Saprophytic fungal infections and lung transplantation--revisited

Fungal infections cause serious morbidity and death in lung transplant recipients. Some centers exclude and others will prophylactically treat patients with evidence of Aspergillus colonization.

Of 126 patients undergoing lung transplantation at the University of North Carolina since January 1990, five patients have died because of invasive Aspergillus and other saprophytic fungal infections. Those cases are reviewed looking for common predisposing factors, including any evidence of prior colonization. In addition, all preoperative and postoperative culture data on all transplant recipients were retrospectively examined to define the prevalence of preoperative and postoperative Aspergillus colonization in 121 patients with and without cystic fibrosis, none of whom had development of significant fungal disease.

Fifty-two percent of 65 patients with cystic fibrosis were colonized with Aspergillus before operation, and 40% after operation at some time. None had development of significant Aspergillus infections, and none received prophylactic antifungal therapy. Most of the deaths from deep-seated fungal infections have been in patients without cystic fibrosis with no evidence of preoperative colonization. These patients had evidence of severe obliterative bronchiolitis, bacterial infections, persisting cytomegalovirus disease, or other major organ failure.

The rationale for excluding patients or for giving amphotericin in the perioperative period in those patients who are colonized before surgery is questioned.