Efficacy and Safety of Short-Term Universal Prophylaxis for Invasive Aspergillosis after Heart Transplantation

Purpose Invasive aspergillosis (IA) infection is an infrequent complication after heart transplant but is associated with high morbidity and mortality. Universal prophylaxis for invasive aspergillosis in HTx patients in the United States has not been explored. From 2012-2014, 6 patients who underwent heart transplantation in our program developed invasive aspergillosis infection. A retrospective analysis of IA cases was performed to identify risk factors but due to small numbers, no definitive conclusion was made. In response, we implemented universal aspergillosis prophylaxis beginning in January 2015 using micafungin starting on post-op day 1 and continued for the duration of the index transplant admission. We report on the efficacy and safety of our policy change. Methods Clinical and transplant related characteristics of patients who underwent heart transplantation in our center from 2012-2014 (Period 1) and from 2015-2016 (Period 2) were retrospectively reviewed and cases of IA were identified. All dual-organ transplant recipients were excluded. Adverse events potentially related to micafungin use during period 2 were recorded. Results During period 1, 16% (6/37) of patients developed IA with a mean onset of 60 days post-transplant (range 9 to 174 days). Two patients died (28%) and all but one IA infection (86%) occurred within 90 days of transplantation. During Period 2, 22 patients underwent heart transplantation and all received micafungin prophylaxis for a mean of 12.8 days. One patient (4%) had micafungin stopped on post-op day 10 for presumed drug-related transaminitis. At one-year follow-up, no IA cases were identified. Conclusion Short-term universal aspergillosis prophylaxis with micafungin post- operatively for the duration of the index transplant admission is effective in preventing post-transplant aspergillosis infection. The medication is safe and well tolerated with a low discontinuation rate.