Tolerability of Extended Multi-Drug Fungal Prophylaxis After Lung Transplant

Abstract

<h3>Purpose</h3> Lung transplant patients are at risk of fungal infections post-transplant and require anti-fungal prophylaxis (AFP). However, utilization and duration of these agents can be limited by adverse effects. The purpose of this evaluation was to assess the tolerability and duration of AFP post-lung transplant at a large academic medical center. <h3>Methods</h3> This single-center retrospective review included lung transplant patients transplanted from August 2017 to August 2018 who received at least 7 days of AFP and were followed for three years. Patients received a combination of an azole anti-fungal agent, inhaled amphotericin B lipid complex (iABLC), and nystatin suspension immediately post-transplant. Pre-transplant colonization rates, prior fungal infections, transplant indication and baseline characteristics were collected. The primary outcome was tolerability of AFP. Secondary outcomes assessed were adherence and duration of AFP. <h3>Results</h3> Forty patients were included and one patient was excluded from the azole analysis due to a history of liver hyperplasia precluding therapy (Table 1). Patients remained on an azole, iABLC, and nystatin therapy a median of 13.9, 36.6, and 32 months post-transplant, respectively. The most common reason for AFP discontinuation was provider decision to end prophylaxis coverage (Table 2). Seven (19.4%) patients in the azole group, one (4.8%) patient in the iABLC group, and one (4.3%) patient in the nystatin group discontinued therapy due to intolerable side effects and adverse reactions. Patient reported adherence rates were highest in the azole group (87.2%), followed by iABLC (67.5%) and lowest with nystatin (45%). <h3>Conclusion</h3> Despite an extended duration of broad AFP, most patients tolerated therapy without limiting adverse effects. Oral AFP of shorter duration yielded the highest patient reported adherence.