1736. Evaluation of Targeted vs. Universal Antifungal Prophylaxis (AP) for Invasive Fungal Infections (IFI) After Lung Transplant (LTx)

BACKGROUND: LTx patients (pt) are at increased risk for IFI. Systemic AP is widely used, but the optimal strategy remains unclear. Our LTx program changed from universal to targeted AP in July 2016; we compared outcomes between the 2 strategies. METHODS: All adult pt who underwent LTx at U. Michigan from July 1, 2014 to December 31, 2017 were studied for 18 mo post-LTx. Universal AP consisted of itraconazole (itra) ± inhaled liposomal amphotericin-B (iAmB) for 6 months. Pt received targeted AP with voriconazole for 3 months if they had a history of pre-LTx Aspergillus colonization or invasive pulmonary aspergillosis (IPA); 14 days of a yeast-active azole was given if donor or recipient had Candida colonization at the time of LTx. All other pt received no AP. Demographics, LTx characteristics, occurrence of proven/probable IFI defined by EORTC/MSG criteria, and mortality data were recorded. RESULTS: Of 105 LTx patients, 73 (70%) were men and 84 (80%) received a double LTx. The most common indication for LTx was idiopathic pulmonary fibrosis (38, 36%). Of 59 pt receiving universal AP, 36 (61%) received itra, and 23 (39%) received itra+iAmB; outcomes did not differ between these 2 regimens. Of 46 patients in the targeted AP cohort, 10 (22%) received antifungals based on predefined criteria. Overall, 19 proven/probable IFI occurred: 14 IPA, 3 invasive Candida infections, 1 Cryptococcus pneumonia, and 1 mold wound infection. IFI occurred in 5 patients (8%) in universal AP group vs. 13 patients (28%) in targeted AP group, P = .008. All but 1 IFI in the targeted AP group occurred among pt for whom antifungals were not recommended or given. IPA occurred in 4 patients (7%) in universal AP group and 9 patients (20%) in targeted AP group, P = 0.05; Candida infections occurred only among patients in the targeted AP cohort. Time to IFI was similar between the 2 AP strategies with the majority occurring <180 days post-LTx (median 109 days). Death occurred in 11 patients (8 in the universal AP cohort and 3 in the targeted AP cohort, P = .34); no deaths were related to IFI. CONCLUSION: When compared with universal AP, targeted AP strategy was associated with a significant increase in IFI post-LTx. Universal AP for 6 months appears to be more effective than our targeted AP strategy for prevention of IFI post-LTx. DISCLOSURES: Marisa H. Miceli, MD, FIDSA, Astellas: Advisory Board, Research Grant; Scynexis: Research Grant.