Invasive aspergillosis (IA) is a significant complication status post lung transplantation with an incidence of 6% to 16%. Because early diagnosis of IA in lung transplant is hampered by the lack of specific clinical signs and by the low sensitivity of culture-based diagnostic methods, the efficacy of bronchoalveolar lavage galactomannan (BAL GM) for early diagnosis is explored in this study.
A retrospective analysis was performed on 45 consecutive lung transplant recipients between January 2015 and February 2016 at UF Health Shands Hospital. All patients were placed on prophylactic itraconazole post-transplant. Surveillance bronchoscopies were performed at 2 weeks, 1 month, 3 months, 6 months, 9 months, and 12 months post-transplant. During each bronchoscopy, bacterial, fungal, and acid-fast bacterial cultures along with BAL GM [an optical density (OD) index of ≥0.5 considered positive] were obtained.
If BAL GM ≥1.0, the patient was switched to voriconazole for further treatment. CT Chest was also evaluated. If BAL GM remained ≤1.0 at the 6 month interval, then prophylaxis was complete. IA was defined using the EORTC/MSG criteria for invasive fungal disease (i.e., patient classified as either having proven, probable or possible IA).
There was a total of 225 observations from the 45 patients. Two patients (4.4%) had proven IA with a mean GM of 4.153 (SE, 0.629) and seven patients (15%) had probable IA with a mean of 2.169 (SE, 0.409).
There was no correlation of cold ischemic time (p = 0.88), primary graft dysfunction (PGD, p = 0.38), presence of Candida species (p =0.048) or non-tuberculous mycobacteria (NTM) in bronchoalveolar lavage (p=0.044), and viral pneumonitis (p =0.047) with a positive BAL GM.
All nine patients with GM >1 were switched to voriconazole from itraconazole which resulted in negative GM levels on follow-up bronchoscopy.
Our data suggest that the implementation of universal antifungal prophylaxis with itraconazole may not be efficacious in preventing IA in lung transplant recipients. On the other hand, surveillance with BAL GM is a strategy that can lead to early detection of IA in patients during the first year after lung transplantation.
A. Emtiazjoo, None