*Purpose: The purpose of this study was to determine the feasibility and scope of a multidisciplinary cytomegalovirus Antiviral Stewardship Program.

*Methods: The principles of antimicrobial stewardship (AMS) were applied to the monitoring and intervention of prophylaxis or treatment with ganciclovir derivatives after solid organ transplant (SOT). A trained transplant pharmacist performed prospective audit and intervention in collaboration with a transplant infectious diseases physician using electronic medical record resources designed specifically for the program. Recommendations were communicated to the transplant provider and treatment plans formulated via multidisciplinary approach. Data were collected on the day of an 8 hour dedicated pharmacist shift occurring weekly from 9/20/2018-10/23/2018

*Results: There were 87 patients reviewed in 100 pharmacist-patient encounters during the study period. An average of 17 patients were evaluated per day. The majority of those reviewed were kidney recipients (65%) of a primary transplant (81%) <1 year postop (66%). Pancreas and liver recipients accounted for a minority of the total population reviewed (18% P and 17% L) however, average review time was longer (17 min P, 17 min L vs 14 min K). Principle enrollment criteria included primary prophylaxis (62%) and treatment of CMV infection (26%). Mean review time for treatment was longer (20 min vs 13 min) and resulted in a greater number of interventions (1.7 vs 0.88) than prophylaxis. Four patients with ganciclovir-resistant (GR) CMV infection were followed (average review time: 21 min). Overall, 6 cases required discussion with TXP ID physician; management of GR-CMV (3), PCR goals for treatment completion (2) and de novo CMV in D-/R- patient (1). Pharmacist recommendations may have been multifactorial and included antiviral management (58%), laboratory based recommendations (50%) and immunosuppressive modification (16%). Acceptance rate by the primary team for encounters with specific recommendations was 97.2% (n=69/71). Of the 29 encounters without specific recommendations 90% were high risk prophylaxis strategies including; D+/R- with high-risk features (37.9%, n=11/29), and preemptive monitoring (24.1% n=7/29).

*Conclusions: Development and implementation of a pharmacist-driven antiviral stewardship program is feasible and there is opportunity for improvement in the provision of care. Enrollment should not be limited by allograft type or to CMV treatment alone. The complexity of management and the potential impact on transplant outcomes necessitates a multidisciplinary approach. Lessons learned from traditional AMS programs can be applied to antiviral management.

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