title: Pre-emptive treatment for cytomegalovirus viraemia to prevent cytomegalovirus disease in solid organ transplant recipients.
abstract: BACKGROUND
  Cytomegalovirus (CMV) is a significant cause of morbidity and mortality in solid organ transplant recipients. Pre-emptive treatment with antiviral agents of patients with CMV viraemia has been widely adopted as an alternative to routine prophylaxis to prevent CMV disease.
  
  
  OBJECTIVE
  This review was conducted to evaluate the efficacy of pre-emptive treatment in preventing symptomatic CMV disease.
  
  
  METHODS
  The Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library Issue 2, 2005), MEDLINE (1966 to February 2005), EMBASE (1980 to February 2005) and reference lists and conference proceedings were searched.
  
  
  METHODS
  We included randomised controlled trials (RCTs) of pre-emptive treatment versus placebo, no treatment or antiviral prophylaxis in solid organ transplant recipients.
  
  
  METHODS
  Two authors assessed the quality and extracted all data. Analysis was with a random-effects model and results expressed as relative risk (RR) and 95% confidence intervals (CI).
  
  
  RESULTS
  Ten eligible trials (476 patients) were identified, six of pre-emptive treatment versus placebo or treatment of CMV when disease occurred (standard care), three of pre-emptive treatment versus antiviral prophylaxis and one of oral versus intravenous pre-emptive treatment. Compared with placebo or standard care, pre-emptive treatment significantly reduced the risk of CMV disease (six trials, 288 patients: RR 0.29, 95% CI 0.11 to 0.80) but not acute rejection (three trials, 185 patient: RR 1.06, 95% CI 0.64 to 1.76) or all-cause mortality (two trials, 176 patients: RR 1.23, 95% CI 0.35 to 4.30). Comparative trials of pre-emptive therapy versus prophylaxis showed no significant difference in the risks of CMV disease, acute rejection or all-cause mortality.
  
  
  CONCLUSIONS
  Few RCTs have evaluated the effects of pre-emptive therapy to prevent CMV disease. Pre-emptive therapy is effective compared with placebo or standard care, but additional head-to-head trials are required to determine the relative benefits and harms of pre-emptive therapy and prophylaxis to prevent CMV disease in solid organ transplant recipients.
authors.affiliation: NHMRC Centre for Clinical Research Excellence in Renal Medicine, Cochrane Renal Group, Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145. gfmstrippoli@aliceposta.it
authors.forename: G F
authors.initials: GF
authors.lastname: Strippoli
authors.forename: E M
authors.initials: EM
authors.lastname: Hodson
authors.forename: C J
authors.initials: CJ
authors.lastname: Jones
authors.forename: J C
authors.initials: JC
authors.lastname: Craig
mesh_terms: D000212:Acyclovir / Q000627:therapeutic use; D000998:Antiviral Agents / Q000627:therapeutic use*; D003586:Cytomegalovirus Infections / Q000517:prevention & control*; D015774:Ganciclovir / Q000627:therapeutic use; D006801:Humans; D016867:Immunocompromised Host; D009894:Opportunistic Infections / Q000517:prevention & control; D016377:Organ Transplantation; D016032:Randomized Controlled Trials as Topic; D014766:Viremia / Q000517:prevention & control* / Q000821:virology
chemical_list: D000998:Antiviral Agents; D015774:Ganciclovir; D000212:Acyclovir