Background: There are no established recommendations for systematic or targeted antifungal prophylaxis in heart transplant recipients (HTRs), resulting in heterogeneous practices. An outbreak of post-surgical invasive aspergillosis (IA) among HTR, which coincided with construction activities near our heart transplant unit, prompted the initiation of primary posaconazole (POS) prophylaxis in patients at highest risk.
Methods: This single-center retrospective descriptive study was conducted from March 2020 to May 2022 and describes the use of POS primary prophylaxis in high-risk HTR. The following risk factors were considered as indications for initiating prophylaxis: re-operation, post-transplantation hemodialysis, post-surgical extracorporeal membrane oxygenation (ECMO), re-transplantation, prolonged post-transplant mechanical ventilation (i.e., >72 h), cytomegalovirus (CMV) infection within the first month post-transplant, and a positive pre-transplant Aspergillus serology. The duration of prophylaxis was individualized, with treatment initiating in response to the risk factor and continuing for a median of 28 days after its resolution.
Results: POS prophylaxis was administered in 12 of 33 HTR (36.4%). The most common risk factors encountered were prolonged mechanical ventilation (>72 h, 91.6%) and CMV infection (58.3%). Most patients (91.6%) had at least two risk factors for IA, and more than half (58.3%) had three or more. Notably, no cases of IA were observed during the study period. Some patients experienced liver function abnormalities and drug-drug interactions.
Conclusion: Targeted POS prophylaxis may be an option for high-risk HTR during an outbreak. Close monitoring of liver function, POS levels, and tacrolimus concentrations is recommended.
Keywords: heart transplant recipient; invasive aspergillosis; posaconazole; posaconazole prophylaxis.
© 2025 The Author(s). Clinical Transplantation published by Wiley Periodicals LLC.