Whole-genome sequencing was funded by PathWest Laboratory Medicine WA.

Hyperammonemia syndrome (HS) is a life-threatening condition occurring in solid organ transplant (SOT) patients affecting primarily lung recipients and is associated with Mycoplasma hominis and/or Ureaplasma spp. infection. The organ donor was a young male who died of hypoxic brain injury and had urethral discharge ante-mortem. The donor and four solid organ transplant recipients had infection with M. hominis and/or Ureaplasma spp. The lung and heart recipients both developed altered conscious state and hyperammonemia syndrome (HS) associated with M. hominis and Ureaplasma spp. infections. Despite treatment with antibiotics and ammonia scavengers, both the lung and heart recipients died at D+102 and D+254 respectively. After diagnosis in the thoracic recipients screening samples from the liver and one kidney recipient were culture positive for M. hominis +/- Ureaplasma spp. Neither the liver nor kidney recipients developed HS. Our case series demonstrates the unique finding of M. hominis and Ureaplasma spp. dissemination from an immunocompetent donor across four different organ recipients. Phylogenetic whole genome sequencing analysis demonstrated M. hominis samples from recipients and donor were closely related, suggesting donor derived infection. Screening of lung donors and/or recipients for Mycoplasma and Ureaplasma spp. is recommended and prompt treatment with antimicrobials to prevent morbidity.

Background: Antifungal prophylaxis remains a mainstay of lung transplantation, given invasive fungal infection is a common and serious complication after lung transplantation. Choice of systemic agent to prevent invasive fungal infection varies between centers and funding of agents remains challenging. Our center has recently changed from posaconazole to a highly bioavailable formulation of itraconazole (SUBA®-itraconazole) at substantially reduced cost, but safety and toxicity require further assessment. A retrospective study of lung transplant patients receiving systemic antifungal prophylaxis from December 2016 through December 2019 following change from posaconazole to itraconazole as standard practice. 150 patients with lung transplants were managed in this time period, with 88 (59%) receiving at least 1 mold-active triazole during the study period. 48 (58%) of these patients received SUBA®-itraconazole; 68 (82%) received posaconazole and 10 (12%) received voriconazole. The average cost per patient during the study period was significantly lower on SUBA®-itraconazole (mean $1548/patient/6 month course) than posaconazole (mean $16 921.35/patient/6 month course). Target trough concentrations for prophylaxis of itraconazole > 0.5 mg/L and posaconazole > 0.7 mg/L were achieved on empiric dosing in 49% and 68% respectively. Overall trough itraconazole (0.50 vs 1.12 mg/L, P < .001) and posaconazole (1.37 vs 2.10 mg/L P < .001) concentrations were significantly lower in patients with cystic fibrosis. Calcineurin inhibitor dose changes on introduction or cessation were similar for SUBA®-itraconazole and posaconazole. Breakthrough invasive fungal infection and toxicity were rare. SUBA®-itraconazole is well-tolerated, associated with rare breakthrough invasive fungal infection, and lower cost. Prospective studies following general introduction are required to determine long-term safety, tolerability, and efficacy.