Influence of Extended Itraconazole Antifungal Prophylaxis on the Development of Fungal Infections After Lung Transplant

Background Invasive fungal infections (IFIs) are associated with a high mortality in lung transplant recipients, with no consensus on optimal antifungal prophylaxis. We aimed to assess the efficacy of long‐term itraconazole compared to short‐term inhaled amphotericin to prevent IFIs post‐transplant. Methods A retrospective review of adult lung transplant recipients from January 2016 to September 2022 was conducted. The cohort was divided into two groups based on initial mold prophylaxis: long‐term itraconazole and short‐term inhaled amphotericin. The primary outcome was the incidence of IFIs. The secondary outcomes included the time to IFI, incidence of fungal species found on cultures, and safety/tolerability. Results A total of 203 patients met the inclusion criteria (amphotericin group n = 108, itraconazole group n = 95). The overall incidence of IFIs was significantly higher in the amphotericin group than the itraconazole group (76.9% vs. 56.8%, p = 0.002). The Kaplan–Meier curve for the risk of IFI within 1 year of transplant showed a shorter time to IFI in the amphotericin group ( p = 0.009). In the amphotericin group, there was an increased incidence of positive fungal cultures compared to the itraconazole group with Aspergillus spp. (25% vs. 8.4%, p = 0.002), Penicillium spp . (25.9% vs. 9.5%, p = 0.002), yeast (70.4% vs. 36.8%, p ≤ 0.001), and other positive fungal cultures (28.7% vs. 12.6%, respectively, p = 0.005). The amphotericin group had more discontinuations due to intolerance than the itraconazole group (12% vs. 3.2%, p = 0.019). Conclusion In adult lung transplant recipients, long‐term prophylaxis with itraconazole was more effective at preventing overall IFIs, positive cultures with Aspergillus spp. , and was better tolerated than short‐term inhaled amphotericin.