Echinocandin use in lung transplant recipients

Abstract

Background Invasive fungal infections (IFI) are associated with significant morbidity and mortality in lung transplant recipients (LTRs). However, data outlining use of echinocandins in prophylaxis and therapy of LTRs are limited. Method A single‐center retrospective cohort study on all LTRs from January‐2010 to December‐2016. Participants were screened for antifungal use to assess rate, tolerability, and clinical outcome of echinocandin use in LTRs, during the first 6 weeks of posttransplant. Results A total of 777 lung transplants were reviewed in 763 LTRs. Antifungals were administered to 268 (35%) of LTRs. Reasons included preemptive antifungal therapy (55% [149/268]), targeted antifungal prophylaxis (34% [92/268]), and definitive IFI therapy (10% [27/268]). Azoles were first‐line agents in 80% (215/268) of LTRs, caspofungin in 11% (30/268), micafungin in 6.7% (18/268), amphotericin B in 1.5% (4/268), and anidulafungin in 0.4% (1/268]). LTRs were started on echinocandins due to abnormal liver enzymes in 91% (46/49). Overall, 23% (50/215) of LTR's were switched off azoles. Of these, 54% (27/50) were switched to echinocandins. Switch from azoles to echinocandin was undertaken due to abnormal liver enzymes in 63% (17/27). No patients receiving first‐line echinocandins were switched to other therapies due to adverse events. Conclusions Our data suggest that echinocandins are utilized in approximately 18.3% of lung transplant recipients. They are the preferred second‐line agents due to a lower adverse‐effect profile compared to the azoles.

Prophylaxis of Fungal Infections in Transplant Patients:What has Changed in Recent Years?

“…49 Concerning LgT, Al Jishi et al, in a single-center retrospective cohort study, investigated the use of echinocandin and concluded that it is an important second-line agent, still preempted by the azoles group, as LgT transplant recipient patients who received antifungal prophylaxis with azoles did not develop disseminated invasive aspergillosis, cryptococcal or endemic fungal infections. 50,51 The comparative studies mentioned in this subtopic on IFI prophylaxis in patients with SOT can be summarized and visualized in Table 2.…”

Antifungal Prophylaxis After Lung Transplantation: Where Are We Now?

“…However, the use of intravenous systemic antifungal agents for primary prophylaxis after the early posttransplant hospitalization period is unpractical; despite that, these drugs are often considered as second-line agents due to their better safety profile when compared with triazoles. 2,6 Triazole antifungal agents are inhibitors of the synthesis of ergosterol, the main sterol in the fungal cell membrane. 26 These agents are the most frequently used class of drugs for systemic antifungal prophylaxis in LTx recipients, as their oral formulations favor long-term use, yet temporary parenteral administration is sometimes practiced in the early post-transplant period.…”

“…1 Yeasts and moulds, in particular, are responsible for 15-35% of all post-transplant infections in LTx recipients and have high mortality rates. [2][3][4][5][6][7][8][9][10] Most fungal infections after LTx are caused by Aspergillus species (spp. ), the most frequent mold, and Candida species (spp.…”

“…), the most frequent yeast. [3][4][5][6] While invasive candidiasis mostly occurs early post-transplant (after a median of 1 month) and is mainly due to technical complications, donor-derived infection or nosocomial infection; non-Candida invasive fungal infections usually occur later, typically between 1-6 months post-transplant (median 3 months). 3,4,7,8 The high incidence of this latter group is caused by potent immunosuppression of the host and continuous exposure of the lung graft to the environment (a situation unique for transplanted lungs and small intestine, compared to all other transplanted solid organs), coupled with impaired defences caused by a blunted cough reflex and impaired muco-ciliary clearance.…”

Perioperative anidulafungin combined with triazole prophylaxis for the prevention of early invasive candidiasis in lung transplant recipients

“…To date, few studies have described the role of echinocandins for antifungal prophylaxis, and none to our knowledge have evaluated combination echinocandin and triazole antifungal prophylaxis in LTRs. 4,[18][19][20][21] The aim of this study was to analyze the effectiveness of a newly implemented institutional protocol utilizing the addition of perioperative anidulafungin to itraconazole prophylaxis compared to itraconazole prophylaxis alone in LTRs.…”