Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
Transplantation. 2012 Aug 15;94(3):281-6. doi: 10.1097/TP.0b013e318255f864.
Lung transplant recipients are at high risk of invasive fungal disease (IFD), particularly invasive aspergillosis and candidiasis. The antifungal strategy that optimally balances effective reduction of IFD with a minimum of toxicity remains undefined; universal triazole prophylaxis is common at lung transplantation (LT) centers, despite the well-known toxicities and costs of this approach.
We implemented an antifungal strategy in March 2007 targeted at LT recipients at highest risk for IFD based on our institutional epidemiology. All patients received inhaled amphotericin B during their initial LT hospitalization, bilateral lung transplant recipients received 7 to 10 days of micafungin, and only patients with growth of yeast or mold in their day-of-transplant cultures received further oral antifungal therapy tailored to their fungal isolate.
IFD events were assessed in sequential cohorts composed of 82 lung transplant recipients before and 83 patients after the implementation of this targeted antifungal strategy. We observed a sharp decline in IFD; in the second cohort, 87%, 91%, and 96% of patients were free of IFD, invasive candidiasis, and invasive aspergillosis at 1 year. Only 19% of patients in the second cohort received systemic antifungal therapy beyond the initial LT hospitalization, and no patients experienced antifungal drug-related toxicity or IFD-associated mortality.
The targeted antifungal strategy studied seems to be a reasonable approach to reducing post-LT IFD events while limiting treatment-related toxicities and costs.
肺移植受者存在侵袭性真菌感染（IFD）的高风险，尤其是侵袭性曲霉病和念珠菌病。能够有效降低 IFD 风险，同时毒性最小化的抗真菌策略仍不明确；尽管这种方法存在众所周知的毒性和成本问题，但在肺移植（LT）中心，普遍采用三唑类药物预防。
我们根据机构流行病学数据，于 2007 年 3 月实施了一种针对 IFD 高危 LT 受者的抗真菌策略。所有患者在初始 LT 住院期间均接受吸入性两性霉素 B 治疗，双侧肺移植受者接受 7-10 天的米卡芬净治疗，仅在移植当天培养出酵母或霉菌生长的患者接受针对其真菌分离株的进一步口服抗真菌治疗。
我们评估了实施这种靶向抗真菌策略前后的 82 例 LT 受者组成的连续队列中的 IFD 事件。我们观察到 IFD 明显减少；在第二队列中，1 年后有 87%、91%和 96%的患者未发生 IFD、侵袭性念珠菌病和侵袭性曲霉病。第二队列中只有 19%的患者在初始 LT 住院后接受了全身性抗真菌治疗，且没有患者出现抗真菌药物相关毒性或 IFD 相关死亡率。
所研究的靶向抗真菌策略似乎是一种降低 LT 后 IFD 事件的合理方法，同时限制了治疗相关毒性和成本。
