Optimal strategies to prevent cytomegalovirus (CMV) disease after pediatric solid organ transplantation (SOT) in a cost effective manner are uncertain. We evaluated the frequency of CMV events (infection/syndrome/disease) before and after a 9/2013 implementation of local evidence-based CMV prevention guideline in children (Cytomegalovirus at http://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/recommendations/topic/). Changes from previous recommendations included decreased induction dosing, early transition to oral valganciclovir, elimination of CMV hyperimmunoglobulin (CMVIG) and increased use of pre-emptive monitoring. Outcomes were compared for the 12 months immediately preceding and subsequent to revised guideline implementation, August 2012-August 2014.

104 patients were transplanted (51 after implementation). No patients had CMV disease in the two year period. Pre-implementation, 5 CMV episodes (9%) occurred within a year post-transplant (3 infection, 2 syndrome) compared to 6 (4 infection, 2 syndrome) (12%) after implementation (Table 1). Post-implementation, two CMV infections occurred in conjunction with protocol deviations (prophylaxis interruption for neutropenia, assignment to incorrect risk category). CMVIG discontinuation resulted in decreased pharmacy costs of $50,000 per month and was not associated with an increase in CMV syndrome, although 2/9 D+ heart transplant recipients had asymptomatic infection. Screening PCR rates increased by an average of 5 tests per patient ($11,000 per month) after implementation in heart and liver recipients. Days of intravenous (IV) ganciclovir administration decreased in heart and liver recipients from means of 9.0 and 17.1 to 4.4 and 12.6, respectively. Screening rates and days of IV therapy did not change in kidney recipients.

Modification of CMV prophylaxis based on current evidence was associated with preliminary cost savings without significant increases in CMV episodes but with increased screening PCRs for heart and liver recipients.

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