Is universal antifungal prophylaxis mandatory in lung transplant patients?

PURPOSE OF REVIEW Lung transplantation remains the main therapy for patients with end-stage lung disease, yet survival remains limited by infection and chronic rejection. Invasive fungal infection, especially invasive aspergillosis, continues to cause a high rate of mortality after lung transplantation, and there is evidence that fungal colonization in itself may have a negative impact as well. This article reviews clinical trials in primary antifungal prophylaxis to determine whether antifungal prophylaxis after lung transplantation is indicated. RECENT FINDINGS A variety of antifungal regimens have been tested after lung transplantation including itraconazole or voriconazole monotherapy, inhaled amphotericin B products, and combination therapy. Studies using a historical cohort that has not received antifungal prophylaxis show a decrease in the incidence of invasive fungal disease and/or invasive aspergillosis with antifungal prophylaxis, with relatively few safety concerns. Both systemic azoles and inhaled amphotericin B products appear to provide benefit. SUMMARY Despite multiple reports of antifungal prophylaxis efficacy, a randomized, controlled, multicenter trial has yet to be performed. The optimal agent or agents for prophylaxis and length of therapy posttransplantation remain unknown. However, sufficient evidence exists for the utility of some type of antifungal prophylaxis posttransplantation for the majority of lung transplant recipients.