Practice variation in Aspergillus prophylaxis and treatment among lung transplant centers: a national survey.

Abstract

Fungal infections remain a substantial cause of mortality in lung transplant (LTx) recipients, yet no comprehensive consensus guidelines have been established for antifungal prophylaxis and treatment of Aspergillus infection in these patients. A cross-sectional study surveyed the directors from 27 of 64 (45.5%) active LTx centers in the United States to examine clinical practice variations in Aspergillus prophylaxis and treatment of colonization and invasive aspergillosis (IA) in LTx recipients. Antifungal prophylaxis increased from 52.3% in 2011 to 77.8% in 2013, with the most common agent being inhaled amphotericin B (61.9%), followed by oral voriconazole (51.9%). A total of 74.1% of centers treat Aspergillus airway colonization, with 80.0% of centers using oral voriconazole. All centers treat IA, with 92.6% using oral voriconazole. The duration of Aspergillus prophylaxis and treatment of colonization or IA varied widely across centers from 3months to >1year. A total of 51.9% of centers reported internal practice variations in the treatment of IA. Factors guiding treatment decisions included microbiologic culture and sensitivity (74.1%), ease of administration (59.3%), interaction with other medications (55.5%), side effect profile (51.8%), and center guidelines (48.1%). Although 85.2% of LTx centers recommended routine skin cancer screening for LTx recipients, only 44.4% of LTx centers reported having a dedicated transplant dermatologist. Most active US LTx centers currently employ antifungal prophylaxis and treat Aspergillus colonization and IA, although choice of agent, route of administration, and duration of therapy across and within centers continue to differ substantially. The number of transplant dermatologists available among US LTx centers is limited. Overall, a strong need exists for more comprehensive consensus guidelines to direct antifungal prophylaxis and treatment of Aspergillus infection in LTx recipients.