A survey of anti-fungal management in lung transplantation.
BACKGROUND
Fungal infections are an important complication of lung transplantation, but no controlled studies of their management have been performed. Knowledge of actual anti-fungal strategies may aid in the design of future prospective studies.


METHODS
Thirty-seven of 69 active lung transplant centers, accounting for 66% of all US lung transplantations, responded to our survey. The survey focused on fungal surveillance, pre- and post-transplant prophylaxis, and approach to fungal colonization.


RESULTS
The median number of lung transplantations performed by the centers in 1999 was 14 per year (range, 1-52), and median time that centers were in in operation was 9 years (range, 2-15 years). Seventy percent of centers had a transplant infectious diseases specialist. Pre-transplant fungal surveillance was performed by 81% of centers, with 67% of these surveying all patients and the remainder surveying only sub-sets of patients. Seventy-two percent of all centers started anti-fungal treatment if Aspergillus spp were isolated before transplantation. Itraconazole was the preferred agent (86%). After transplantation, 76% of centers gave anti-fungal prophylaxis, although 24% of these did so only in selected patients. Prophylactic agents in order of preference were inhaled amphotericin B (61%), itraconazole (46%), parenteral amphotericin formulations (25%), and fluconazole (21%); many centers used more than 1 agent. Prophylaxis was initiated within 24 hours by 71% and within 1 week by all centers. Median duration of prophylaxis was 3 months (range, <1 month-lifetime). All 37 centers used anti-fungal therapy if colonization with Aspergillus spp was detected for a median duration of 4.5 months. Itraconazole was the preferred agent. Only 59% of centers treated patients colonized with Candida spp. In a statistical analysis, centers with larger volumes were less likely to treat pre-transplant colonization with Candida spp but more likely to use agents other than itraconazole for post-transplant colonization with Aspergillus spp. Only 14% of centers engaged in any anti-fungal research at the time of the survey.


CONCLUSIONS
The majority of surveyed lung transplant programs actively manage fungal infection with prophylaxis or pre-emptive therapy, despite the absence of controlled trials. This survey may provide an impetus and a basis for designing prospective studies.
Dummer
J Stephen
JS
Division of Infectious Diseases, Vanderbilt Transplant Center, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA.
Lazariashvilli
Nikoloz
N
Barnes
Jean
J
Ninan
Mathew
M
Milstone
Aaron P
AP
D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use*; D001228:Aspergillosis / Q000175:diagnosis / Q000517:prevention & control; D001999:Bronchoscopy; D002177:Candidiasis / Q000517:prevention & control; D019538:Health Care Surveys; D006801:Humans; D017964:Itraconazole / Q000627:therapeutic use; D008172:Lung Diseases, Fungal / Q000188:drug therapy / Q000517:prevention & control*; D016040:Lung Transplantation; D009894:Opportunistic Infections / Q000175:diagnosis / Q000188:drug therapy / Q000517:prevention & control*; D011292:Premedication; D014481:United States
D000935:Antifungal Agents; D017964:Itraconazole; D000666:Amphotericin B