Practice variation in Aspergillus prophylaxis and treatment among lung transplant centers: a national survey

Background Fungal infections remain a substantial cause of mortality in lung transplant ( LT x) recipients, yet no comprehensive consensus guidelines have been established for antifungal prophylaxis and treatment of Aspergillus infection in these patients. Methods A cross‐sectional study surveyed the directors from 27 of 64 (45.5%) active LT x centers in the United States to examine clinical practice variations in Aspergillus prophylaxis and treatment of colonization and invasive aspergillosis ( IA ) in LT x recipients. Results Antifungal prophylaxis increased from 52.3% in 2011 to 77.8% in 2013, with the most common agent being inhaled amphotericin B (61.9%), followed by oral voriconazole (51.9%). A total of 74.1% of centers treat Aspergillus airway colonization, with 80.0% of centers using oral voriconazole. All centers treat IA , with 92.6% using oral voriconazole. The duration of Aspergillus prophylaxis and treatment of colonization or IA varied widely across centers from 3 months to >1 year. A total of 51.9% of centers reported internal practice variations in the treatment of IA . Factors guiding treatment decisions included microbiologic culture and sensitivity (74.1%), ease of administration (59.3%), interaction with other medications (55.5%), side effect profile (51.8%), and center guidelines (48.1%). Although 85.2% of LT x centers recommended routine skin cancer screening for LT x recipients, only 44.4% of LT x centers reported having a dedicated transplant dermatologist. Conclusion Most active US LT x centers currently employ antifungal prophylaxis and treat Aspergillus colonization and IA , although choice of agent, route of administration, and duration of therapy across and within centers continue to differ substantially. The number of transplant dermatologists available among US LT x centers is limited. Overall, a strong need exists for more comprehensive consensus guidelines to direct antifungal prophylaxis and treatment of Aspergillus infection in LT x recipients.