Targeted antifungal prophylaxis in heart transplant recipients.
BACKGROUND
Antifungal prophylaxis after heart transplantation is usually targeted to high-risk recipients, but the duration is normally fixed and empirical. Our purpose was to assess the efficacy of a personalized prophylactic approach based on the duration of the risk factors.


METHODS
In a prospective cohort, from 2003 to 2010, prophylaxis was only administered to patients with risk factors (13 of 133) and duration was personalized, starting with the risk factor and continued a median of 20 days after its resolution.


RESULTS
Antifungal prophylaxis was prescribed only in 9.8% of the recipients and was effective in all but one patient who should have received a higher dose of caspofungin due to his obesity. Despite suffering an outbreak of invasive aspergillosis (IA) in the intensive care unit due to extremely high concentration of spores in the air (three cases with no personal risk factors), there was a reduction in the incidence of IA (8.6% vs. 2.2%; P=0.01) and Aspergillus-related mortality (5.75% vs. 1.5%; P=0.06).


CONCLUSIONS
Targeted prophylaxis for IA in heart recipients provided only to patients with risk factors and maintained for a median of 20 days after their disappearance is effective and safe. A high environmental load of Aspergillus spores in the intensive care unit would also indicate the need for antifungal prophylaxis in all exposed patients.
1 Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain. 2 Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain. 3 Department of Experimental Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain. 4 Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain. 5 Red Española de Investigación en Patología Infecciosa (REIPI), Madrid, Spain. 6 CIBER de Enfermedades Respiratorias (CIBER RES), Palma de Mallorca, Spain. 7 Spanish Study Group of Infections in Transplant Recipients (GESITRA), Madrid, Spain. 8 Department of Bioengineering and Aerospace Engineering, Universidad Carlos III de Madrid. 9 Address correspondence to: Patricia Muñoz, M.D., Ph.D., or Maricela Valerio, M.D., Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, 28007 Madrid, Spain.
Patricia
P
Muñoz
Maricela
M
Valerio
Jesús
J
Palomo
Maddalena
M
Giannella
Juan F
JF
Yañez
Manuel
M
Desco
Emilio
E
Bouza
D000293:Adolescent; D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000008:administration & dosage*; D003428:Cross Infection / Q000382:microbiology / Q000517:prevention & control; D004196:Disease Outbreaks; D004334:Drug Administration Schedule; D005260:Female; D016027:Heart Transplantation / Q000009:adverse effects* / Q000401:mortality; D006801:Humans; D055744:Invasive Pulmonary Aspergillosis / Q000382:microbiology / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000382:microbiology / Q000401:mortality / Q000517:prevention & control* / Q000635:transmission; D018579:Patient Selection; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
D000935:Antifungal Agents