Antiviral prophylaxis in haematological patients: systematic review and meta-analysis.
OBJECTIVE
Antiviral prophylaxis is commonly prescribed to haematological cancer patients. We conducted a systematic review and meta-analysis to quantify its overall benefit in specific clinical scenarios.


METHODS
Randomised controlled trials assessing antiviral prophylaxis versus placebo, no treatment, pre-emptive treatment or another antiviral drug were included. Patients undergoing haematopoietic stem cell transplantation (HSCT) or intensive chemotherapy for acute leukaemia or high-grade lymphoma were included. No restrictions on language, year or publication status were applied. Overall mortality, herpes simplex virus (HSV) and cytomegalovirus (CMV) diseases were assessed as primary outcomes. Pooled relative risks (RRs) and numbers needed to treat (NNT) with 95% confidence intervals (CI) are reported.


RESULTS
HSCT was the condition assessed in 22 trials and intensive chemotherapy in 5 trials. In the pre-engraftment setting of autologous or allogeneic HSCT, antiviral prophylaxis (mainly acyclovir for HSV seropositive recipients) significantly reduced HSV (NNT 2, 2-2, control event rate (CER) 61.9%) and CMV disease, with no effect on overall mortality. In the allogeneic post-engraftment setting (mainly CMV-seropositive recipients/donors), antiviral prophylaxis resulted in a significant reduction in overall mortality, RR 0.79 (0.65-0.95), NNT 12 (7-50, CER 39.4%) and all viral-related outcomes. In this setting, acyclovir significantly reduced overall mortality (RR 0.71, 0.53-0.96, 4 trials) and ganciclovir/maribavir significantly reduced CMV disease (RR 0.26, 0.14-0.48, 5 trials). During chemotherapy, acyclovir significantly decreased HSV disease (NNT 3, 2-4, CER 37.4%) and infection rates, with no effect on mortality.


CONCLUSIONS
Antiviral prophylaxis reduced mortality with a small NNT in the post-engraftment setting of allogeneic HSCT. In the pre-engraftment phase and during chemotherapy only viral-related morbidity was reduced.
Yahav
Dafna
D
Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Sackler Faculty of Medicine, Tel-Aviv University, Israel. dafna.yahav@gmail.com
Gafter-Gvili
Anat
A
Muchtar
Eli
E
Skalsky
Keren
K
Kariv
Galia
G
Yeshurun
Moshe
M
Leibovici
Leonard
L
Paul
Mical
M
D000212:Acyclovir / Q000627:therapeutic use; D000970:Antineoplastic Agents / Q000627:therapeutic use; D000998:Antiviral Agents / Q000627:therapeutic use*; D001562:Benzimidazoles / Q000627:therapeutic use; D003586:Cytomegalovirus Infections / Q000517:prevention & control*; D015774:Ganciclovir / Q000627:therapeutic use; D019337:Hematologic Neoplasms / Q000628:therapy*; D018380:Hematopoietic Stem Cell Transplantation / Q000379:methods / Q000401:mortality; D006561:Herpes Simplex / Q000517:prevention & control*; D006801:Humans; D019226:Oral Ulcer / Q000821:virology; D016032:Randomized Controlled Trials as Topic; D012263:Ribonucleosides / Q000627:therapeutic use; D016896:Treatment Outcome; D004004:Dichlororibofuranosylbenzimidazole / Q000031:analogs & derivatives
D000212:Acyclovir; D000970:Antineoplastic Agents; D000998:Antiviral Agents; D001562:Benzimidazoles; D015774:Ganciclovir; D012263:Ribonucleosides; C400401:maribavir; D004004:Dichlororibofuranosylbenzimidazole