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, 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 (I2=66.64%), number needed to treat was 6.8. A subgroup analyses with exclusion of heart transplant recipients also showed a statistically significant reduction of IAI with AFP (OR 0.183, 95%CI 0.0449-0.744, p=0.018). Conclusion The present 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 antifungal prophylaxis. Therefore, there is a clear need for an adequately powered RCT. This article is protected by copyright. All rights reserved.