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Discontinuation of Anti-Fungal Prophylaxis in Lung Transplant Recipients: Why Does It Happen
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The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
3 year survival (0.68 vs 0.84%) (Figure 1, p=0.291). Of the Achromobacter patients, forty-two percent (11/26) had positive explant bronchial cultures and forty-six percent (12/26) had Achromobacter isolated after transplantation. Of the 12 patients with recurrent Achromobacter, only 4 had positive explant cultures. Only 1 of 11 deaths was attributable to Achromobacter. Conclusion: Lung transplantation is a viable treatment option for patients with end stage CF and a history of infection with Achromobacter and these patients should be considered candidates for transplantation.
785 Risk of Skin Cancers with Long-Term Itraconazole in Lung Transplant Recipients K. Pennington, R. Razonable, S. Peters, R. Daly, J. Scott, M. Brutinel, H. Sekiguchi, M. Wylam and C. Kennedy. Mayo Clinic, Rochester, MN. Purpose: The objective of this study was to determine if long term itraconazole use, as antifungal prophylaxis, in lung transplant recipients is an independent risk factor for skin cancer. Methods: We retrospectively reviewed patients who received a lung transplant at Mayo Clinic Rochester from 2002 to 2010. The antifungal prophylaxis protocol at our institution is triazole therapy, itraconazole or voriconazole, for a minimum of 3 years. Patients who died within 6 months of initial transplant were excluded. Characteristics to help assess independent risk for the development of cutaneous cancers and type of antifungal prophylaxis were noted. Patients who were exposed to both voriconazole and more than 6 months of itraconazole were analyzed separately. Results: We identified 102 patients who underwent lung transplant at Mayo Clinic from 2002 to 2010; 11 patients died within 6 months of transplant and were excluded. Of the remaining 91 patients, 44 received only itraconazole prophylaxis, 10 received only voriconazole prophylaxis, and 37 received both itraconazole and voriconazole. No statistically significant difference between the baseline characteristics of the 3 groups was observed with the exception of race. There was a lower proportion of Caucasians in the voriconazole only group compared with the itraconazole only and combined itraconazole/voriconazole groups (p=0.02). Out of the 91 patients included in the study, 40 (44.0%) were diagnosed with skin cancer post-transplant, and 5 (12.5%) developed aggressive, metastatic cutaneous squamous cell carcinoma. Follow-up time was similar between patients who developed skin cancer (93.0 § 45.0 months) and those who did not (62.0 § 49.0 months, p=0.23). No significant difference was found in incidence of skin cancer or rate of metastatic squamous cell carcinoma between patients in the three groups (p=0.65) Duration of itraconazole was greater in patients who developed skin cancer [median 62.5 months (22.7, 87.5) vs 32.0 (18.0, 64.8), p=0.07] despite similar follow-up time. Absolute exposure (i.e.
exposed to itraconazole or not) did not appear to correlate with the development of skin cancer post-transplant. Conclusion: Prolonged itraconazole exposure when used as a prophylactic agent in lung transplant recipients appears to correlate with the development of skin cancers but further studies are warranted. 786 Donor to Host Transmission of Infection in Lung Transplantation E.J. Wainstein,1 A. Smud,1 N. Ma~nez,1 M.L. Orazi,1 L. Barcan,1 G.N. Svetliza,1 C. Quinteros,1 A. Dietrich,2 A. Da Lozzo,2 E. Beveraggi,2 D.E. Smith,2 and H.M. Castro.1 1Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; and the 2 Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. Purpose: To evaluate the incidence and etiology of donor infection and donor to host transmission of infections in lung transplantation. Methods: We performed a retrospective cohort study of lung transplant patients at Hospital Italiano de Buenos Aires from January 2010 to March 2017. We analyzed data from electronic medical records. Donor infection was classified as bacteremia, graft colonization or isolated contamination of preservation fluids. Donor-to-host transmission of infection was defined as any infection in the recipient due to at least one microorganism also isolated from the donor and with identical antimicrobial susceptibility pattern. Results: We included 55 lung transplant patients. Mean age was 48 years (SD 16), Single lung transplantation was performed in 75% of the cases. Cause of transplantation was chronic obstructive pulmonary disease (n=19), interstitial lung disease (n= 15), cystic fibrosis (n= 16) and others (n=5). Incidence of donor infection was 92.7% (n=51, 95%CI 82-98). Isolated contamination of preservation fluids was determined in 76.4% of cases (n= 42), graft colonization in 83.6% (n= 46) and bacteremia in 12.7% (n=7). The most common microorganisms isolated were gram positive coccus. Incidence of donor to host transmission of infection was 12.7% (n= 7, 95% CI 524). All cases were related to graft colonization. 40% (n=3) of recipients that developed infection had inadequate antibiotic prophylaxis. The microbiological etiologies were Acinetobacter baumannii (n=2), Klebsiella pneumoniae (n=2), Citrobacter koseri (n=1), Aspergillus fumigatus (n=1) and Methicillin-Sensitive Staphylococcus Aureus (n=1). Types of host infection were pneumonia (n=5), tracheobronchitis (n=1) and empyema (n=1). Infection-related death occurred in one patient. Conclusion: The incidence of donor infection was high but donor to host transmission of infection after lung transplantation was an uncommon event. Inadequate antibiotic prophylaxis was high in those with donor to host transmission of infection. The most frequent etiology for donor infection was gram positive cocci. Gram negative bacteria was the most frequent cause of donor to host transmission of infection.
787 Susceptibility Testing of Exophiala dermatitidis to Inform PeriOperative Prophylaxis at Time of Lung Transplantation A. Perry,1 S. Mattu,1 S. Peart,1 A. Hague,1 G. Meachery,2 A. Fisher,2 K. Gould,1 J. Samuel,1 and A. Robb.1 1Microbiology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, United Kingdom; and the 2Institute of Transplantation, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, United Kingdom. Purpose: Exophiala dermatitidis is a black fungus that frequently colonises the lungs of people with cystic fibrosis (CF). Mucoid and non-mucoid variants can be detected from the same sputum for some patients, but their role in chronic CF lung disease is not fully understood and attempts at early eradication are not routinely performed. Invasive infections with this species are rare; however in 2014 we reported our first case of fatal, invasive infection with a highly mucoid strain of E. dermatitidis in a 34 year old
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
3 year survival (0.68 vs 0.84%) (Figure 1, p=0.291). Of the Achromobacter patients, forty-two percent (11/26) had positive explant bronchial cultures and forty-six percent (12/26) had Achromobacter isolated after transplantation. Of the 12 patients with recurrent Achromobacter, only 4 had positive explant cultures. Only 1 of 11 deaths was attributable to Achromobacter. Conclusion: Lung transplantation is a viable treatment option for patients with end stage CF and a history of infection with Achromobacter and these patients should be considered candidates for transplantation.
785 Risk of Skin Cancers with Long-Term Itraconazole in Lung Transplant Recipients K. Pennington, R. Razonable, S. Peters, R. Daly, J. Scott, M. Brutinel, H. Sekiguchi, M. Wylam and C. Kennedy. Mayo Clinic, Rochester, MN. Purpose: The objective of this study was to determine if long term itraconazole use, as antifungal prophylaxis, in lung transplant recipients is an independent risk factor for skin cancer. Methods: We retrospectively reviewed patients who received a lung transplant at Mayo Clinic Rochester from 2002 to 2010. The antifungal prophylaxis protocol at our institution is triazole therapy, itraconazole or voriconazole, for a minimum of 3 years. Patients who died within 6 months of initial transplant were excluded. Characteristics to help assess independent risk for the development of cutaneous cancers and type of antifungal prophylaxis were noted. Patients who were exposed to both voriconazole and more than 6 months of itraconazole were analyzed separately. Results: We identified 102 patients who underwent lung transplant at Mayo Clinic from 2002 to 2010; 11 patients died within 6 months of transplant and were excluded. Of the remaining 91 patients, 44 received only itraconazole prophylaxis, 10 received only voriconazole prophylaxis, and 37 received both itraconazole and voriconazole. No statistically significant difference between the baseline characteristics of the 3 groups was observed with the exception of race. There was a lower proportion of Caucasians in the voriconazole only group compared with the itraconazole only and combined itraconazole/voriconazole groups (p=0.02). Out of the 91 patients included in the study, 40 (44.0%) were diagnosed with skin cancer post-transplant, and 5 (12.5%) developed aggressive, metastatic cutaneous squamous cell carcinoma. Follow-up time was similar between patients who developed skin cancer (93.0 § 45.0 months) and those who did not (62.0 § 49.0 months, p=0.23). No significant difference was found in incidence of skin cancer or rate of metastatic squamous cell carcinoma between patients in the three groups (p=0.65) Duration of itraconazole was greater in patients who developed skin cancer [median 62.5 months (22.7, 87.5) vs 32.0 (18.0, 64.8), p=0.07] despite similar follow-up time. Absolute exposure (i.e.
exposed to itraconazole or not) did not appear to correlate with the development of skin cancer post-transplant. Conclusion: Prolonged itraconazole exposure when used as a prophylactic agent in lung transplant recipients appears to correlate with the development of skin cancers but further studies are warranted. 786 Donor to Host Transmission of Infection in Lung Transplantation E.J. Wainstein,1 A. Smud,1 N. Ma~nez,1 M.L. Orazi,1 L. Barcan,1 G.N. Svetliza,1 C. Quinteros,1 A. Dietrich,2 A. Da Lozzo,2 E. Beveraggi,2 D.E. Smith,2 and H.M. Castro.1 1Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; and the 2 Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. Purpose: To evaluate the incidence and etiology of donor infection and donor to host transmission of infections in lung transplantation. Methods: We performed a retrospective cohort study of lung transplant patients at Hospital Italiano de Buenos Aires from January 2010 to March 2017. We analyzed data from electronic medical records. Donor infection was classified as bacteremia, graft colonization or isolated contamination of preservation fluids. Donor-to-host transmission of infection was defined as any infection in the recipient due to at least one microorganism also isolated from the donor and with identical antimicrobial susceptibility pattern. Results: We included 55 lung transplant patients. Mean age was 48 years (SD 16), Single lung transplantation was performed in 75% of the cases. Cause of transplantation was chronic obstructive pulmonary disease (n=19), interstitial lung disease (n= 15), cystic fibrosis (n= 16) and others (n=5). Incidence of donor infection was 92.7% (n=51, 95%CI 82-98). Isolated contamination of preservation fluids was determined in 76.4% of cases (n= 42), graft colonization in 83.6% (n= 46) and bacteremia in 12.7% (n=7). The most common microorganisms isolated were gram positive coccus. Incidence of donor to host transmission of infection was 12.7% (n= 7, 95% CI 524). All cases were related to graft colonization. 40% (n=3) of recipients that developed infection had inadequate antibiotic prophylaxis. The microbiological etiologies were Acinetobacter baumannii (n=2), Klebsiella pneumoniae (n=2), Citrobacter koseri (n=1), Aspergillus fumigatus (n=1) and Methicillin-Sensitive Staphylococcus Aureus (n=1). Types of host infection were pneumonia (n=5), tracheobronchitis (n=1) and empyema (n=1). Infection-related death occurred in one patient. Conclusion: The incidence of donor infection was high but donor to host transmission of infection after lung transplantation was an uncommon event. Inadequate antibiotic prophylaxis was high in those with donor to host transmission of infection. The most frequent etiology for donor infection was gram positive cocci. Gram negative bacteria was the most frequent cause of donor to host transmission of infection.
787 Susceptibility Testing of Exophiala dermatitidis to Inform PeriOperative Prophylaxis at Time of Lung Transplantation A. Perry,1 S. Mattu,1 S. Peart,1 A. Hague,1 G. Meachery,2 A. Fisher,2 K. Gould,1 J. Samuel,1 and A. Robb.1 1Microbiology, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, United Kingdom; and the 2Institute of Transplantation, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, United Kingdom. Purpose: Exophiala dermatitidis is a black fungus that frequently colonises the lungs of people with cystic fibrosis (CF). Mucoid and non-mucoid variants can be detected from the same sputum for some patients, but their role in chronic CF lung disease is not fully understood and attempts at early eradication are not routinely performed. Invasive infections with this species are rare; however in 2014 we reported our first case of fatal, invasive infection with a highly mucoid strain of E. dermatitidis in a 34 year old