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Rationale: In lung transplant recipients (LTRs), the aspergillus PCR assay has higher sensitivity to detect aspergillus species in broncho-alveolar lavage (BAL) fluid, compared to BAL fungal culture. A positive aspergillus PCR may represent an aspergillus infection or mere colonization. Some reports argue that aspergillus colonization is a risk factor for future invasive infection in LTRs and may be associated with excess mortality, though this speculation was not firmly established. We set to determine whether a positive aspergillus PCR assay obtained during routine post-transplant surveillance bronchoscopies, was associated with increased early or late all-cause mortality. Methods: BAL samples obtained from LTRs during early surveillance bronchoscopies (conducted at days 3, 14 and 28 post-transplantation) at the Rabin Medical Center (RMC) were routinely sent for aspergillus PCR testing. 72 consecutive patients underwent lung transplantation at RMC during the study period (5/2015-10/2016). Excluded were patients who were re-transplanted (N=4), and patients for whom no early surveillance PCR result was available (N=8). LTRs received itraconazole prophylaxis for one year post-transplant. Analysis of data was retrospective. A p-value <0.05 was considered statistically significant. Results: Sixty consecutive patients (mean age 52.8y, 76% males, 58.3% double lung) who met the above criteria, were included in the final analysis. Of these, 18 (30%) had at least one positive aspergillus PCR result during the early surveillance period and up to 60 days post-transplant, while 42 had consistently negative PCR results. After a mean follow-up of 1.61 years, all-cause mortality was similar (33.3%) in both groups. However, the distribution of early vs late mortality was different, with most deaths (4 out of 6) in the PCR+ group occurring >360 days (compared to only 2/14 deaths in the PCR- group; p=0.064). Age, gender and number of transplanted lungs did not differ between these two groups. Among the 18 patients with PCR+ for aspergillus during surveillance, only 3 had aspergillus infections (1 probable invasive aspergillosis; 2 tracheobronchial aspergillosis), while the others had colonization. The trend towards different mortality timing, persisted upon exclusion of these 3 aspergillosis cases (p=0.069). Conclusions: A positive aspergillus PCR assay in the early post-transplant period was associated with a trend towards increased late all-cause mortality, in a single-center retrospective study. It remains to be tested in future prospective studies, whether this finding represents a true association between aspergillus colonization and increased late mortality, and whether extension of anti-fungal prophylaxis beyond 1 year in colonized patients may decrease late mortality.
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