Management of Fungal Infections in MCS and Cardiothoracic Organ Transplant Recipients (eBook)

ISHLT Monograph Series (Volume 12)

Shahid Husain MD MS (Autor)

James K Kirklin MD, Amparo Sole MD PhD, Orla Morrissey MD PhD (Herausgeber)

eBook Download: EPUB

2020 | 1. Auflage
120 Seiten
Bookbaby (Verlag)
978-1-0983-3118-4 (ISBN)

Infos

'Management of Fungal Infections in Mechanical Circulatory Support and Cardiothoracic Organ Transplant Recipients,' summarizes the most current literature in the field of fungal infections related to MCS and heart/lung transplantation. It is the collective effort of many people in the international field and works to inform readers about contemporary innovations.

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"e;Management of Fungal Infections in Mechanical Circulatory Support and Cardiothoracic Organ Transplant Recipients,"e; summarizes the most current literature in the field of fungal infections related to MCS and heart/lung transplantation. It is the collective effort of many people in the international field and works to inform readers about contemporary innovations. This as a useful resource in improving medical procedural outcomes and is the culmination of work contributed from around the globe.

Textauszug

Chapter 1

EPIDEMIOLOGY OF FUNGAL INFECTIONS

Contributors: Denis Hadjiliadis, Kate Gould, Fernanda P. Silveira, Aimee K. Zaas

Incidence/Prevalence of Fungal Colonization in Lung Transplant Candidates

All the information on fungal colonization in lung transplant candidates comes from observational studies, mostly single center and some from multiple centers. As sampling practices, geographic location and populations differ in the studies, the confidence on the exact prevalence of fungal colonization in lung transplant candidates is low. Data is more robust in the cystic fibrosis (CF) population, due to their ability to produce sputum and the more consistent surveillance that occurs in this patient population. Studies are heterogeneous and include colonization at any time pre-transplant up to the time of transplant. In addition, sampling might be playing a role in the identification of fungal pathogens prior to lung transplantation. In a study looking at explants lungs the overall prevalence was 5% (14/304).1 In one of the largest series, with a relatively large population of patients with CF, there were fungal organisms in 59% (79/133) of patients. More specifically, Aspergillus was present in 33% (44/133) of patients.2 Other smaller series have identified fungi in 8% (7/84) of patients.3

Unfortunately, the only classification and differentiation of patients in these series was whether the patients had CF or not as their underlying diagnosis. All reports show that the prevalence of fungal colonization in lung transplant candidates with CF is higher compared to other recipients. The differences are large in different studies, ranging from 22 to 81% in three different studies.2-5 In the same series patients without CF had prevalence from 0 to 52%.2,3 In one series, when Aspergillus was reported separately, patients with CF had prevalence of 50% (16/32), while the rest of patients had prevalence of 28% (28/101).2 In the study of explants, fungi were found in 11% (4/35) of explants in patients with CF vs. 4% (10/269) in patients without CF.1 In Summary, CF patients have higher incidence/prevalence of fungal colonization among lung transplant candidates.

These data suggest that fungal colonization is common in lung transplant candidates; however, the exact prevalence is very difficult to estimate. There are many limitations in the studies examining the prevalence/incidence in lung transplant candidates. Sampling is one of the main limitations. Studies from many centers with diverse geographic distribution and representative pre-transplant diagnoses, utilizing standardized sampling techniques are needed to better answer the question.

Aspergillius Colonization

Evidence Summary

There are multiple studies assessing the presence of fungal colonization in lung transplant recipients. Studies have focused primarily on colonization by molds, particularly Aspergillus. The studies have differences, although all of them are case series of patients after lung transplantation.6-16 The rates of fungal colonization range from 20 to 50% and the numbers of patients in each one of the series from 32 to 455 patients.6-15 Most of the largest series have rates of colonization between 30% and 40%, therefore making this rate likely more accurate.

In all the series the presence of CF greatly increased the rates of fungal colonization in lung transplant recipients. Patients with CF as their underlying diagnosis have rates from 42 to 76%; in contrast the rates for non-CF patients ranged from 21 to 40%, with the largest series (299 patients) having the lowest rate.1,5,13-16

Another study assessed the species of Aspergillus which was responsible for the colonization.17 A. fumigatus was the most common (59%), followed by A. flavus (35%).

There are also some studies that assessed the effect of prophylaxis on colonization. All of them showed that prophylaxis reduced colonization. In one study it was reduced from 0.83 infections per person-year to 0.63 infections per person-year.6 In another study, rates of colonization were lower with voriconazole compared to itraconazole (25.7% vs. 34.4%).11 Finally, voriconazole use in the most recent era decreased colonization to a significant extent for Aspergillus (0.4 per patient-year to 0.24 per patient-year) and even a greater degree for Candida (0.53 per patient-year to 0.16 per patient-year).7 In another study the timing of Aspergillus colonization was different for tracheobronchitis (three months) vs. invasive infection (33 months).18 Based on these studies it is clear that prophylaxis decreases colonization rates; azole antifungals were the most commonly used medications in these studies. However, there is not enough data to specifically know which prophylaxis strategy (if any) is better than others.

The different rates of colonization in studies are likely related to many different reasons, including pre-transplant diagnosis mix, intensity of surveillance and length of post-transplant follow-up of patients. However, most of the events occur early.

In summary, fungal colonization is common after lung transplantation. Pretransplant diagnosis of CF is a major risk factor for post-transplant colonization; most of the events occur early.

Recommendations (Table 1)

1. Cardiothoracic recipients should have fungal colonization diagnosed or excluded before transplant. (Class of Recommendation I, Level of Evidence B)

Incidence/Prevalence of IFI after Lung Transplantation

Evidence Summary

The incidence of invasive fungal infections (IFIs) is a lot lower than fungal colonization after lung transplantation.3,4,13 The rates range from 3 to 14%, with the largest series being closer to the lower numbers (6.6% in one series with 335 patients and 8.6% in a large multicenter trial).1-12, 19-21 When specifically looking at the rarer, but potentially severe invasive infection with zygomycetes rate is even lower and it is between 0.28 and 1.4%.21, 22

Voriconazole significantly decreased the incidence of IFIs from 14 to 23% to 1.5 to 4.2%.6,7 Voriconazole utilization also led to lower rates of IFI compared to itraconazole in a small series (4 vs. 12.5%) in a study of 67 patients.11 All recent studies appear to have lower incidence of IFI and in most of these series prophylaxis with azoles and especially voriconazole has been utilized.6,7 Nebulized liposomal amphotericin B was found to prevent IFIs after lung transplantation in one small study.19

In this setting pre-transplant diagnosis of CF, led once again to increased risk of post- transplant IFI.2-4 The series are smaller and therefore less confidence can be placed in actual rates (rates are from 11 to 13% for CF and 4% to 6% for non-CF patients).2-4

In summary, IFI is common (albeit less common than colonization) after lung transplantation. Prophylaxis decreases the rate of IFI after lung transplantation, although there is not enough to know the best prophylaxis strategy.

Recommendations (Table 1)

2. The risk of developing IFI should be evaluated before and after cardiothoracic transplant. (Class of Recommendation I, Level of Evidence C)

Incidence/Prevalence of IFI after Heart Transplantation

There is paucity of studies addressing the incidence/prevalence of fungal infections after heart transplantation, but incidence is low. Based on treatment need in one study, the prevalence was 1.0% per year (overall 45/750 (6%) of patients needed treatment).15 A multicenter study from 15 transplant centers in the United States suggested that the cumulative incidence of IFI after heart transplantation was 3.4% per year.21 Candida accounted for 49% of the infections, while Aspergillus accounted for 23%. More than half of the infections occurred in the first 90 days.21 In another study, looking specifically at invasive aspergillosis the incidence was a lot lower and all of the infections occurred in the first year post- transplant: 0.53% in the first year and 0.14% per year (3/686 (0.4%) patients developed invasive aspergillosis).15 A single center study over an 11-year period found that 1.7% (8/455 patients) developed probable or proven invasive aspergillosis (incidence 0.4 cases per 100 patient-year), in the absence of antifungal prophylaxis.13 Finally, another very old study, which unfortunately did not separate heart, heart-lung or lung transplant recipients suggested that nebulized amphotericin B led to a decrease in the incidence of IFIs in the first year post-transplant from 0.12 per patient year to 0.02 per patient year.23

Overall, the incidence of IFIs after...

Produkt-Details

• Erscheint lt. Verlag: 15.10.2020
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Allgemeines / Lexika
• ISBN-10: 1-0983-3118-4 / 1098331184
• ISBN-13: 978-1-0983-3118-4 / 9781098331184