*Purpose: Letermovir (LET), a novel anti-CMV agent, was recently approved for CMV prophylaxis in stem cell transplant recipients and is currently under investigation as a potential CMV prophylaxis agent in solid organ transplant (SOT). The role of LET in the treatment of active CMV DNAemia is unknown; yet, it has been used off-label for this indication in selected cases. Data for using LET for CMV treatment is limited with conflicting conclusions. The purpose of this review was to assess the efficacy of LET for CMV treatment in SOT recipients who were resistant to or did not tolerate ganciclovir (GAN)/valganciclovir (VAL) or foscarnet (FOS).

*Methods: This was a single-center, retrospective review of all SOT recipients who received LET for treatment of CMV at any time point post-transplant.

*Results: From 01/2018-11/2018, a total of 5 patients received LET for CMV treatment (Table 1). Time to first positive CMV was an average of 143+90.6 days post-transplant. Patients were initially treated with GAN, VAL, CMV immunoglobulin, and/or FOS. Average time to starting LET was 450 days (range 30-1339) post first positive CMV viral load (VL). The average CMV viral load at LET initiation was 662 + 557.9 IU/mL. Reasons for switching to LET were leukopenia (n=1), known drug resistance (n=2), FOS nephrotoxicity (n=1), and worsening CMV colitis (n=1). LET did not result in improvement of CMV VL in three patients. In one patient, CMV VL improved, but has not yet become undetectable. In one patient, CMV VL decreased significantly and at times was undetectable. No adverse effects were reported in patients treated with LET.

*Conclusions: LET was successful in achieving decreased or undetectable CMV VL in 2/5 patients. Based on this case series, LET may be a reasonable second-line agent in cases where GAN/VAL or FOS may not be used for the treatment of active CMV infection. A head-to head study of VAL versus LET may elucidate the effectiveness of LET as a first-line agent for the treatment of active CMV infection in SOT.

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