To the Editor:
Pennington and colleagues’ study (1) supports administering antifungal prophylaxis to lung transplant recipients, as they found an approximately 50% reduction in all-cause mortality in those receiving prophylaxis. Yet they did not find a statistically significant reduction of invasive fungal infections. This could be due to insufficient statistical power but raises the possibility that the reduction of noninvasive fungal infections contributes to improved mortality. The authors stated that they were not able to evaluate the subsets of those who may derive a greater benefit from antifungal prophylaxis, such as patients with fungal airway colonization, high-risk occupations, or certain pretransplant diagnoses.
Our retrospective study of Candida in pulmonary secretions (2) found that among 82 inpatients and 11 outpatients referred for pulmonary consultation and followed for up to 5 years, Candida was likely clinically significant in 61%. Of the inpatients, death (or probable death) occurred in 43 (63%), 42 (98%) of whom died of definite or probable respiratory failure, with 13 (31%) deaths likely being related to mucus plugging, 16 (38%) deaths possibly resulting from mucus plugging, 6 (14%) deaths resulting from unknown causes, and 7 (17%) deaths not resulting from mucus plugging.
It is possible some of the mortality benefit from antifungal prophylaxis is due to preventing noninvasive fungal pulmonary disease, including Candida-associated pulmonary disease. It would be interesting to know how many lung transplant deaths occur in patients with mucus plugging, atelectasis, and Candida in their pulmonary secretions.
Footnotes
Author Contributions: D.C.J. did first draft of letter and A.P.P. helped revise the letter, and both contributed to intellectual content and final approval.
Author disclosures are available with the text of this letter at www.atsjournals.org.
References
- 1. Pennington KM, Dykhoff HJ, Yao X, Sangaralingham LR, Shah ND, Peters SG, et al. The impact of antifungal prophylaxis in lung transplant recipients. Ann Am Thorac Soc. 2021;18:468–476. doi: 10.1513/AnnalsATS.202003-267OC. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Johnson DC, Chirumamilla SK, Paez AP. Respiratory Candida in patients with bronchitis, mucus plugging, and atelectasis. Open Respir Med J. 2020;14:87–92. doi: 10.2174/1874306402014010087. [DOI] [PMC free article] [PubMed] [Google Scholar]