Aspergillosis in Transplant patients Pr Faouzi SALIBA faouzi.saliba@ pbr.aphp.fr Faculté de Médecine Paris Sud Réanimation - Centre Hépato-Biliaire Hôpital Paul Brousse - Villejuif- France

Incidence of Fungal Infections after SOT Invasive Fungal Infections Aspergillus Candida Kidney 1.4–14% 0–10% 90–100% Heart 5–20% 77–91% 8–23% Liver 7–42% 9–34% 35–91% Lungs/Heart-Lungs 15–35% 25–50% 43–72% Small Intestine 40–59% 0–3.6% 80–100% Pancreas 18–38% 0–3% 97–100% Gabardi S. et al. Transplant Int 2007;20:993–1015, Singh N. Clin Infect Dis 2000:31;545–53. 2

Outcome of Patients according to the presence of Fungal Infections after LT 85% 69% 91% 48% 77% Logrank p <0.0001 No Fungal Infection Fungal Colonisation Treated fungal infection years Saliba F et al, European Society of Organ transplantation (ESOT), Paris Sept 2009 Saliba F et al, International Conference on Antimicrobial Agents and Chemotherapy (ICAAC) San Francisco, Sept 2009 3

Incidence and mortality of IA after SOT Type of transplantation Incidence (% pts) Time (days) (Extremes) Mortality (% pts) Liver 2 (1-8) 17 (6- 1107) 87 Lung 6 (3-14) 120 (4-1410) 68 Heart 5.2 (1-15) 45 (12-365) 78 Kidney 0.7 (0-4) 82 (20-801) 77 Pancreas 1.1-2.9 - 100 Intestine 2.2 (0-10) 289 (10-956) 66 Singh N. and Paterson DL, Clin Microb Reviews; 2005, 18, N°1: 44-69. Singh N et al, AJT 2009; 9, S180-191

Invasive Aspergillose : Mortality Denning DW Clin Infect Dis till 1995 Paterson DL, Singh N Medicine 1987-1997 Lin QY 1995-1999 Bone marrow 90 % 92 % 86.7 % AIDS/HIV 81 % - 85.7 % Liver transplant. 93 % 87 % 67.6 % Kidney transplant. 70 % 75 % 62.5 % Lung Transplant. 77 % 55 % Heart transplant. 50 % 78 % 43.6 % Pancreas transplant 100 %

Mortality of IA after LT 1985 - 1997: 26/1307 patients (2 %) 24/26 (92 %) patients Death directly related to aspergillosis : 16 patients (68 %) Other causes of death : Technical Complications: 2 patients Recurrent disease : 1 patient Sepsis : 5 patients 13/24 patients had autopsy : 7 positive 4 confirming the diagnosis 3 revealing the diagnosis C.H.B. Saliba F. et al, Paul Brousse expeirence

Mortality at 3 months after the diagnosis of IFI A prospective Survey 25 US Transplant Centers (2001-2002) Total IFI BMT N = 251 SOT N = 316 Invasive Fungal Infections 46% 67% 30% (p= < 0.001) Invasive Aspergillosis 60% 69 45% Invasive Candidosis 36% 61% 29% Pappas PG et al, ICAAC 2003, Chicago, Abstract actualisé N° M-1010

Invasive Fungal Infections: Time of occurrence Earlier Reports Most of the cases occurred within the first three months (CNS involvement++) Recent studies* * 55% of the cases occurred > 3 months ** 43% of the cases occurred > 3 months * Singh N, Clin Infect Dis 2003; 36:46–52 ** Gavaldà J et al, Clin Inf Dis 2005; 41:52-9

Invasive Aspergillosis : Time of diagnosis A retrospective case-control study : 156 cases of proven or probable invasive aspergillosis 11 Spanish centers (RESITRA) Since the start of the centers’ transplantation programs to December 2001 Gavaldà J et al, Clin Inf Dis 2005; 41:52-9

Pattern of Fungal Infections in SOT Patients Immunosuppression impairs inflammatory response Scarcity of clinical and/or radiologic signs associated with inflammation Progress of infection prior to clinical presentation Infection often advanced at time of diagnosis Rapidly progressive Absence of surrogate markers that could allow early diagnosis Efficacy of therapeutic agents limited by toxicity and drug interactions

Diagnosis of Pulmonary Aspergillosis Pulmonary Infection Early diagnosis difficult radiographs often normal Sputum cultures often negative "halo" sign on chest CT scan highly suggestive in BMT is exceptionally present in SOT Broncho-alveolar lavage ++ Direct exam, Culture, Ag, PCR Halo sign ??

Galactomannan for Diagnosis of IA Meta-analysis 1996- 2005: 27 studies Population Sensitivity (%) Specificty Hematologic malgnancy 70 92 BMT 82 86 Pediatric BMT + malignancy 89 85 Solid organ transplant 22 84 Real-time PCR performed on the first positive GM increased sensitivity to 62% (Botterel F et al, Transpl Infect Dis 2008, 10: 333-8.) Pfeiffer CD et al, Clin Infect Dis 2006; 42: 1417-27

Risk factors of IA

Invasive Aspergillosis : role of the environement Old ICU New protected ICU E n v i r o n e m e n t culture + + + - + - - - - - 12/767 pts (1.6 %) 4/541 pts (0.7 %) C.H.B. Saliba F et al. 40th ICAAC, Toronto 2000.

Ventilation System - Liver transplantation ICU (Paul Brousse Hospital) Characteristics 1. HEPA Filters (99.97 %) 2. Unidirectionnel airflow 3. Room positive air pressure 4. Hermetic rooms 5. Air renewal rate (20times/h) 6. Air velocity (2.5-3m/s) Maintenance Cultures air and surfaces (3 months) Disinfection and HEPA filter change (1/year) Noise Reduction HEPA Filtre Blowing filtered air Double vitrage + store intérieur Trappe Blowing Blowing : 800 m3/h Double glass + interior storage rail support Bed Double glass + interior storage EXTRACTION : 800 m3/h Blowing 300 m3/h Double vitrage + store intérieur EXTRACTION C.H.B. Interior corridor Saliba F et al. 40th ICAAC, Toronto, September 2000.

Risk Factors for IFI in Liver Transplant Recipients Clinical parameters Fungal Infections Retransplantation Aspergillus spp + Candida spp Need for hemodialysis Prophylaxis of SBP Candida spp Dysfunction of the graft Aspergillus spp CMV Infection HHV6 Infection C.H.B.

Invasive Aspergillosis: Risk factors of early IA (1) < 3 months OR (95% CI) p Use of vascular amines > 24h 2.2 (1.2 - 4.1) < 0.0001 Renal failure after SOT 4.9 (2.4 -9.8) Hemodialysis after SOT 3.2 (1.3 - 8.1) 0.014 > 1 episode of bacterial infetion (3.2 - 17.4) < 0.006 CMV disease 2.3 (1.1 - 4.9) < 0.029 Gavaldà J et al, Clin Inf Dis 2005; 41:52-9

Invasive Aspergillosis : Risk factors of late IA (2) > 3 months OR (95% CI) p Age > 50 years 2.5 (1.3 - 5.1) 0.009 Renal failure after SOT 3.9 (1.9 -7.8) < 0.0001 High levels of CNI (1.2 - 5) 0.01 > 1 episode of bacterial infetion 7.5 (3.2 - 17.4) De novo cancer 69.3 (6.4 - 75.3) Chronic graft rejection 5 (1.9 - 13) 0.001 Gavaldà J et al, Clin Inf Dis 2005; 41:52-9

Risk factors of occurrence of IA during the first year post LT (Multivariate analysis) 667 LT (1999-2005) RR 95% CI p Hemodialysis prior to LT 2.7 [1.1-6.8] 0.03 Arterial Hypertension prior to LT [1.2-5.9] 0.01 Acute fulminant hepatic failure 3.7 [1.6-8.8] CMV disease (1rst month) 3.5 [1.3-9.5] Saliba F et al, personnal experience

Risk factors of IA after Lung transplantation Early Fungal Infections Single lung transplant Surgical factors include: Lung/airway denervation anastomotic ischemia provides nidus for fungal infection Stents predispose to tracheal infection Diffuse airway ischemia Acute allograft rejection CMV infection Pre and post transplant Aspergillus colonisation Acquired hypogammagloblinemia (IgG < 400mg/dl) Transmission with the allograft Late Fungal Infections Bronchiolitis obliterans syndrome ?

Risk factors of IA after Heart transplantation Isolation of Aspergillus from redspiratory tract cultures Reintervention CMV disease Hemodialysis Existence of an episode of IA in the program in the program 2 months before or after heart transplant Overall mortality : 67% Munoz P et al, Curr Opin Infect Dis 2006; 19: 365-370 Singh N et al, Am J Transplant 2009, 9, S180-S191 .

Risk factors of IA after Renal transplantation High doses or prolonged duration of corticosteroids Graft failure requiring Hemodialysis Potent immunosuppressive therapy for rejection Overall mortality : 67-75 % Singh N et al, Am J Transplant 2009, 9, S180-S191 .

Prophylaxis Targeted prophylaxis Preemptive Therapy

Fungal Prophylaxis after Liver transplantation Drugs that have been shown to non efficaceous in preventing IFI after transplantation Nystatin Fungizone Conventional low dose of Amphotericin B 0.2 - 0.5 mg/kg/day x 7 - 21 days

Prophylaxis of IFI after LTx A randomized controlled study itraconazole vs placebo Itraconazole 5 mg/kg prior to LTx then 2.5 mg/kg BID after LTx All IFI were due to Candida Study was not sufficient to show any efficacy against IA p = 0.049 1 (4%) (24%) Colby WD. 39th ICAAC, San Francisco, 1999 Abstract N°1650.

Prophylaxis with Liposomal Amphotericin B after Liver Transplantation Randomized study of liposomal amphotericin B (1 mg/kg/day x 5 days) vs placebo Placebo (n=37) Liposomal amphotericin B (n=40) Infection (1 month) 6 (16 %) Infection (>1 month to 1 year) 5 (IA:1) 4 (IA:3) Survival (1 year) 78% 80% Mortality (1 year) due to IFI 3 1 Tollemar JG, et al. Transplant Proc 1995;27:1195-8 27

Targeted Prophylaxis (preemptive) in Liver transplant recipients requiring Hemodialysis n = 148; dialysis: 22, others: 126 No prophylaxis n = 38; dialysis: 11, others: 27 ABLC/L-AmB 5 mg/kg/j 1997 Singh N et al, Transplantation 2001

Fungal prophylaxis Prophylaxis was targeted to high-risk patients mainly ALF, Retransplantation, End-stage cirrhosis in the ICU A total of 198 high-risk patients received a fungal prophylaxis 146 high-risk patients (21.9%) received Amphotericin B lipid complex (ABLC) fungal prophylaxis Dosage: 1mg/kg/day x 1w then 2.5 mg/kg biw Day 1 to day 7 (mean) : 76 ± 16 mg Cumulated dose (mean) : 955 ± 609 mg Mean duration : 23 ± 12 days 50 patients received Fluconazole Mean dose : 245 ± 108 mg/day (median : 200 mg) Mean duration : 18 ± 11 days Saliba F et al, European Society of Organ transplantation (ESOT), Paris Sept 2009 Saliba F et al, International Conference on Antimicrobial Agents and Chemotherapy (ICAAC) San Francisco, Sept 2009

Results : Candida infection p=0.0002 p=0.0001 p= NS p=0.009 p= 0.03 Saliba F et al, European Society of Organ transplantation (ESOT), Paris Sept 2009 Saliba F et al, International Conference on Antimicrobial Agents and Chemotherapy (ICAAC) San Francisco, Sept 2009

Results : Aspergillosis ABLC prophylaxis : 1mg/Kg/day x 3 weeks P= NS Saliba F et al, European Society of Organ transplantation (ESOT), Paris Sept 2009 Saliba F et al, International Conference on Antimicrobial Agents and Chemotherapy (ICAAC) San Francisco, Sept 2009

Prophylaxis with Caspofungin in High-risk Liver Transplant Recipients A prospective multicentre Spanish study Duration of prophylaxis: 21 days (range 5–54 days) Successful response: 88.7% 2 patients developed IFI after end of therapy: Mucor and Candida albicans Fortun J and GESITRA study group. Transplantation 2009;87:424-37

Attitude towards prophylaxis of Liver transplant Centers in USA Survey : electronic questionnaire 67/106 (63%) of the centers answered Traitement of choice: Fluconazole (86%) Traitement of choice for moulds: Echinocandins (41%) Voriconazole (25%) Polyene (18%) Combination therapy : Primary therapy for IA: 47% For salvage therapy IA: 80% Prophylaxis Fluconazole vs non-Fluconazole Higher rate of mould infections (Aspergillosis, zygomycosis and scedosporiosis) RR 1.5 (95% CI 1.0-2.2; p=0.04) Singh N et al, Am J Transplant 2008, 8:426-31.

Prophylaxis of high-risk patients after Liver transplantation (Recommendations of the AST Infectious disease Community of Practice) Lipid formulation of AmB (II 2) 3-5 mg/kg/day Or an Echinocandin (II 3) Duration 3-4 weeks or until resolution of risk factors Singh N et al, Am J Transplant 2009, 9, S180-S191 .

Prophylaxis for high-risk patients after Lung transplantation (recommendations of the AST Infectious disease Community of Practice) Inhaled amphotericin B 6-30 mg/day - 25 mg/day Inhaled lipid formulations of amphotericin B Nebulized ABLC (II 3) 50 mg/every 2 days for 2 weeks Once a week x 13 weeks (minimum) Nebulized L-AmB 25 mg three times per week x 2 months Then once a week x 6 months Then twice per month In high-risk patients Voriconazole* : 400 mg/day x 4 months Itraconazole*: 400 mg/day x 4 months Monitor liver enzymes and azole and Immunosuppressive drugs +++ Singh N et al, Am J Transplant 2009, 9, S180-S191 .

Voriconazole for Prophylaxis after Lung transplantation Targeted prophylaxis Itraconazole or Inhaled ampho B N= 30 p IFI 1 (1.5%) 7 (23%) 0.001 Non-Aspergillus infections at 1 year 2 (3%) 0.004 Husain S et al, AJT 2006; 6:3008-16

Prophylaxis for high-risk patients after Heart transplantation (Recommendations of the AST Infectious disease Community of Practice) Voriconazole 200mg BID for 50-150 days Singh N et al, Am J Transplant 2009, 9, S180-S191 .

Management of Invasive Fungal Infection Early specific diagnosis often requires invasive procedure Effective therapy must take into consideration: Common altered liver and kidney functions Drug toxicities Liver, kidney, brain… Drug interactions Immunosuppressive drugs: Calcineurine inhibitors: Cyclosporine, tacrolimus mTOR inhibitors: sirolimus, everolimus Antimicrobials Glycopeptides, aminoglycosides, rifampicin… 38

ABLC in the treatment of IA after SOT ABLC (5mg/Kg/day) compared to an historical group of c-AmB (1.1 mg/kg/day) Mortality (%) Linden PK et al, CID 2003; 37:17-25

Survival after treatment of IA after SOT A prospective and retrospective study Caspofungine + Voriconazole L-AmB Days after the diagnosis 100 75 50 25 First-line treatment : Caspofungine + Voriconazole (n=40) between 2003 et 2005 Historical group : L-AmB (n=47) between 1999 and 2002 L-AmB (n=47) between 1999 and 2002 67% 51% Probability of Survival (%) Singh et al. Transplantation 2006

Survival after treatment of IA after SOT A prospective and retrospective study P=0.08 Total success 70% 51% P=0.79 Complete response 17,5% 21,3% P=0.048 Partial 52,5% 29,8% First-line treatment : Caspofungine + Voriconazole (n=40) between 2003 et 2005 Historical group : L-AmB (n=47) between 1999 and 2002L-AmB (n=47) between 1999 and 2002 Response rate (%) Singh et al. Transplantation 2006

Caspofungine for treatment of IA after SOT A retrospective study : 81 SOT patients with IFI IA : 22 patients, 19 treated with Caspofungine Proven : 7 patients Probable 12 patients 74% 78% 70% Winkler M et al, Transplant inf Dis 2010

Conclusion Invasive Aspergillosis has a major impact on patient survival Risk factors for developping IA are now well known Serum, sputum and BAL galactomannan could be of help but need further evaluation Prophylaxis should be administered only to high-risk patients Further multicenter trials are needed to evaluate their efficacy Echinocandins are currently under evaluation Management of IA is comparable to the non-transplant setting