LETTER
Preemptive Ganciclovir Therapy in Renal Transplantation
Daniel C. Brennan, MD;
Gregory A. Storch, MD; and
Bruce J. Lippman, MD
1 April 1996 | Volume 124 Issue 7 | Page 693
TO THE EDITOR:
Hibberd and colleagues [1] recently showed that administration of ganciclovir during antilymphocyte therapy in renal transplant recipients who tested positive for cytomegalovirus (CMV) antibody decreased the incidence of CMV disease. They called this treatment strategy "preemptive therapy." We believe that a more accurate term would have been "selected prophylactic therapy."
The term "prophylaxis" connotes the use of an agent to prevent disease in patients at risk when no evidence suggests the imminent development of that disease. Thus, we use antibiotics for endocarditis prophylaxis when a patient with a heart murmur (but no overt evidence of bacteremia) has an invasive procedure. The term "preemptive" is most often used in military parlance when the risk for an event is imminent or in the early stages of development. For example, a "preemptive strike" was used against the Iraqis during the Persian Gulf war when military surveillance identified the presence of missile sites. A "prophylactic strike" would have been one in which all the Iraqi machine factories were attacked because they had the capability of missile production, although no missiles had been detected. Truly preemptive therapy for CMV has already been shown to be useful in bone marrow transplant recipients who began receiving ganciclovir early on the basis of detection of CMV excretion by culture of throat swabs, blood, urine, or bronchoalveolar lavage fluid [2, 3].
We suggest that the term "preemptive therapy" be reserved for patients with evidence of active but asymptomatic CMV infection who receive anti-CMV therapy [2, 3]. The phrase "selected prophylactic therapy" should be applied to the clinical situation described by Hibberd and associates [1]. We believe this term to be philologically and clinically more accurate.
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Author and Article Information
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Washington University School of Medicine; St. Louis, MO 63110
1. Hibberd PL, Tolkoff-Rubin NE, Conti D, Stuart F, Thistlethwaite JR, Neylan JF, et al. Preemptive ganciclovir therapy to prevent cytomegalovirus disease in cytomegalovirus antibody-positive renal transplant recipients. A randomized controlled trial. Ann Intern Med. 1995; 123:18-26.
2. Schmidt GM, Horak DA, Niland JC, Duncan SR, Forman SJ, Zaia JA, et al. A randomized, controlled trial of prophylactic ganciclovir for cytomegalovirus pulmonary infection in recipients of allogeneic bone marrow transplants. N Engl J Med. 1991; 324:1005-11.
3. Goodrich JM, Mori M, Gleaves CA, Du Mond D, Cays M, Ebeling DF, et al. Early treatment with ganciclovir to prevent cytomegalovirus disease after allogeneic bone marrow transplantation. N Engl J Med. 1991; 325:1601-7.
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