Antiviral therapy of CMV disease in children.

Cytomegalovirus (CMV) remains an important cause of morbidity and mortality in infants and children. The main burden of disease occurs in congenital infection, postnatal infection in premature infants and in older immunocompromised children (now predominantly following transplantation) in developed countries. In lower income countries, CMV is a major co-pathogen in human immunodeficiency virus [HIV]-infected infants. Antiviral treatment options remain very limited. The guanosine analogue ganciclovir (GCV) was first used in children over 20 years ago, but the optimal dose, duration and route of administration remain poorly evidence based. In particular there are very limited data in premature infants and older children. Direct comparison studies between the intravenous ganciclovir and the oral valyl-ester valganciclovir (VGCV) have not been performed. CMV disease is important, but not very common and there remains a need to identify useful surrogate markers of successful antiviral therapy to facilitate clinical trials. Cidofovir and foscarnet have very significant toxicity. No other anti-CMV agent has successfully completed phase III studies. There remain few other antiviral agents effective against CMV on the horizon. This chapter reviews the current clinical spectrum of CMV disease in childhood and the evidence base for both GCV and VGCV use in clinical practice. It also discusses the antiviral studies currently being performed and those that need to be performed.