*Purpose: Cytomegalovirus (CMV) in solid organ transplant (SOT) is associated with negative graft and patient outcomes. Prophylactic agents of choice have substantial cytotoxicity, and patients may be switched to the preemptive monitoring (PEM) approach which complicates management. The purpose of this study is to evaluate the role of pharmacist antiviral stewardship (AVS) efforts directed at patients receiving PEM due to antiviral intolerance.

*Methods: A CMV AVS program was implemented in June 2018 to monitor and intervene on SOT patients receiving CMV primary and secondary prophylaxis (PPX), and those with CMV disease. Principles of antimicrobial stewardship were applied to the monitoring and intervention of patients receiving PEM conversion. Patients were followed weekly by a dedicated transplant pharmacist performing prospective audit and intervention, in collaboration with the transplant infectious disease (ID) service, using electronic medical record resources designed for the program. Recommendations were communicated to the transplant team, and plans were developed utilizing a multidisciplinary approach. Data was collected from 9/1-11/11/19.

*Results: 167 encounters in 33 patients occurred in the study period. 79% were kidney transplants recipients and 88% received lymphocyte depleting induction; 94% were transplanted in 2019, 85% were seropositive for CMV at transplant, and 15% were high risk serostatus (D+/R-). Median time from PPX to PEM conversion was 80 days (IQR 49); most (91%) were switched due to leukopenia (mean WBC 1.6 ± 0.85 at conversion). Time spent in review followed a bell curve with 65% of encounters requiring a review time between 10-20 minutes. Pharmacists identified issues and suggested interventions in 40% of encounters. There were 112 recommendations in 67 encounters (mean 1.7 recommendations/encounter). Recommendations centered around improvement in antiviral (41%), laboratory (24%), and immunosuppressive (IS) management (20%). Of the 46 antiviral recommendations, 37% were to initiate or discontinue preemptive therapy and 20% were to suggest return to universal PPX. Consulting transplant ID to formulate the recommendation was required in 3% of cases. Antiviral, laboratory, and IS recommendations were accepted exactly as suggested in 78%, 93%, and 73% of cases, respectively. Only one recommendation was rejected.

*Conclusions: These results demonstrate that a dedicated AVS pharmacist, utilizing prospective audit and feedback, can identify and intervene on patient care issues related to PEM. Given the high-risk nature of PEM, high rate of identified improvement opportunities, and minimal transplant ID consults necessary, PEM management is a very high yield area for CMV AVS and an excellent point of focus for transplant programs that desire to initiate an AVS program.

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