A NATIONWIDE SURVEY OF ANTIFUNGAL PROPHYLAXIS IN LUNG TRANSPLANT

Abstract

SESSION TITLE: Contemporary Lung Transplant Outcomes SESSION TYPE: Original Investigations PRESENTED ON: 10/20/2019 2:15 PM - 3:15 PM PURPOSE: Fungal infections in lung transplant recipients are associated with a 3-fold increase in mortality. While most experts agree on the need for antifungal prophylaxis in lung transplant, no standard of care exists. We surveyed lung transplant centers to determine the current goals, types, duration, and barriers of antifungal prophylaxis. METHODS: We developed and refined our survey through an iterative process. The ACCP Transplant Network endorsed our survey, and it was emailed to a physician representative at each adult lung transplant center in the United States. Transplant centers were eligible for participation if the center had completed 1 or more lung transplants in 2017. Non-responders were contacted on 2 more occasions. Surveys were collected from 11/29/2018-2/15/2019. Descriptive statistics were used to report findings. RESULTS: 44 of 62 (70.9%) eligible lung transplant centers completed the survey, representing all 11 OPTN regions. The median number of transplants performed per center was 26.5 (IQR 37.5). Four (9.1%) centers reported using pre-transplant prophylaxis to prevent post-transplant tracheobronchitis (3 of 4) and invasive fungal infections (4 of 4), with nebulized amphotericin (2), posaconazole (1), or voriconazole (1). Universal and selective/pre-emptive post-transplant prophylaxis was used by 35 (79.5%) and 4 (9.1%) centers, respectively, with the goal of preventing tracheobronchitis (23; 52.3%), invasive fungal infections (35; 79.5%), and chronic lung allograft dysfunction (11; 25.0%). Fungal colonization or donor marijuana use was the indication for selective prophylaxis. Nebulized amphotericin (27; 61.4%) and itraconazole (11; 25.0%) were the most commonly preferred antifungal medications, with most centers using ≥2 medications (33; 75.0%). Newer antifungals, posaconazole and isavuconazole, were preferred agents for 10 (22.7%) centers. Duration of post-transplant prophylaxis ranged from post-transplant hospitalization to lifelong. The most commonly reported barriers to antifungal prophylaxis were insurance prior authorizations (28; 63.6%), drug cost (24; 54.5%), and insurance coverage denial (23; 52.3%). CONCLUSIONS: The majority of transplant centers use post-transplant antifungal prophylaxis. While the goal of prophylaxis is similar among centers, the medication and duration of prophylaxis varies. In comparison to a prior survey in 2008, we observed an increase in preference for newer antifungal agents and a predilection for universal prophylaxis. Cultural acceptance of marijuana likely led to donor marijuana use becoming a selective criterion for some transplant centers. CLINICAL IMPLICATIONS: Almost universally, drug cost and insurance coverage are barriers to antifungal prophylaxis. Disparate practice patterns will continue to allow insurance companies to deny coverage for these medications until a standard of care is developed. DISCLOSURES: No relevant relationships by Patricio Escalante, source=Web Response No relevant relationships by Cassie Kennedy, source=Web Response No relevant relationships by Kelly Pennington, source=Web Response No relevant relationships by Raymund Razonable, source=Web Response No relevant relationships by Kathleen Yost, source=Web Response