Evaluation of Universal versus Preemptive Antifungal Prophylaxis in Lung Transplantation

Abstract

Infections from various fungi are increasingly recognized in the setting of lung transplant and guidelines do not distinguish one superior strategy between universal or preemptive. Limited studies exist comparing the two approaches and this study aims to evaluate the incidence mold infections post lung transplant (LTx) before and after the implementation of a protocol change. Our institution's PRE-protocol (PRE) included a pre-emptive prophylaxis for high risk IMI (invasive mold infection) with positive donor or recipient mold colonizations. POST-protocol implementation, a universal prophylaxis approach using itraconazole 200mg PO BID for lifetime post-transplant was employed. A single-center, retrospective chart review was conducted on adult LTx recipients. Patients receiving LTx between 1/2012-5/2016 were included in the PRE cohort and those between 8/2016-5/2019 were included in the POST cohort. A total of 150 patients were included in the PRE cohort and 127 in the POST cohort. Baseline demographics were similar among the cohorts in regards to mean age, gender, bilateral transplant and race. Incidence of IMI or disseminated fungal disease was n=13 (9%) vs n=1 (1%) in the PRE vs POST cohort; p=0.002. A total of 94/150 (63%) vs 51/127 (40%); p=.001 patients developed post LTx fungal colonization. The distribution of types of mold (Table 1) show that there was significantly less BAL colonization with aspergillus with the universal prophylaxis protocol (POST) 33 vs 64%. Median time to first fungal colonization was similar in both groups 108 vs 109 days in the respective PRE and POST groups. Discontinuation rates of itraconazole was n=28 (22%) among the POST cohort. While fungal colonization is ubiquitous, invasive and disseminated fungal infections can result in detrimental outcomes post lung transplant. The strategy of lifelong universal prophylaxis for molds may confer decreased colonization rates and in turn lower incidence if invasive and disseminated disease.