**10. Infection prophylaxis**

Infections remain a major source of morbidity and mortality after lung transplantation. Prophylaxis against bacterial, viral and fungal organisms usually starts immediately postoperatively in the recipients. Initial antibiotic prophylaxis should be directed towards adequate anaerobic coverage and tailored towards any positive donor or recipient culture detected prior to transplantation. These antibiotics are usually continued between three to fourteen days post transplant depending upon the individual transplant center's protocol. Lung transplant recipients with septic lung disease (cystic fibrosis, bronchiectasis) who may be colonized with resistant organisms often receive two synergistic antibiotics based on prior sensitivities during this time period.

Lung Transplantation 305

Fig. 1. Kaplan-Meier survival by diagnosis for adult lung transplants performed between January 1990 and June 2008. AT Def, α1-antitrypsin deficiency emphysema; CF, cystic fibrosis; COPD, chronic obstructive pulmonary disease; IPAH, idiopathic pulmonary arterial

**Cause of death No. (%) No. (%) No. (%) No. (%) No. (%) No. (%)**  Bronchiolitis 6 (0.3) 159 (4.7) 781 (25.4) 508 (29.2) 507 (25.2) 95 (19.7) Acute rejection 74 (3.8) 61 (1.8) 48 (1.6) 10 (0.6) 15 (0.7) 1 (0.2) Lymphoma 1 (0.1) 86 (2.5) 63 (2.1) 28 (1.6) 46 (2.3) 23 (4.8) Other malignancy 4 (0.2) 100 (3.0) 202 (6.6) 151 (8.7) 219 (10.9) 47 (9.7)

CMV 0 96 (2.8) 29 (0.9) 5 (0.3) 4 (0.2) 0 Non-CMV 396 (20.1) 1,205 (35.6) 710 (23.1) 329 (18.9) 363 (18.0) 81 (16.8) Graft failure 557 (28.3) 589 (17.4) 591 (19.2) 327 (18.8) 379 (18.8) 87 (18.0) Cardiovascular 213 (10.8) 144 (4.3) 118 (3.8) 82 (4.7) 99 (4.9) 36 (7.5) Technical 162 (8.2) 76 (2.2) 18 (0.6) 8 (0.5) 12 (0.6) 6 (1.2) Other 553 (28.1) 871 (25.7) 513 (16.7) 289 (16.6) 370 (18.4) 107 (22.2)

Lung transplant remains an effective treatment for selected patients with end-stage lung disease. The major rate limiting step for lung transplantation at present is the available donor organs. Chronic allograft dysfunction remains a major source of morbidity and mortality after lung transplantation. Investigations into improving donor lung availability, preventive and therapeutic approaches for OB and alternative for transplantation for end-

Table 2. Causes of Death Following Lung Transplantation in Adult Recipients.

**0–30 days 31 days–1 year >1–3 years >3–5 years >5–10 years >10 years (***n* **= 1,966) (***n* **= 3,387) (***n* **= 3,073) (***n* **= 1,737) (***n* **= 2,014) (***n* **= 483)** 

hypertension; IPF, idiopathic pulmonary fibrosis. J Heart Lung Transplant. 10: 1083-1141, 2010

J Heart Lung Transplant. 10: 1083-1141, 2010

Infection

**12. Conclusion** 

Viral prophylaxis is most commonly targeted against cytomegalovirus (CMV). Aggressive prophylactic therapy is directed towards this organism because of its high virulence and association with mortality in the lung transplant population. Lung transplant recipients with either donor or recipient serology that is positive for CMV usually receive prophylactic therapy with valganciclovir anywhere between three months to lifelong therapy. CMV negative lung transplant recipients who received a CMV positive donor lung may also receive CMV immunoglobulin in addition to their current valganciclovir therapy. Unfortunately, while valganciclovir prophylaxis decreases the incidence of CMV infection during the time of administration, prophylaxis does not completely prevent the development of CMV infection especially after prophylaxis therapy is discontinued. The optimal duration and type of therapy are still a matter of debate. Acyclovir and its derivatives are given to CMV negative lung transplant recipients who receive CMV negative donors in order to prevent the development of Herpes infections.

Fungal prophylaxis varies among the different transplant centers depending upon prior colonization, mechanical airway complications and environmental factors. In general some centers provide general fungal prophylaxis while others consider preemptive therapy depending upon surveillance bronchoscopy findings. Lung transplant recipients are at increased risk for developing *Aspergillus spp.* colonization of the airways leading to anastomotic infections and ulcerative tracheobronchitis. Itraconazole (or other azole substitutes) and inhaled amphotericin are the most common fungal prophylactic agents that are currently used. The azoles will increase the levels of the calcineurin inhibitors (cyclosporine and tacrolimus) so that the doses of these immunosuppressive medications should be decreased by at least 1/3 of their original dose. Calcineurin levels should be checked approximately one week after starting an azole. Of note, voriconazole and sirolimus should not be used together due to the significant rise in sirolimus levels.
