Antifungal Prophylaxis After Lung Transplantation: Where Are We Now?

Abstract

BackgroundLung transplantation is an important treatment option for various end-stage lung diseases. However, survival remains limited due to graft rejection and infections. Despite that fungal infections are frequent and carry a bad prognosis, there is currently no consensus on efficacy, optimal drug, route or duration of antifungal prophylaxis. This narrative review summarizes current strategies for antifungal prophylaxis after lung transplantation. MethodsEnglish-language articles in Embase, Pubmed, UptoDate and bibliographies were used to assess efficacy and safety of available antifungal agents for prophylaxis in adult lung transplant recipients. ResultsOverall, there are limited high quality data. Universal prophylaxis is more widely used and may be preferable over targeted prophylaxis. Both formulations of inhaled amphotericin B and systemic azoles are effective at reducing fungal infection rates, yet with their own specific advantages and disadvantages. The benefit of combination regimens has yet to be proven.Considering the post-transplant timing of onset of fungal infections, postoperative prophylaxis during the first postoperative months seems indicated for most patients. ConclusionsBased on existing literature, universal antifungal prophylaxis with inhaled amphotericin B and/or systemic voriconazole for at least 3 to 6 months after lung transplantation may be advisable, with a slight preference for amphotericin B because of its better safety profile.

Chronic Lung Allograft Dysfunction, a Review in 2023

“…Koutsokera et al [9] published a series of more than 400 pts, where the detection of donor-specific antibodies (DSA) was an early marker associated with the development of graft dysfunction. Some studies have suggested that the presence of pre-transplant HLA antibodies does not impact the risk of development of CLAD and mortality [10]. However, recent literature suggests that pre-transplant HLA antibodies are associated with worse waitlist and post-transplant survival, as well as higher rates of acute cellular rejection and BOS [11].…”

Bring it on: Top five antimicrobial stewardship challenges in transplant infectious diseases and practical strategies to address them

“…53,54 For lung transplant recipients, the preferred choice between universal or pre-emptive antifungal prophylaxis against Aspergillus (the latter involving routine surveillance with broncho-alveolar lavage culture and galactomannan) is undefined, but either approach is recommended over no prophylaxis. 55,56 Although 90% of US transplant centers had previously reported routine universal antifungal prophylaxis for lung transplant recipients, a review of administrative claims data showed that only 41.5% of patients received antifungal prophylaxis. 57 The reasons for this incongruence is unknown, but further analysis could potentially provide insights to stewardship areas of interest.…”

Efficacy of different durations of antifungal prophylaxis with nebulized amphotericin B after lung transplantation: a retrospective cohort study

“…The American Society of Transplantation Infectious Disease Community of Practice recommended 2016 a regimen of NAB for 3–4 months ( 8 ). It has also been suggested that universal antifungal prophylaxis with inhaled amphotericin B and systemic voriconazole for a minimum of 3–6 months following lung transplantation may be beneficial ( 9 ). A Chinese national survey found that invasive pulmonary aspergillosis (IPA) mostly occurs in the first 4–6 months post-transplant ( 3 ).…”