Aspergillosis In Lung Transplant Recipients Research Articles

Aspergillus Galactomannan Titer as a Diagnostic Marker of Invasive Pulmonary Aspergillosis in Lung Transplant Recipients: A Single-Center Retrospective Cohort Study

Invasive pulmonary aspergillosis (IPA) can occur in immunocompromised patients, and an early detection and intensive treatment are crucial. We sought to determine the potential of Aspergillus galactomannan antigen titer (AGT) in serum and bronchoalveolar lavage fluid (BALF) and serum titers of beta-D-glucan (BDG) to predict IPA in lung transplantation recipients, as opposed to pneumonia unrelated to IPA. We retrospectively reviewed the medical records of 192 lung transplant recipients. Overall, 26 recipients had been diagnosed with proven IPA, 40 recipients with probable IPA, and 75 recipients with pneumonia unrelated to IPA. We analyzed AGT levels in IPA and non-IPA pneumonia patients and used ROC curves to determine the diagnostic cutoff value. The Serum AGT cutoff value was 0.560 (index level), with a sensitivity of 50%, specificity of 91%, and AUC of 0.724, and the BALF AGT cutoff value was 0.600, with a sensitivity of 85%, specificity of 85%, and AUC of 0.895. Revised EORTC suggests a diagnostic cutoff value of 1.0 in both serum and BALF AGT when IPA is highly suspicious. In our group, serum AGT of 1.0 showed a sensitivity of 27% and a specificity of 97%, and BALF AGT of 1.0 showed a sensitivity of 60% and a specificity of 95%. The result suggested that a lower cutoff could be beneficial in the lung transplant group. In multivariable analysis, serum and BALF AGT, with a minimal correlation between the two, showed a correlation with a history of diabetes mellitus.

82. Incidence rates of invasive aspergillosis among lung transplant recipients in timeperiods with universal and targeted antifungal prophylaxis - a nationwide cohort study

Abstract Background The best stategy for prevention of invasive aspergillosis (IA) after lung transplantation (LTX) has not been determined. In 2016, Danish guidelines for IA prophylaxis was changed from 12 weeks of universal prophylaxis with voriconazole to targeted prophylaxis with posaconazole and inhaled amphotericin B for high risk patients. In a previous study we found significantly higher rates of adverse events in the period with universal prophylaxis. The objectives of this study were to compare rates of IA 1) in time periods before and after change of guidelines; 2) during persontime on vs. persontime without antifungal prophylaxis in the total study period. Methods In a Danish nationwide study we included all adult lung transplant recipients (LTXr), 2010–2019. Proven and probable IA were defined using ISHLT criteria. Patients were censored at the first of following events: death, retransplantation, end of 2019, or one year after LTX. The cumulative hazard of IA was calculated using the Nelson Aalen estimator. Rates of IA were analyzed in bi- and multivariate Poisson regression models adjusted for the time period after LTX (0–6 and 6–12 months). Persontime on protocol prophylaxis (start to end + 14 days) was treated as time-updated variable. Results A total of 295 LTXr were followed for 245 person-years, of whom 183/193 vs. 6/102 initiated antifungal prophylaxis during the universal vs. the targeted prophylaxis period (Table 1). IA was diagnosed in 34/193 (17.6%) vs. 15/102 (14.7%) LTXr the first year after transplantation in the universal vs. targeted prophylaxis period. Overall, similar cumulative hazards of IA were observed between the universal and targeted prophylaxis period (p=0.59, Figure 1). The adjusted incidence rate ratio (aIRR) of IA during the universal vs. targeted prophylaxis period was 1.30 (95% CI 0.69–2.44), (Table 2). In the total study period, the aIRR of IA during persontime on vs. persontime without antifungal prophylaxis was 0.87 (95% CI 0.40–1.88), (Table 2). Characteristics of lung transplant recipients in time periods with universal voriconazole and targeted posaconazole and inhaled amphotericin B prophylaxis. Proven and probable invasive aspergillosis including anastomosis infection, trakeobronkitis and pneumonia according to ISHLT criteria. *) Underlying diseases categorized as high risk of invasive aspergillosis. Incidence rates (IR) and incidence rate ratios (IRR) of invasive aspergillosis in lung transplant recipients in two multivariate models. Poisson regression models comparing rates of IA in model 1) during universal prophylaxis time period versus targeted prophylaxis time period and in model 2) during persontime on prophylaxis (start to end + 14 days) versus persontime without prophylaxis in the total study period 2010–2019. Adjusted for time after LTX IRR: Bivariable model including the listed variables in bold and adjustment for time after transplantation (time-updated). Fully adjusted IRR: Multivariable model with adjustment for sex, age, high risk underlying disease, single/double lung transplant, Aspergillus prior to transplantation and time after transplantation (time-updated). Abbreviations: LTX = lung transplant recipients; CI = confidence interval; IR = incidence rates per 100 person-years; IRR = incidence rate ratio; Ref. = reference. Cumulative hazards of invasive aspergillosis the first year after lung transplantation in time periods with universal voriconazole versus targeted posaconazole and inhaled amphotericin B prophylaxis. Conclusion A strategy of targeted prophylaxis, for high risk patients only, may be preferred over universal voriconazole prophylaxis after LTX due to similar rates of IA and lower rates of adverse events. Disclosures Maiken C. Arendrup, DMSci, PhD, MD, Chiesi, Gilead: Honoraria|F2G, Cidara, Scynexis: Grant/Research Support Michael Perch, MD, Boeringer-Ingelheim: Travel grant|PulmonX: Expert Testimony|Roche: Grant/Research Support|Takeda: Expert Testimony|Therakos: Honoraria|Zambon: Advisor/Consultant|Zambon: Expert Testimony Marie Helleberg, PhD, DMSc, AstraZeneca: Advisor/Consultant|Gilead: Advisor/Consultant|Gilead: Honoraria|GSK: Advisor/Consultant|GSK: Honoraria|Janssen: Advisor/Consultant|Roche: Advisor/Consultant|Sobi: Advisor/Consultant.

Statin Use May Be Associated With a Lower Risk of Invasive Aspergillosis in Lung Transplant Recipients.

Statins are competitive inhibitors of 3-hydroxy-3methylglutaryl coenzyme A reductase (HMG-CoA reductase) that catalyses HMG-CoA conversion to mevalonate, a process involved in synthesizing cholesterol in humans and ergosterol in fungi. The effect of statin use on the risk of development of invasive aspergillosis (IA) in lung transplant recipients (LTRs) is not well documented. This retrospective study included LTRs from 2010 to 2017 who were followed for one-year post-transplant. Proven or probable IA was diagnosed as per ISHLT criteria. We performed a multivariable Cox proportional hazards model of the association between IA and statin use (minimum of 2 weeks duration prior to IA), adjusting for other known IA risk factors. We identified 785 LTRs, 44% female, mean age 53 years old, the most common underlying disease being pulmonary fibrosis (23.8%). In total, 451 LTRs (57%) received statins post-transplant, atorvastatin was the most commonly used statin (68%). The mean duration of statins post-transplant was 347 days (interquartile range [IQR]: 305 to 346). And 55 (7%) LTRs developed IA in the first-year post-transplant. Out of these 55 LTRs, 9 (16.3%) had received statin before developing IA. In multivariable analysis, statin use was independently associated with a lower risk of IA (P = .002, SHR 0.30, 95% confidence interval [CI] 95% .14-.64). Statin use was also associated with a lower incidence of post-transplant Aspergillus colonization, 114 (34%) in the no statin group vs 123 (27%) in the statin group (P = .038). The use of statin for a minimum of two weeks during the first-year post-transplant was associated with a 70% risk reduction of IA in LTRs.

Risk factors of breakthrough aspergillosis in lung transplant recipients receiving itraconazole prophylaxis

IntroductionInvasive Aspergillus infection (IA) in lung transplantation can result in poor outcomes. Itraconazole has been shown to be effective for fungal prophylaxis in lung transplant recipients. However, IA remains a major cause of death after lung transplantation. Therefore, we aimed to clarify the risk factors for IA on itraconazole prophylaxis. MethodsWe examined 120 recipients to uncover their IA epidemiology, clinical characteristics, and outcomes. In addition, a case-control study was performed to identify risk factors of IA. ResultsOf the 120 patients, 12 developed IA under itraconazole prophylaxis. The patient demographics and clinical characteristics were compared among the following two groups: IA group, 12 patients, and control group, 108 patients. Significant differences were observed in age (p = 0.004), history of interstitial pneumonia (p = 0.032), and CMV infection (p < 0.001) between the groups. Before the onset of IA, 92% (11/12) of the patients received itraconazole with trough concentrations above the therapeutic range. IA developed at 272.9 ± 114.1 days after lung transplantation. Of the 12 patients who developed IA, 66.7% (8/12) had early cessation of cytomegalovirus (CMV) prophylaxis due to toxicity of valganciclovir, as follows: leukocytopenia in 4 patients, and renal dysfunction in 4 patients. Of the 8 patients who stopped valganciclovir, 75% (6/8) developed CMV infection subsequently. ConclusionThis study suggests that older age, history of interstitial pneumonia, and CMV infection may be important risk factors for IA on itraconazole prophylaxis. These results may help clinicians optimize prophylactic strategies for IA.

Late Onset Invasive Pulmonary Aspergillosis in Lung Transplant Recipients in the Setting of a Targeted Prophylaxis/Preemptive Antifungal Therapy Strategy.

Invasive pulmonary aspergillosis (IPA) is a significant cause of morbidity and mortality in lung transplant recipients (LTRs). It is unclear how a targeted prophylaxis/ preemptive antifungal therapy strategy impacts the incidence of IPA beyond the first-year posttransplant. This is a retrospective cohort of LTRs from January 2010 to December 2014. We included all LTRs who survived beyond the first year and followed them until death or 4 years postoperatively. Incidence of probable/proven IPA and Aspergillus colonization were assessed as per International Society for Heart and Lung Transplantation (ISHLT) criteria. Patients with risk factors, positive Aspergillus cultures, or galactomannan (GM) received targeted prophylaxis/preemptive therapy within the first-year posttransplant. During the study period, 350 consecutive LTRs underwent 1078 bronchoscopies. Positive bronchoalveolar lavage for GM or Aspergillus cultures was reported for 15% (52/350) of LTRs between 2 and 4 years after transplantation. Among them, the median time to positive Aspergillus culture or GM positivity was 703 days (interquartile range, 529-754 d). The incidence rate of IPA and Aspergillus colonization was 30 of 1000 patient-y, and 63 of 1000 patient-y, respectively. The mortality rate was significantly higher in patients with IPA than without IPA (107/1000 patient-years versus 18/1000 patient-years; P < 0.0001). Rate of first-year colonization and IPA was 33% and 9%, respectively. Among the 201 patients who had a negative bronchoscopy during the first year posttransplant, only 6 (3%) developed IPA during the follow-up. A targeted prophylaxis/preemptive therapy strategy within the first-year posttransplant resulted in 4% incidence of IPA at 4-years after transplantation. However, IPA was associated with higher mortality.

Late Onset Invasive Pulmonary Aspergillosis in Lung Transplant Recipients Treated with a Preemptive/ Targeted Antifungal Therapy Strategy: 4 Year Follow Up

Purpose Invasive pulmonary aspergillosis (IPA) is a significant cause of morbidity and mortality in lung transplant recipients (LTRs). Centers employing universal antifungal prophylaxis have reported up to 60% of the IPA episodes occur after the first year post transplant. We previously reported the incidence of IPA during the first year after transplant in a cohort of LTRs treated with preemptive prophylaxis. It is unclear how a preemptive/targeted antifungal therapy strategy impacts the incidence of IPA beyond 1 year post transplant. Methods Retrospective study of consecutive LTRs from 1 Jan 2010 to 31 Dec 2014 with a 4 year follow up on those who survived at least 1 year. Incidence of probable/ proven IPA, bronchoalveolar (BAL) Aspergillus spp. cultures or Galactomannan (GM) positivity (index value >1) were recorded during this period. IPA, Aspergillus colonization and preemptive/ targeted prophylaxis were defined according to criteria established by ISHLT. Patients with probable/ proven IPA, positive Aspergillus cultures and/ or GM received preemptive/ targeted therapy. Results There were a total of 350 consecutive LTRs with 1078 bronchoscopies . 82% (288/350) were double lung transplants, with median age of 53.9 yrs. 73% (254/350) LTRs did not receive induction immunosuppression with basiliximab or thymoglobulin . 15% (52/350) LTRs had positive BAL for GM and/ or Aspergillus cultures beyond 1 year of transplantation. Median time to positive Aspergillus culture or positive GM was 608 days. Figure 1 shows the distribution of positive Aspergillus culture and GM in the cohort after 1 year . 3% (10/350) LTRs met criteria for probable IPA. Beyond 1 year, none of the Aspergillus culture or GM negative patients had biopsy proven IPA. All cause mortality in LTRs with IPA was 10% (1/10). Conclusion Undergoing a preemptive strategy beyond 1 year post transplantation resulted in a low frequency of treatment for IPA when assessing positive BAL cultures or GM.

Host miRNA Profile of Invasive Aspergillosis in Lung Transplant Recipients

Purpose MicroRNAs (miRNAs) are small noncoding RNAs of ∼22 nucleotides that play a crucial role in post-transcriptional regulation of gene expression. Dysregulation of miRNA expression has been shown during various microbial infections. We sought to identify the miRNAs that distinguish invasive aspergillosis (IA) from non-IA in transplant recipients. Methods We used the Nanostring nCounter Human miRNA v3 panel to measure human miRNAs in bronchoalveolar lavage (BAL) samples collected from lung transplant recipients (LTRs) with IA (n=10) and without IA (n=9). We also measured human miRNA in peripheral blood mononuclear cells (PBMCs) collected from 6 hematological malignancy patients with IA and 6 healthy controls. The miRNA profile was compared using the permutation test of 100000 trials for each of the comparisons. We used mirDip (http://ophid.utoronto.ca/mirDIP/index.jsp#r) to obtain their gene targets. Subsequently we used pathDIP (http://ophid.utoronto.ca/pathDIP/) to determine the corresponding pathway enrichment. Results When we analyzed BAL samples of LTRs (10 IA samples vs 9 non-IA samples), we found that the expression of 58 miRNAs was significantly different (p-value < 0.05) between the two groups. We also found 48 miRNAs that were significant different when comparing 6 IA vs. 6 non-IA PBMC samples. We selected 4 miRNAs that had differential expression in both blood and BAL, and had at least 2 folds change in both blood and BAL for IA for pathway analysis. These included hsa-miR-101-3p, hsa-miR-1285-5p, hsa-miR-99b-5p and hsa-miR-877-5p (Fig 1a and b). These miRNAs target 449 genes, including genes regulating toll-like receptors, IL2, IL-6, IL-7 and IL 17 signaling pathways. Conclusion This preliminary data suggests that IA may have a distinctive miRNA profile that can assist in the diagnosis and prognostication of these patients. Further work is required in a larger cohort to validate these findings. MicroRNAs (miRNAs) are small noncoding RNAs of ∼22 nucleotides that play a crucial role in post-transcriptional regulation of gene expression. Dysregulation of miRNA expression has been shown during various microbial infections. We sought to identify the miRNAs that distinguish invasive aspergillosis (IA) from non-IA in transplant recipients. We used the Nanostring nCounter Human miRNA v3 panel to measure human miRNAs in bronchoalveolar lavage (BAL) samples collected from lung transplant recipients (LTRs) with IA (n=10) and without IA (n=9). We also measured human miRNA in peripheral blood mononuclear cells (PBMCs) collected from 6 hematological malignancy patients with IA and 6 healthy controls. The miRNA profile was compared using the permutation test of 100000 trials for each of the comparisons. We used mirDip (http://ophid.utoronto.ca/mirDIP/index.jsp#r) to obtain their gene targets. Subsequently we used pathDIP (http://ophid.utoronto.ca/pathDIP/) to determine the corresponding pathway enrichment. When we analyzed BAL samples of LTRs (10 IA samples vs 9 non-IA samples), we found that the expression of 58 miRNAs was significantly different (p-value < 0.05) between the two groups. We also found 48 miRNAs that were significant different when comparing 6 IA vs. 6 non-IA PBMC samples. We selected 4 miRNAs that had differential expression in both blood and BAL, and had at least 2 folds change in both blood and BAL for IA for pathway analysis. These included hsa-miR-101-3p, hsa-miR-1285-5p, hsa-miR-99b-5p and hsa-miR-877-5p (Fig 1a and b). These miRNAs target 449 genes, including genes regulating toll-like receptors, IL2, IL-6, IL-7 and IL 17 signaling pathways. This preliminary data suggests that IA may have a distinctive miRNA profile that can assist in the diagnosis and prognostication of these patients. Further work is required in a larger cohort to validate these findings.

Clinical risk factors for invasive aspergillosis in lung transplant recipients: Results of an international cohort study.

Invasive aspergillosis (IA) is a frequent complication in lung transplant recipients (LTRs). Clinical risk factors for IA have not been fully characterized, especially in the era of extensive anti-fungal prophylaxis. The primary objective of this study was to evaluate the clinical risk factors associated with IA in LTRs. The secondary objective was to assess the mortality in LTRs who had at least 1 episode of IA compared with LTRs who never had experienced IA. We conducted an international, multicenter, retrospective cohort study of 900 consecutive adults who received lung transplants between 2005 and 2008 with 4years of follow-up. Risk factors associated with IA were identified using univariate and multiple regression Cox proportional hazards models. Anti-fungal prophylaxis was administered to 61.7% (555 of 900) of patients, and 79 patients developed 115 episodes of IA. The rate to development of the first episode was 29.6 per 1,000 person-years. Aspergillus fumigatus was the most common species isolated (63% [72 of 115 episodes]). Through multivariate analysis, significant risk factors identified for IA development were single lung transplant (hazard ratio, 1.84; 95% confidence interval, 1.09-3.10; p = 0.02,) and colonization with Aspergillus at 1 year post-transplantation (hazard ratio, 2.11; 95% confidence interval, 1.28-3.49; p = 0.003,). Cystic fibrosis, pre-transplant colonization with Aspergillus spp, and use of anti-fungal prophylaxis were not significantly associated with the development of IA. Time-dependent analysis showed IA was associated with higher mortality rates. Incidence of IA remains high in LTRs. Single-lung transplant and airway colonization with Aspergillus spp. within 1 year post-transplant were significantly associated with IA.

Predictive Cytokine Profile for Invasive Aspergillosis in Lung Transplant Recipients in the Setting of Pre-emptive Prophylaxis

We studied cytokine patterns predictive of subsequent invasive aspergillosis (IA) in lung transplant recipients (LTRs) with Aspergillus spp (Asp) colonization post-transplant.

A strategy for prevention of fungal infections in lung transplantation: Role of bronchoalveolar lavage fluid galactomannan and fungal culture

The optimal strategy for prevention of invasive fungal infections in lung transplant recipients remains undetermined. We studied strategies based on bronchoalveolar lavage fungal culture and galactomannan for prevention of invasive aspergillosis in lung transplant recipients. Consecutive lung transplant recipients were evaluated during the period January 2010 to September 2014. Rates of invasive aspergillosis and all-cause mortality were recorded at 1 year. Criteria established by the International Society for Heart and Lung Transplantation were used to define invasive fungal infections. Multivariate Cox regression analyses were performed to assess the outcomes of mortality and invasive aspergillosis. A total of 519 lung transplant recipients with 3,077 bronchoscopies were included in our study. The cumulative incidence of fungal infections was 14% (75 of 519). Of these patients, 10.6% (54 of 519) developed Aspergillus-related clinical syndromes. Using multivariate analysis, pre-emptive therapy was associated with significantly lower rates of invasive aspergillosis at 1 year post-transplantation compared with no pre-emptive therapy (hazard ratio [HR] 0.23, 95% confidence interval [CI] 0.09 to 0.58). Pre-emptive therapy and invasive aspergillosis had similar mortality rates compared with no invasive aspergillosis, or negative culture and galactomannan at 1 year (HR 0.54, 95% CI 0.23 to 1.28; and HR 0.99, 95% CI 0.44 to 2.25, respectively). During follow-up, 50% (259 of 519) of patients were negative for galactomannan and Aspergillus culture in bronchoalveolar lavage, and did not receive anti-fungal treatment. Only 2 patients developed invasive aspergillosis in this cohort. Our study suggests that use of bronchoalveolar lavage culture and a galactomannan-directed pre-emptive approach significantly decreased the risk of invasive aspergillosis, allowing a 50% reduction in anti-fungal exposure compared with a universal prophylaxis approach, without affecting mortality at 1 year.

(40) - Aspergillus Galactomannan Detection in Exhaled Breath Condensate for the Diagnosis of Invasive Aspergillosis in Lung Transplant Recipients

(40) - Aspergillus Galactomannan Detection in Exhaled Breath Condensate for the Diagnosis of Invasive Aspergillosis in Lung Transplant Recipients

(39) - Clinical Risk Factors for Invasive Aspergillosis in Lung Transplant Recipients: Results of an International Cohort Study

(39) - Clinical Risk Factors for Invasive Aspergillosis in Lung Transplant Recipients: Results of an International Cohort Study

Effect of calcineurin inhibition on phenotypic maturation of dendritic cells in an in-vitro model of invasive aspergillosis in lung transplant recipients

BackgroundInvasive aspergillosis in lung transplant recipients on immunosuppression has high morbidity and mortality. The calcineurin inhibitor FK506 inhibits the calcineurin–NFAT (nucleated factor of activated T cells) axis, which impairs the innate response to fungal infection. Immature dendritic cells (DCs) have a crucial immune signalling role by phagocytosing antigen, and then maturing and stimulating the T cell response. We investigated the effect of FK506 on phenotypic maturation of DCs in response to Aspergillus fumigatus infection. MethodsPeripheral blood mononuclear cells from healthy volunteers were negatively isolated by density gradient centrifugation (Ficoll, GE Healthcare, Amersham, UK) and were differentiated into DCs with molgramostim (GM-CSF) and interleukin 4. Day 5 cells were matured with interferon (IFN) γ. Day 7 cells were treated with FK506 or inoculated with swollen conidia of A fumigatus (multiplicity of infection 1:1). Cells were then stained with PE-bound anti-CD83 (a late maturation marker) and PerCP-Cy5.5-bound anti-CD209 (a DC-specific marker) and analysed by imaging flow cytometry (ImageStream, Amnis, Seattle, USA). Statistical analysis was performed with Graphpad Prism (version 6.0). Findings5000 cells per condition were analysed. The subset of DCs was identified by gating for CD209 positivity. We demonstrated upregulation of CD83 on the surface of DCs with IFNγ stimulation (26 228 mean fluorescence units [SE 1462] vs 12 534 [799], p<0·0001) A fumigatus infection of unstimulated DCs (29 888 [1393] vs 12 534 [799], p<0·0001), and A fumigatus infection of IFNγ-stimulated DCs (36 778 [1356] vs 26 228 [1462], p<0·0001). CD83 mean fluorescence intensity was reduced with FK506 treatment of IFNγ-stimulated DCs (26 228 [1462] vs 20 219 [846], p=0·0004), A fumigatus-infected unstimulated DCs (29 888 [1393] vs 24 289 [1253], p=0·0028), and A fumigatus-infected, IFN γ-stimulated DCs (36 778 [1356] vs 30 159 [1279], p=0·0004), but unchanged for unstimulated, uninfected DCs (12 534 [799] vs 11 942 [762], p=0·5921). InterpretationBoth A fumigatus infection and IFNγ stimulation promote phenotypic maturation of DCs in vitro, and treatment with FK506 inhibits maturation in this context. These findings suggest that FK506 has an inhibitory effect on innate antigen presentation to T cells and that it might impair the adaptive immune response to invasive aspergillosis in lung transplant recipients. FundingMedical Research Council Chain-Florey Clinical Research Fellowship.

Utility of Bronchoalveolar Lavage Galactomannan in Diagnosis of Aspergillosis in Lung Transplant Recipients

Purpose Pulmonary aspergillosis is a significant cause of morbidity and predictor of all-cause mortality post lung transplantation (LTx), including potentially contributing to development of bronchiolitis obliterans syndrome (BOS), despite prophylactic strategies and advances in immunosuppression and surgical technique. Specific treatment exists, but side effects are significant, while delay in diagnosis and treatment can worsen outcomes. Analysis of the risk-benefit ratio of commencing treatment is important. Galactomannan (GM) is a major constituent of Aspergillus cell walls released during hyphal growth, indicating active replication. Serum GM is widely used in immunocompromised haematology patients to diagnose invasive aspergillosis, but limited sensitivity has been observed in LTx recipients. There are few studies on BAL GM (and optimal optical density {OD}) post LTx. AIMS: Evaluate utility and determine optimal OD of BAL GM in diagnosis of aspergillosis post-LTx. Methods and Materials LTx recipients undergoing bronchoscopy for surveillance or clinical indications between September 2010 and November 2012 were assessed. BAL specimens were analysed for GM using ELISA. OD > 1.5 and 0.5 were compared with the current gold standard - direct microscopy and fungal cultures (FC). Results 76 bronchoscopies performed. Fungal elements were negative in all patients. At GM OD > 1.5 Sensitivity, specificity, PPV and NPV were 72, 100, 100 and 95% respectively. At OD > 0.5, Sensitivity, specificity, PPV and NPV were 100, 64, 32, 100% respectively. Conclusions BAL GM increases accuracy of early detection of pulmonary aspergillosis in LTx patients, with minimal additional risk. In this study, OD > 1.5 was the optimal cut-off. Results GM OD > 1.5 FC + FC - Total GM + 8 0 8 GM - 3 65 68 Total 11 65 76 Results GM OD > 0.5 FC + FC - Total GM + 11 23 34 GM - 0 42 42 Total 11 65 76

Risk Factors for Voriconazole Hepatotoxicity at 12 Weeks in Lung Transplant Recipients

Voriconazole is commonly used for prophylaxis and treatment of invasive aspergillosis in lung transplant recipients. However, the use of voriconazole may at times be limited by the development of hepatotoxicity. Our goal is to determine predictors of voriconazole-associated hepatotoxicity in lung transplant recipients. We conducted a single center retrospective cohort study of lung transplant recipients from 2006 to 2010 who received voriconazole therapy. We compared characteristics of patients who developed hepatotoxicity and those who did not. One hundred five lung transplant recipients received voriconazole. Hepatotoxicity occurred in 51% (54/105) of patients and lead to discontinuation in 34% (36/105). In univariate analysis, age less than 40 years, cystic fibrosis, use of azathioprine, history of liver disease and early initiation of voriconazole were associated with hepatotoxicity. In multivariable logistic regression analysis, perioperative initiation of voriconazole (within 30 days of transplantation) was independently associated with hepatotoxicity (OR 4.37, 95% CI: 1.53-12.43, p = 0.006). The five risk factors identified in the univariate analysis were used to build a K-nearest neighbor algorithm predictive model for hepatotoxicity. This model predicted hepatotoxicity with an accuracy of 70%. Voriconazole therapy initiated within the first 30 days of transplantation is associated with a greater risk of developing hepatotoxicity.

Comparison of an Aspergillus Real-time Polymerase Chain Reaction Assay With Galactomannan Testing of Bronchoalvelolar Lavage Fluid for the Diagnosis of Invasive Pulmonary Aspergillosis in Lung Transplant Recipients

Early diagnosis and treatment of invasive pulmonary aspergillosis (IPA) improves outcome. We compared the performance of publicly available pan-Aspergillus, Aspergillus fumigatus-, and Aspergillus terreus-specific real-time polymerase chain reaction (PCR) assays with the Platelia galactomannan (GM) assay in 150 bronchoalveolar lavage (BAL) samples from lung transplant recipients (16 proven/probable IPA, 26 Aspergillus colonization, 11 non-Aspergillus mold colonization, and 97 negative controls). The sensitivity and specificity of pan-Aspergillus PCR (optimal quantification cycle [Cq], ≤35.0 by receiver operating characteristic analysis) and GM (≥.5) for diagnosing IPA were 100% (95% confidence interval, 79%-100%) and 88% (79%-92%), and 93% (68%-100%) and 89% (82%-93%), respectively. The sensitivity and specificity of A. fumigatus-specific PCR were 85% (55%-89%) and 96% (91%-98%), respectively. A. terreus-specific PCR was positive for the 1 patient with IPA due to this species; specificity was 99% (148 of 149 samples). Aspergillus PCR identified 1 patient with IPA not diagnosed by GM. For BAL samples associated with Aspergillus colonization, the specificity of GM (92%) was higher than that of pan-Aspergillus PCR (50%; P = .003). Among negative control samples, the specificity of pan-Aspergillus PCR (97%) was higher than that of BAL GM (88%; P = .03). Positive results for both BAL PCR and GM testing improved the specificity to 97% with minimal detriment to sensitivity (93%). A recently developed pan-Aspergillus PCR assay and GM testing of BAL fluid may facilitate the diagnosis of IPA after lung transplantation. A. fumigatus- and A. terreus-specific real-time PCR assays may be useful in rapidly identifying the most common cause of IPA and a species that is intrinsically resistant to amphotericin B, respectively.

433 Risk Factors for Voriconazole Hepatotoxicity in Lung Transplant Recipients

Voriconazole (VORI) is commonly used for prophylaxis and treatment of invasive aspergillosis in lung transplant recipients (LTR). We assessed the clinical risk factors associated with hepatotoxicity in LTR receiving VORI therapy.

Intrapulmonary Disposition of Amphotericin B After Aerosolized Delivery of Amphotericin B Lipid Complex (Abelcet; ABLC) in Lung Transplant Recipients

Inhaled amphotericin preparations have been used for prophylaxis against invasive aspergillosis in lung transplant recipients. However, no published data exist regarding the pharmacokinetic profile of amphotericin B lipid complex in lung transplant recipients. We prospectively determined the concentrations of amphotericin B in the epithelial lining fluid (ELF) and plasma after aerosolized nebulization (AeroEclipse), of amphotericin B lipid complex at 1 mg/kg every 24 hr for 4 days in 35 lung transplant recipients. One brochoalveolar lavage sample and a simultaneous blood sample were collected at various time points after the fourth dose from each subject. High-performance liquid chromatography and high-performance liquid chromatography-MS-MS were used to measure amphotericin B. Concentrations of amphotericin B in ELF (median, 25-75 IQR) were at 4 hr (n=5) 7.20 μg/mL (1.3-17.6), 24 hr (n=6) 8.26 μg/mL (3.9-82.7), 48 hr (n=5) 2.15 μg/mL (1.4-5.5), 72 hr (n=4) 1.25 μg/mL (0.75-5.5), 96 hr (n=6) 0.86 μg/mL (0.55-1.4), 120 hr (n=4) 1.04 μg/mL (0.44-1.6), 144 hr (n=1), 4.25 μg/mL, 168 hr (n=3) 1.14 μg/mL, and 192 hr (n=1) 1 μg/mL. The plasma concentration of the drug remained below 0.08 μg/mL at all time points. During the study, the side effects noted included wheezing, coughing, and 12% decline in forced expiratory volume in 1 sec. We conclude that administration through aerosolized nebulization of amphotericin B lipid complex every 24 hr for 4 days in lung transplant recipients achieved amphotericin B concentrations in ELF above minimum inhibitory concentration of the Aspergillus nearly at 168 hr after the last inhaled dose and is well tolerated.

Diagnosis of Invasive Aspergillosis in Lung Transplant Recipients by Detection of Galactomannan in the Bronchoalveolar Lavage Fluid

Galactomannan (GM) detection in serum samples has been used to diagnose invasive aspergillosis (IA). Limited sensitivity has been observed in lung transplant recipients, for whom bronchoalveolar lavage (BAL) testing has been advocated. Because airway colonization with Aspergillus species occurs frequently in these patients, false-positive GM results have been reported if the cutoff validated for sera is used (i.e., 0.5). Herein, we prospectively studied BAL fluid samples from 60 lung transplant patients to determine the optimal cutoff for BAL GM testing. Only one sample per patient was studied. BAL samples were vortexed and processed according to the manufacturer's instructions for serum samples. Sensitivity, specificity, and likelihood ratios were calculated in reference to proven or probable IA cases using receiver operating characteristic analysis. Eight patients had IA during the study (incidence 13.3%), including four patients with proven IA. Aspergillosis increased 5-fold the risk of death in lung transplant recipients. The positive predictive value of a positive BAL GM test at the 0.5 cutoff was low (24.2%). Raising the cutoff improved test specificity without compromising sensitivity. The best cutoff was defined at 1.5 (sensitivity 100% and specificity 90.4%). This study reinforces the importance of BAL GM testing in lung transplant recipients, particularly to exclude the diagnosis of IA. To minimize the frequency of false-positive results, a higher test cutoff should be applied to BAL samples, in comparison with serum samples.

Fungi and Molds following Lung Transplantation

The landscape of fungal infections in lung transplant recipients has significantly changed over the course of time. The initial predominance of CANDIDA species has given way to the prominence of ASPERGILLUS species in the current era followed by other mold infections, namely, SCEDOSPORIUM and Zygomycetes, which are emerging as newer pathogens. CRYPTOCOCCUS NEOFORMANS is another important pathogen responsible for the morbidity in lung transplant recipients. The use of widespread antifungal prophylaxis directed against the mold infections has resulted in delayed onset of invasive aspergillosis in lung transplant recipients. In recent studies cumulative incidence rate of invasive aspergillosis was noted to be 2.4% at 12 months. Invasive mold infections in lung transplant may present as tracheobronchitis, invasive pulmonary infections, or disseminated disease. Invasive pulmonary infections are now the most common manifestations of mold infections, followed by tracheobronchitis. Pre- or posttransplant ASPERGILLUS colonization, along with preceding cytomegalovirus infections, hypogammaglobulinemia, and single-lung transplants are considered significant risk factors for invasive aspergillosis. Recently posttransplant colonization has been implicated in the development of bronchiolitis obliterans syndrome. The appropriate antimold prophylaxis strategy, by the use of either voriconazole or inhaled amphotericin, remains to be fully determined. Advances in the diagnosis and treatment of invasive aspergillosis have resulted in significant decreases in mortality. The risk factors for other mold infections such as SCEDOSPORIUM or Zygomycetes are being elucidated. Infections with these organisms, however, carry mortality up to 80%. The current article reviews the changes in the epidemiology of invasive molds and CRYPTOCOCCUS infections and other emerging fungal pathogens and highlights the controversies surrounding antifungal prophylaxis in lung transplant recipients.