, tacrolimus, mycophenolate Day 8 biopsy: antibody mediated rejection

50 Antibody-mediated rejection management: 6 further sessions immunoadsorption + plasmapheresis + MMF increased Ongoing rejection with creatinine rising 231 umol/l Laparoscopic splenectomy day 16 Repeat biopsies at 3 weeks and 7 weeks post-transplant: nil rejection Creatinine stabilised umol/l Routine 10 week screening tests: CMV PCR negative, CMV IgG positive Infection prophylaxis: Post-splenectomy immunisations: Haemophilus, meningococcal, pneumoccocal vaccines, annual influenza vaccine Bacterial prophylaxis: amoxicillin 250mg daily lifelong CMV prophylaxis: valganciclovir 450mg daily for 6 months PCP prophylaxis: Resprim 400/80mg daily (After ceasing valganciclovir prophylaxis usually monthly CMV PCR)

51 7 months post-transplant 2 week history of fevers + upper abdominal cramps + loose BM Cr 259 umol/l CMV PCR positive. 1,155,757 copies/ml CMV IgG negative Urgent RTx biopsy

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53 Biopsy: significant interstitial lymphocytic infiltrate involving 50%, scattered CMV positive cells, consistent with CMV nephritis, possible underlying borderline rejection

54 6/21/17 6/22/17 6/23/17 6/24/17 6/25/17 6/26/17 6/27/17 6/28/17 6/29/17 6/30/17 7/1/17 7/2/17 7/3/17 7/4/17 7/5/17 7/6/17 7/7/17 7/8/17 7/9/17 7/10/17 7/11/17 7/12/17 CMV viraemia + nephritis management: 7 months post-transplant Commenced on IV ganciclovir, plasmapheresis, mycophenolate withheld Cr further rose to 480 umol/l Hb 58, platelets 48, blood film: red cell fragmentation++, schistocytes+ INR 1.3, APTT 42, D-dimer 0.61, fibrinogen 1.1, haptoglobin <0.1, LDH 944, DAT positive Likely DIC + haemolysis secondary to severe viraemia, other possibilities:?hus 3 weeks IV ganciclovir + 3x CMV IVIG Progress: Slow clinical progress ongoing fevers, loose BM, weight loss Progressive reduction in CMV load Cr down to ~290umol/L Progressive improvement in Hb and platelets Repeat biopsy after 3 weeks IV ganciclovir: interstitial infiltrate involving ~40% of biopsy, 2 CMV inclusions seen, improving CMV nephritis CMV copies 1 week 2 weeks 3 weeks

55 Progress: Changed to PO valganciclovir 450mg daily 2 weeks later: Cr rise to 337 umol/l, CMV PCR low positive (<1000 copies/ml) Urgent biopsy: diffuse lymphoid infiltrate with occasional tubulitis, occasional CMV nuclei only, more consistent with T cell mediated rejection 3 doses pulse IV methylprednisolone 500mg, 250mg, 250mg PO prednisolone, tacrolimus (target 6-8), MMF 500mg TDS Drop in Cr to 298 umol/l Over next 3 months: CMV PCRs low positive (<1000 copies/ml) Plan: valganciclovir 450mg daily for total 6 months + CMV PCR monitoring

56 12 months post-transplant Febrile + sore throat + mouth ulceration/plaques + generally unwell Total WCC 0.6, Neutrophils 0.3, Hb 86, Platelets 100 Creatinine 396 umol/l ESBL Klebsiella UTI meropenem valganciclovir/resprim/mycophenolate withheld, commenced GCSF CMV PCR low positive (<1000 copies/ml) EBV IgG positive (previously negative), EBV PCR positive in blood,? acute EBV infection Pancytopenia slow to improve, tacrolimus withheld, daily GCSF Worsening Cr 494 umol/l, unable to biopsy Repeat CMV PCR 1 week later: 125,647 copies Resumed valganciclovir 450mg 2 nd daily (renally adjusted treatment dose) + daily GCSF, mycophenolate/tacrolimus withheld

57 Outpatient progress: 3 weeks after resuming PO valganciclovir: CMV PCR 23,874 copies Progressive decline in graft function (Cr 792 umol/l, egfr 6mL/min), likely chronic rejection Fluid overload, HTN, lethargy commenced dialysis via vascath 14 months post-transplant CMV PCR 10,869 copies/ml Continued on valganciclovir 450mg 2 nd daily

58 Progress 16 months post-transplant Admitted for graft nephrectomy: Rationale: to come off immunosuppression + eliminate CMV reservoir + severe HTN, with view for retransplantation in future Borderline neutropenic (N ) CMV PCR 156,876 copies IV ganciclovir 3x per week after dialysis Resistance testing requested However: Fevers + generally unwell, CRP 244, WCC 8.4 No alternative source of infection found CMV PCR 325,340 copies/ml despite IV ganciclovir CMV resistance testing: ganciclovir resistance, no mutations associated with foscarnet or cidofivir

59 Progress 16 months post-transplant Commenced on IV foscarnet 60mg/kg after dialysis 2-3 weeks induction treatment Repeat CMV PCR after 1 week on foscarnet: low positive (<1000 copies) Side effects of foscarnet Recurrent fevers, no clear source, vascath removed, received antibiotics Slow to respond but achieved low positive viral load Foscarnet ceased, observed CMV Quantiferon 24 months post-transplant has not cleared CMV

60 CMV PCR CMV copies Nephrectomy, recommenced IV ganciclovir weeks IV Off IV foscarnet ganciclovir valganciclovir 100 for neutropenia Treatment dose PO 10 valganciclovir Treatment dose PO valganciclovir 1 6/21/17 7/21/17 8/21/17 9/21/17 10/21/17 11/21/17 12/21/17 1/21/18 2/21/18 3/21/18

61 OUTLINE 1 CMV in the Transplant Population 2 CMV epidemiology Australia and International At-risk populations 3 Diagnosis and Clinical Consequences Methods 4 Antiviral Resistance 5 Novel Antivirals 6 Summary

62 Trial Design Treatment Follow-up Randomization (within 28 days post-transplant) Week 14 ( 100 days) post-transplant (end of study therapy) Week 24 (6 months) post-transplant Week 48 post-transplant (final follow-up visit) Letermovir arm n=373 Dose: 240 mg qd w/ cyclosporine or 480 mg qd w/o cyclosporine Placebo arm n=192 QD=once daily. Marty FM et al. N Engl J Med doi: /nejmoa

63 Full Eligibility Criteria Inclusion criteria 1 Aged 18 years CMV seropositive Receiving a first allogeneic HCT Undetectable plasma CMV DNA within 5 days of randomization Could start study drug by Day 28 post-transplant Neutrophil engraftment was not required for randomization. 2 Highly unlikely to become pregnant or to impregnate a partner Be able to read, understand, and complete questionnaires and diaries Understand study procedures, alternate treatment available, and risks involved with the study, and voluntarily agree to participate by giving written informed consent 1. Marty FM et al. N Engl J Med. 2017;(suppl). _appendix.pdf. Accessed December 11, Marty FM et al. N Engl J Med doi: /nejmoa

64 Efficacy Endpoints Primary Proportion of patients with clinically significant CMV infection* through Week 24 after transplantation among patients without detectable CMV DNA at randomization (primary efficacy population). Patients who discontinued the study before Week 24 for any reason, or with missing outcomes at Week 24, were imputed as having a primary endpoint event. Key secondary Proportion of patients with clinically significant CMV infection through Week 14. Time to clinically significant CMV infection through Week 24. *Defined as onset of CMV end-organ disease or initiation of anti-cmv PET based on documented CMV viremia (as measured by the central laboratory). Marty FM et al. N Engl J Med doi: /nejmoa

65 Primary Endpoint: Clinically Significant CMV Infection Through Week 24 After Transplantation Primary efficacy population a Endpoint Letermovir (n=325) Placebo (n=170) Difference (95% CI) P value Primary endpoint at Week 24 after transplantation, n (%) 122 (37.5) 103 (60.6) Clinically significant CMV infection, n (%) 57 (17.5) 71 (41.8) Initiation of PET 52 (16.0) 68 (40.0) CMV disease b 5 (1.5) 3 (1.8) Discontinued trial before Week 24, n (%) 56 (17.2) 27 (15.9) Owing to AE 6 (1.8) 1 (0.6) Owing to death without CMV 28 (8.6) 12 (7.1) Owing to other reason c 22 (6.8) 14 (8.2) Missing outcome in Week 24 visit window, n (%) 9 (2.8) 5 (2.9) (-32.5, -14.6) <0.001 a The primary endpoint was the proportion of patients with clinically significant CMV infection through Week 24 after transplantation among patients without detectable CMV DNA at randomization (primary efficacy population); patients who discontinued the trial for any reason before Week 24 (Day 168) after transplantation or who had missing data at Week 24 were imputed as having a primary endpoint event. The proportion of patients with clinically significant CMV infection (or an imputed primary endpoint event) through Week 14 (Day 100) after transplantation (end of the trial) was a key secondary endpoint. The 95% CIs and P values for the differences in percentage response were calculated with the use of the stratum-adjusted Mantel-Haenszel method, with the difference weighted by the harmonic mean of sample size per group for each stratum (high risk or low risk). Two-sided P values and 95% CIs are presented. The protocolspecified calculations for the Week 24 primary endpoint and the Week 14 endpoint with the use of a 1-sided P value with an alpha level of yielded the same results. b All the cases of CMV disease were adjudicated by a clinical adjudication committee whose members were unaware of the group assignments. All the confirmed events of CMV disease through Week 24 after transplantation affected the gastrointestinal tract. c Other reasons for discontinuation from the trial included loss to follow-up, physician s decision, and withdrawal by patient. Marty FM et al. N Engl J Med doi: /nejmoa

66 Incidence of Clinically Significant CMV Infection Around Week 18, the incidence of clinically significant CMV infection after prophylaxis increased among patients who had received letermovir a finding that reflected ongoing or new periods of CMV risk, mostly as a result of GVHD and glucocorticoid use. Marty FM et al. N Engl J Med doi: /nejmoa

67 Clinically Significant CMV Infection, High-Risk Subgroup Marty FM et al. N Engl J Med doi: /nejmoa

68 Clinically Significant CMV Infection, Low-Risk Subgroup Marty FM et al. N Engl J Med doi: /nejmoa

69 Time to Clinically Significant CMV Infection, Safety Population Marty FM et al. N Engl J Med. 2017;(suppl). nejmoa _appendix.pdf. Accessed December 11,

70 Death From Any Cause Through Week 48 Marty FM et al. N Engl J Med doi: /nejmoa

71 Conclusions Letermovir prophylaxis was Effective in preventing clinically significant CMV infection when used through Day 100 after transplantation. Associated with only mild adverse events, which allows for the administration before hematologic engraftment. Not associated with any affect on time to engraftment. Not associated with a higher rate of myelotoxic or nephrotoxic events. Associated with lower all-cause mortality than placebo. Marty FM et al. N Engl J Med doi: /nejmoa

72 Novel quinazoline compounds as CMV inhibitors Poster CD-PP-030, Manfred Marschall

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74 Summary Genotyping of resistance mutations informs treatment options Monitoring essential to profile antiviral resistance genotypes Characterisation of new mutations is essential for accurate diagnosis of resistance UL97 + UL54 mutations detected more frequently multidrug resistance Antiviral therapy problematic in these patients

75 Summary Prophylaxis with ValGCV daily for 3-6 mths Treatment of disease with GCV IVI for 14 dys, cease after 2 negative PCR Treatment of infection with ValGCV Genotyping of resistance mutations informs treatment with multidrug resistance emerging Monitoring of GCV levels needed for rapidly changing renal function

76 GUIDELINES 2015 Dose CrCl (ml/min)/dose > mg OD mg OD mg alt. days < mg twice weekly Duration D+/R- 6 months D-/R+ 3 months D+/R- 3 months D-/R- no prophylaxis and when receiving T cell antibody therapy (eg ATG) for rejection or delayed graft function

77 International Guidelines High rates of initial CMV prevention used (93%) 46% using only universal prophylaxis 21% only preemptive therapy 33% a hybrid combination dependent on recipient risk Socioeconomic and geographic influence was evident, with 26% of respondents from developing countries using no CMV prevention, more preemptive therapy used in Asia Valganciclovir most common antiviral dosing often below recommendations (33% in infection) Molecular monitoring was used by 84% of clinicians Management of antiviral-associated neutropenia antiviral dose reduction or withdrawal (51%) [Le Page 2013]

78 Acknowledgments CMV Research Group Prof William Rawlinson Dr Stuart Hamilton Dr Wendy van Zuijlen Miss Diana Wong Project Support NHMRC Project Grant NHMRC Early Career Fellowship Go8/DAAD Joint Research Cooperation Scheme Research Group Hanife Bahsi (Technician) Mirjam Steingruber (PhD student) Sabrina Wagner (Technician) Corina Hutterer (Postdoc) Nathalie Krieglstein (Bachelor) Manfred Marschall (PI) Jens Milbradt (Assistant Prof) Eric Sonntag (PhD student)