{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T03:56:22Z","timestamp":1790826982624,"version":"4.1.0"},"reference-count":24,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Transplant Infectious Dis"],"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Cytomegalovirus (CMV) infection remains a major challenge in lung transplant (LTx) recipients, particularly in antiviral\u2010resistant or refractory (R\/R) cases. Letermovir, effective for prophylaxis, has been used off\u2010label as salvage therapy for R\/R CMV infection; however, data on treatment\u2010emergent resistance in LTx recipients remain limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We retrospectively analyzed 61 consecutive LTx recipients treated with letermovir for R\/R CMV infection between March 2018 and August 2024.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Overall, 21 patients (35%) developed R\/R CMV under therapy and were genotypically tested; in 19 (31.1%), UL56 mutations conferring letermovir resistance were detected after a median of 96 [51\u2013395] days. In contrast, 40 patients (65.6%) showed a &gt;\u00a01 log decline in viral load within 14.5 [5\u201331] days and viral clearance after 34 [6\u2013126] days. Patients who developed resistance had significantly higher viral loads at initiation (35.100 [13.900\u2013228.000] vs. 7.805 [1.173\u201330.350] IU\/mL;\n                      <jats:italic>p<\/jats:italic>\n                      = 0.018) and less frequent positive CMV\u2010specific immune responses (7.1%\u00a0vs. 38.7%;\n                      <jats:italic>p<\/jats:italic>\n                      = 0.038). Time to 1 log decline was shorter in patients without resistance (16 [5\u201331] vs. 34 [17\u201358] days;\n                      <jats:italic>p<\/jats:italic>\n                      \u00a0&lt;\u00a00.001). Multivariable regression identified slow viral load decline (OR 0.721;\n                      <jats:italic>p<\/jats:italic>\n                      \u00a0&lt;\u00a00.001) and higher baseline viral load (OR 1.110;\n                      <jats:italic>p<\/jats:italic>\n                      = 0.044) as independent risk factors.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>\n                      Letermovir use for active R\/R CMV infection was associated with treatment\u2010emergent resistance in approximately one\u2010third of patients, particularly in those with high baseline viral loads and delayed virological response. These findings support cautious use of letermovir for treatment, preferably in selected patients with low viral loads or limited alternative therapeutic options, with close virological monitoring and early resistance testing.\n                      <jats:boxed-text content-type=\"graphic\" position=\"anchor\">\n                        <jats:graphic xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" mimetype=\"image\/png\" position=\"anchor\" specific-use=\"enlarged-web-image\" xlink:href=\"graphic\/tid70324-gra-0001-m.png\">\n                          <jats:alt-text>image<\/jats:alt-text>\n                        <\/jats:graphic>\n                      <\/jats:boxed-text>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/tid.70324","type":"journal-article","created":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T03:16:46Z","timestamp":1790824606000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Letermovir in Refractory and Resistant CMV After Lung Transplantation: Therapeutic Potential and Emergence of Resistance"],"prefix":"10.1111","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4117-0175","authenticated-orcid":false,"given":"Tobias","family":"Veit","sequence":"first","affiliation":[{"name":"Department of Medicine V, LMU University Hospital Ludwig Maximilian University of Munich  Munich Germany"},{"name":"Comprehensive Pneumology Center (CPC\u2010M) Ludwig Maximilian University of Munich  Munich Germany"},{"name":"German Center for Lung Research (DZL)  Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan","family":"Trost","sequence":"additional","affiliation":[{"name":"Department of Medicine V, LMU University Hospital Ludwig Maximilian University of Munich  Munich Germany"},{"name":"Comprehensive Pneumology Center (CPC\u2010M) Ludwig Maximilian University of Munich  Munich Germany"},{"name":"German Center for Lung Research (DZL)  Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6569-9703","authenticated-orcid":false,"given":"Teresa","family":"Kauke","sequence":"additional","affiliation":[{"name":"German Center for Lung Research (DZL)  Munich Germany"},{"name":"Laboratory For Immunogenetics Ludwig Maximilian University of Munich  Munich Germany"},{"name":"Division of Thoracic Surgery LMU University Hospital Ludwig Maximilian University of Munich  Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-5808-0114","authenticated-orcid":false,"given":"Nina","family":"Engels","sequence":"additional","affiliation":[{"name":"Laboratory For Immunogenetics Ludwig Maximilian University of Munich  Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gabriela","family":"Leuschner","sequence":"additional","affiliation":[{"name":"Department of Medicine V, LMU University Hospital Ludwig Maximilian University of Munich  Munich Germany"},{"name":"Comprehensive Pneumology Center (CPC\u2010M) Ludwig Maximilian University of Munich  Munich Germany"},{"name":"German Center for Lung Research (DZL)  Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2251-4382","authenticated-orcid":false,"given":"Michael","family":"Gerckens","sequence":"additional","affiliation":[{"name":"Department of Medicine V, LMU University Hospital Ludwig Maximilian University of Munich  Munich Germany"},{"name":"Comprehensive Pneumology Center (CPC\u2010M) Ludwig Maximilian University of Munich  Munich Germany"},{"name":"German Center for Lung Research (DZL)  Munich Germany"},{"name":"Institute of Lung Health and Immunity (LHI) Helmholtz Munich  Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2501-3356","authenticated-orcid":false,"given":"Carlo","family":"M\u00fcmmler","sequence":"additional","affiliation":[{"name":"Department of Medicine V, LMU University Hospital Ludwig Maximilian University of Munich  Munich Germany"},{"name":"Comprehensive Pneumology Center (CPC\u2010M) Ludwig Maximilian University of Munich  Munich Germany"},{"name":"German Center for Lung Research (DZL)  Munich Germany"},{"name":"Institute of Lung Health and Immunity (LHI) Helmholtz Munich  Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0841-860X","authenticated-orcid":false,"given":"Sebastian","family":"Michel","sequence":"additional","affiliation":[{"name":"German Center for Lung Research (DZL)  Munich Germany"},{"name":"Department of Cardiac Surgery LMU University Hospital Ludwig Maximilian University of Munich  Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Zoller","sequence":"additional","affiliation":[{"name":"Department of Anaesthesiology LMU University Hospital Ludwig Maximilian University of Munich  Munich Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valeria","family":"Hackemann","sequence":"additional","affiliation":[{"name":"National Reference Center for Retroviruses Max Von Pettenkofer Institute, Gene Center and Virology Ludwig Maximilian University of Munich  Munich 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