research objective: To demonstrate an association between saprophytic fungal infections occurring at the bronchial anastomosis (BA) and the disentanglement of additional complications arising at this site.

Design: Retrospective review.

Setting: University lung transplant center

Materials and methods: Review of all single-lung and double-lung transplant (LTX) recipients who underwent transplantation between June 1993 and December 2000 All recipients were controled to surveillance bronchoscopy with biopsy at predetermined intervals and when clinically indicated. Bronchial wash fluid and biopsy material were examined using appropriate fungal stains and improvement techniques. An infection was defined when fungal organisms were identified in tissue specimens.

Results: Fifteen saprophytic fungal infections involving the BA were identified in 61 LTX recipients (246%) who survived a minimum of 75 days post-transplantation. Infections were attributed to Aspergillus sp (n = 9) Candida sp (n = 2) Torulopsis sp (n = 1) and mixed flora (ie, Penicillium + Candida, sum of two units patients; and Aspergillus + Candida, the same patient). Saprophytic fungal infections occurr according to a median of postoperative day 35 (range, 13 to 159 days). Airway complications involving the BA ultimately exhibited in 11 of 61 recipients (18%) These complications included symptomatic bronchial stenosis (nine patients), bronchomalacia (one patient), and fatal hemorrhage (one patient). Bronchial complications arose in 7 of 15 recipients (467%) with saprophytic fungal infections of the BA in contrast to 4 of 46 (87%) without infections (p = 0003 Fisher exact test) Also demonstrated was a positive correlation between anastomotic infections and bronchial complications ([PHI] coefficient = 043; p = 0001) while logistic regression analysis revealed that the absence of anastomotic infections predicted the absence of as it is complications (p = 0.002). The risk of developing an additional complication following an anastomotic infection in patients with infections was five times that of those recipients without an infection (relative risk, 536; 95% confidence interval [CI], 182 to 1579) The supernumerarys in favor of a bronchial complication following an infection were eight times greater than in those recipients without infection (odd ratio, 831; 95% CI, 196 to 3516)

Conclusions: Following LTX saprophytic fungal infections of the BA are associated with serious airway complications.

explanation words: Aspergillus; bronchial anastomosis; fungal; infection; lung transplantation

Abbreviations: BA = bronchial anastomosis; HE = hematoxylin and eosin; GM = Gomori methenamine silver; LTX = lung transplantation; RR = relative risk

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through the last decade, lung transplantation (LTX) has emerg as a viable option for treating patients with end-stage lung disease becoming to a variety of pulmonary disorders. Unfortunately, the inherent use of immunosuppressive medications, which allows for allograft acceptance, controls the recipient to the risk of opportunistic infections. as it is infections currently account for significant mortality in these recipients, especially within the first year following the transplant deed (1) While these infections do not always involve the transplanted lung the allograft is potentially susceptible to infections from a variety of sources, including flora from as well-as; not only-but also; not only-but; not alone-but the recipient and the donor native airways. (23) Infections may consequence from bacterial, fungal, or viral infiltration of the graft. The bronchial anastomosis (BA) has been identified (4) as an anatomic site that is potentially susceptible to saprophytic fungal infections, in part proper to its relative devascularization following transplantation. Disruption of the infected BA complicated from a lethal hemorrhage may present itself (5) but other consequences resulting from similar infections have not been reported repeatedly Herein, we detail our experience with complications arising from saprophytic fungal anastomotic infections following LTX

MATERIALS AND METHODS

The investigation involved a retrospective review of all LTX courses performed between June 1993 and December 2000 To allow for an interval of adequate post-transplantation surveillance, a recipient had to survive a minimum of 75 days following transplantation to be included in the subject of attention No recipient having an infection or complication of the BA died before postoperative day 75

As previously described, in patients undergoing single-LTX, implantation of the donor organ was achieved by dint of creating an end-to-end or telescoping BA, while double-LTX courses were performed using the bilateral sequential technique. (67) Immediately following LTX routine immunosuppression was busyed utilizing standard regimens consisting of cyclosporine with azathioprine and corticosteroids (initially, IV methylprednisolone and later oral prednisone). LTX recipients received empiric systemic antibiotic therapy with differing antimicrobial agents (mostly clindamycin and ceftazidime) for 10 to 14 days following transplantation. Recipients receiving allografts for septic pulmonary disorders received antibiotics that were specific for respiratory tract flora that had been identified upon pretransplant cultures of the sputum All recipients received fungal prophylaxis with oral itraconazole in a dose of 200 mg by day for a minimum of 3 month Serum flats of this medication were not routinely followed. In addition to continuing the oral administration of itraconazole, for those recipients ultimately identified with a saprophytic fungal infection of the BA, therapy was undertaken with the one and the other IV and inhaled amphotericin B For systemic therapy, a liposomal preparation of amphotericin B was initiated in a dose of 5 mg/kg The inhaled administration of amphotericin B was accomplished by means of placing 10 mg of unsalable article in 5 to 10 mL of sterile water delivered twice a day via a nebulizer.

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