Surveillance invasiver Fadenpilzmykosen in lungentransplantierten Patienten: Effekt antimykotischer Prophylaxe mit Itraconazol und Voriconazol

Abstract

Between January 2002 and December 2003 all 157 patients (pts) that underwent lung transplantation (LTx) at our institution were prospectively screened for invasive aspergillosis (IA) during their perioperative hospital stay. Patients were regarded as IA positive, if they met the EORTC criteria for 'probable' or 'proven' IA. Records of pts were screened retrospectively for antimycotic prophylaxis. Eight of the 157 pts developed 'probable' or 'proven' IA (5.1%) within 17 +/- 10 days after LTx. This was associated with a 14-fold increased mortality compared with all pts without aspergillosis (P < 0.01, OR 13.8, CI(95%) 2.5-82). Preoperative colonization with Aspergillus was a significant risk factor for IA (P < 0.001, OR 21.9, CI(95%) 4.9-97). We switched our prophylactic strategies to the primary administration of voriconazole in high risk pts (pre-LTx colonization) starting in December 2002. Six pts (6%) of 101 pts receiving itraconazole for antimycotic prophylaxis beginning at postoperative day (POD) one developed IA, of which three pts showed cerebral aspergillosis. One pt (5%) of 18 pts receiving voriconazole prophylaxis developed IA, while 10 pts showed pretransplant colonization with Aspergillus species. Thirty-eight pts received itraconazole prophylaxis at a later time point (>POD 14). By switching our prophylactic strategy to the use of voriconazole in high risk pts, we have decreased the incidence of IA from 8% (six of 75) in 2002 to 2% (two of 82) in 2003. This study shows a high incidence of IA during the very early postoperative course after LTx of 5%. This is associated with a significantly increased risk for mortality. Voriconazole prophylaxis appears to be superior to itraconazole, especially in high risk pts with pretransplant Aspergillus colonization.

Five-years surveillance of invasive aspergillosis in a university hospital

“…On the one hand, many patients received antifungal treatment although we found that the criteria were uncertain for IA. On the other hand, antifungal drugs are used for prophylaxis, especially in transplanted patients [4]. Obviously clinicians are often uncertain about the indication for antimycotic therapy or aim to prevent colonization in the first place [16].…”

“…are widely found in the environment, water, soil and in decomposing plants, spores can be easily inhaled and may then cause invasive pulmonary disease. The IA incidence in organ transplant recipients may be as high as 5%; mortality rates of up to 80% have been reported [4]. Antifungal therapy is expensive and adverse effects can be severe [5].…”

Epidemiology of invasive respiratory disease caused by emerging non‐Aspergillus molds in lung transplant recipients

“…Post-transplantation single isolation (9.9%) and colonization (5.8%) by non-Aspergillus molds were common findings, as has been described (range 14-23.6%) (7,8). Of note, all but 1 episode resolved, with only 1 subsequent case of invasive infection (1 Scopulariopsis).…”

“…The prevalence of Penicillium species and dematiaceous molds was high, mainly in sputum and tracheal aspirate. Detection of these molds (with the notable exception of Penicllium marneffei) possibly corresponded to normal contamination of laboratory samples, a single isolation, or respiratory tract colonization (8). Despite the high percentage of positive specimens, only 1 subsequent case of invasive disease (ulcerative tracheobronchitis) was caused by Penicillium species.…”

“…Pre-transplantation Scedosporium species colonization is a known risk factor for invasive disease following the procedure (5), but no data are available on other non-Aspergillus molds. Post-transplantation Aspergillus colonization is a reported risk factor for IFI (6), but isolation of molds other than Aspergillus species did not seem to be associated with invasive disease in some studies (7,8).…”