Expert consensus on the management of cytomegalovirus infection in pediatric allogeneic hematopoietic stem cell transplantation

Cytomegalovirus (CMV) infection is the most frequent viral complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). In the pediatric setting, several issues on its management are still debated due to the limited evidence compared to adults. The aim of this consensus was to promote harmonization of practices to improve prevention, control and treatment of CMV infection in children and adolescents. Consensus was generated through voting by a panel of experts from 8 Italian pediatric transplant units who selected 11 topics on prevention of CMV infection and disease, risk factors, diagnosis, prophylaxis, pre-emptive, and therapeutic approaches and formulated 11 statements. Statements were generated on impact of CMV infection on allo-HSCT outcome; risk factors for infection; monitoring of patients at risk; duration of infection risk; CMV prophylaxis and CMV pre-emptive strategies; choice of the antiviral therapy; use of CMV-IgG; antiviral combination therapy; role of adoptive cell therapy; therapeutic drug monitoring. All statements reached a mean score of ≥7 (agreement) at the first voting round and reached an even higher level of consensus at the second voting round after discussion and possible modification of some statements. In conclusion, CMV infection is a risk factor for lower survival and higher non-relapse mortality. We propose a set of expert consensus-generated recommendations aimed at harmonizing the management of CMV infection in pediatric allo-HSCT. We recognize that this field has several unmet needs and emphasize the need for further specific clinical investigations.