Is universal antifungal prophylaxis mandatory in adults after lung transplantation? A review and meta‐analysis of observational studies

Background Lung transplant ( LTX ) recipients are at high risk of invasive Aspergillus infections ( IAI ). However, no randomized‐controlled trials ( RCT ) or international guidelines on antifungal prophylaxis ( AFP ) in the LTX population exist. Methods A meta‐analysis was performed to determine whether AFP reduces the rate of IAI after LTX . A total of six eligible observational studies (five with no prophylaxis, one with targeted prophylaxis, three studies including heart/lung transplantation) with a total of 748 patients were included. Results The pooled odds ratio ( OR ) for IAI (62 IFI in the intervention arm and 82 in the control group) was 0.234 (95% confidence interval [ CI ] 0.097‐0.564, P =0.001, z =−3.237). Pooled studies were characterized by substantial heterogeneity ( I 2 =66.64%); number needed to treat was 6.8. A subgroup analyses with exclusion of heart transplant recipients also showed a statistically significant reduction in IAI with AFP ( OR 0.183, 95% CI 0.0449‐0.744, P =0.018). Conclusion This study suggests that universal antifungal prophylaxes reduces incidence of IAI after LTX . However, included studies are limited by small sample size, single‐center structure without randomization, mixed population (including heart/heart‐lung transplant), and heterogeneity due to variations in immunosuppression, type, and duration of AFP. Therefore, there is a clear need for an adequately powered RCT .