2014 - Transplant Infectious Disease Conference

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Drugs and Devices

5.2 - New ISHLT Guidelines: antifungal prophylaxis in lung, heart and VAD patients

Presenter: Shahid, Husain, Toronto, Canada
Authors: Shahid Husain

Fungal Infections in cardiothoracic organ transplant recipients an important cause of morbidity and mortality. The  higher mortality associated with these infections has prompted center specific strategies resulting in significant variation in antifungal management practices  The Infectious Diseases Council of the International Society for Heart and Lung Transplantation (ISHLT) convened an international and multidisciplinary panel of experts in the field. The Panel members approved the most relevant questions to be addressed in the areas of epidemiology, diagnosis, prophylaxis, and treatment of FIs, including therapeutic drug monitoring (TDM) of antifungal agents in adult and pediatric heart, lung, and MCS device patients. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to appraise the evidence. The recommendations have been submitted to ISHLT Standards and Guidelines committee pending approval.

Panel has recommended cystic fibrois  be considered as a significant risk factor of fungal infections post lung transplantation. Use of serum galactomannan GM and beta D glucan is not recommended for the diagnosis. While bronchoalveolar lavage GM is recommended to be considered for diagnosis as well as for preemptive therapy. Anti-candida prophylaxis is recommended during the first month followed by preemptive or universal prophylaxis. Duration of antifungal prophylaxis ranges from 4-6 months. Combination antifungal therapy is not routinely recommended nor does the secondary prophylaxis for aspergillosis. TDM of azoles (itraconazole, posaconazole, voriconazole) are encouraged both in prophylaxis and treatment of fungal infections. The routine antifungal prophylaxis of mechanical circulatory support devices (MCSD) is not suggested. Drive line infection is recommended to be treated with either an echinocandin or liposomal amphotericin. Majority of the recommendations have moderate to low quality of evidence.

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