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1136. Universal Prophylaxis for Prevention of Invasive Aspergillus in Lung Transplant Recipients

Abstract Background Invasive aspergillosis (IA) is a significant complication status post lung transplantation with an incidence of 6% to 16%. Because early diagnosis of IA in lung transplant is hampered by the lack of specific clinical signs and by the low sensitivity of culture-based diagnostic methods, the efficacy of bronchoalveolar lavage galactomannan (BAL GM) for early diagnosis is explored in this study. Methods A retrospective analysis was performed on 45 consecutive lung transplant recipients between January 2015 and February 2016 at UF Health Shands Hospital. All patients were placed on prophylactic itraconazole post-transplant. Surveillance bronchoscopies were performed at 2 weeks, 1 month, 3 months, 6 months, 9 months, and 12 months post-transplant. During each bronchoscopy, bacterial, fungal, and acid-fast bacterial cultures along with BAL GM [an optical density (OD) index of ≥0.5 considered positive] were obtained. If BAL GM ≥1.0, the patient was switched to voriconazole for further treatment. CT Chest was also evaluated. If BAL GM remained ≤1.0 at the 6 month interval, then prophylaxis was complete. IA was defined using the EORTC/MSG criteria for invasive fungal disease (i.e., patient classified as either having proven, probable or possible IA). Results There was a total of 225 observations from the 45 patients. Two patients (4.4%) had proven IA with a mean GM of 4.153 (SE, 0.629) and seven patients (15%) had probable IA with a mean of 2.169 (SE, 0.409). There was no correlation of cold ischemic time (P = 0.88), primary graft dysfunction (PGD, P = 0.38), presence of Candida species (P =0.048) or non-tuberculous mycobacteria (NTM) in bronchoalveolar lavage (P = 0.044), and viral pneumonitis (P = 0.047) with a positive BAL GM. All nine patients with GM >1 were switched to voriconazole from itraconazole which resulted in negative GM levels on follow-up bronchoscopy. Conclusion Our data suggest that the implementation of universal antifungal prophylaxis with itraconazole may not be efficacious in preventing IA in lung transplant recipients. On the other hand, surveillance with BAL GM is a strategy that can lead to early detection of IA in patients during the first year after lung transplantation. Disclosures All authors: No reported disclosures.

Background. Strongyloides stercoralis is an intestinal nematode endemic to the tropics, subtropics, and to a limited extent the United States and Europe. The global estimates of strongyloidiasis are reported to range from 3 to 100 million infected worldwide; however, the true US prevalence is unclear. The seroprevalence of infection in solid-organ transplant candidates and recipients in the New Orleans, Louisiana region is also unknown. The purpose of this study was to identify the prevalence of Strongyloides seropositivity within transplant candidates at Ochsner Medical Center (OMC).
Methods. Patients were identified using EPIC-CLARITY with ICD-9 and ICD-10 codes for any solid-organ transplant at OMC from July 2012 to December 2016. Inclusion criteria were age 18 or older, patients evaluated for solid-organ transplant, and Strongyloides IgG testing. Patients were excluded if they had other immunocompromising conditions or exposures including but not limited to steroids, TNF-alpha, or biologic agent use. The primary outcome was the overall prevalence rate of strongyloidiasis at OMC. Secondary outcome was the comparison of prevalence between January 1, 2012 to July 31, 2016 (when testing was ordered based on risk stratification) vs. August 1, 2016 to December 31, 2016 (when routine testing was implemented).
Results. We analyzed a total of 1,047 patients which had 1,128 tests ordered for Strongyloides. Of those, 985 were unique patients (62 patients had multiple serological tests resulting in 81 repeat tests). During July 1, 2012 to July 31, 2016 testing yielded a total of 822 tests. From August 1, 2016 to December 31, 2016 testing yielded 306 tests.
Conclusion. Our data suggest that testing based on risk stratification yielded a lower prevalence rate as compared with generalized testing, underestimating the true incidence of disease (2.7% vs. 6.9%). Testing all patients being evaluated for transplantation will capture a greater number of patients with positive serology.
Disclosures. J. Garcia-Diaz, Astellas Pharma: Speaker's Bureau, Speaker honorarium. Background. Invasive aspergillosis (IA) is a significant complication status post lung transplantation with an incidence of 6% to 16%. Because early diagnosis of IA in lung transplant is hampered by the lack of specific clinical signs and by the low sensitivity of culture-based diagnostic methods, the efficacy of bronchoalveolar lavage galactomannan (BAL GM) for early diagnosis is explored in this study.

Universal Prophylaxis for Prevention of Invasive Aspergillus in Lung Transplant Recipients
Methods. A retrospective analysis was performed on 45 consecutive lung transplant recipients between January 2015 and February 2016 at UF Health Shands Hospital. All patients were placed on prophylactic itraconazole post-transplant. Surveillance bronchoscopies were performed at 2 weeks, 1 month, 3 months, 6 months, 9 months, and 12 months post-transplant. During each bronchoscopy, bacterial, fungal, and acid-fast bacterial cultures along with BAL GM [an optical density (OD) index of ≥0.5 considered positive] were obtained. If BAL GM ≥1.0, the patient was switched to voriconazole for further treatment. CT Chest was also evaluated. If BAL GM remained ≤1.0 at the 6 month interval, then prophylaxis was complete. IA was defined using the EORTC/MSG criteria for invasive fungal disease (i.e., patient classified as either having proven, probable or possible IA).
Results. There was a total of 225 observations from the 45 patients. Two patients (4.4%) had proven IA with a mean GM of 4.153 (SE, 0.629) and seven patients (15%) had probable IA with a mean of 2.169 (SE, 0.409). There was no correlation of cold ischemic time (P = 0.88), primary graft dysfunction (PGD, P = 0.38), presence of Candida species (P =0.048) or non-tuberculous mycobacteria (NTM) in bronchoalveolar lavage (P = 0.044), and viral pneumonitis (P = 0.047) with a positive BAL GM. All nine patients with GM >1 were switched to voriconazole from itraconazole which resulted in negative GM levels on follow-up bronchoscopy.
Conclusion. Our data suggest that the implementation of universal antifungal prophylaxis with itraconazole may not be efficacious in preventing IA in lung transplant recipients. On the other hand, surveillance with BAL GM is a strategy that can lead to early detection of IA in patients during the first year after lung transplantation.
Disclosures. All authors: No reported disclosures.