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

2. 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

3. 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

4. Incidence and mortality of IA after SOT Type of transplantation
Incidence (% pts)
Time (days)
(Extremes)
Mortality (% pts)
Liver
2 (1-8)
17 ( ) 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 -
100
Intestine
2.2 (0-10)
289 (10-956) 66
Singh N. and Paterson DL, Clin Microb Reviews; 2005, 18, N°1:
Singh N et al, AJT 2009; 9, S

5. Invasive Aspergillose : Mortality
Denning DW
Clin Infect Dis
till 1995
Paterson DL, Singh N
Medicine
Lin QY
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 %

6. Mortality of IA after LT
: 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

7. Mortality at 3 months after the diagnosis of IFI
A prospective Survey 25 US Transplant Centers ( )
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

9. 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

10. 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

11. 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

12. 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 ??

13. Galactomannan for Diagnosis of IA
Meta-analysis : 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: )
Pfeiffer CD et al, Clin Infect Dis 2006; 42:

14. Risk factors of IA

15. 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.

16. 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.

17. 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.

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

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

20. Risk factors of occurrence of IA during the first year post LT (Multivariate analysis) 667 LT ( ) RR
95% CI p
Hemodialysis prior to LT
2.7
[ ]
0.03
Arterial Hypertension prior to LT
[ ]
0.01
Acute fulminant hepatic failure
3.7
[ ]
CMV disease (1rst month)
3.5
[ ]
Saliba F et al, personnal experience

21. 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 ?

22. 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:
Singh N et al, Am J Transplant 2009, 9, S180-S191 .

23. 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 : %
Singh N et al, Am J Transplant 2009, 9, S180-S191 .

24. Prophylaxis Targeted prophylaxis Preemptive Therapy

25. 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
mg/kg/day x days

26. Prophylaxis of IFI after LTx
A randomized controlled study itraconazole vs placebo
Itraconazole 5 mg/kg prior to LTx then 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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 ; p=0.04)
Singh N et al, Am J Transplant 2008, 8:

34. 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 .

35. Prophylaxis for high-risk patients after Lung transplantation (recommendations of the AST Infectious disease Community of Practice)
Inhaled amphotericin B
6-30 mg/day 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 .

36. 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:

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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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