Summary to Emerging Fungal Infections In Solid Organ Transplant Recipients

1. Therapy with an agent that has proven activity against the fungus should be administered as early as possible.

2. Immunosuppression should be reduced when clinically feasible. To date, immune reconstitution inflammatory syndrome has not been described with emerging or rare fungal pathogens.

3. Surgical debridement of the affected areas should be performed whenever feasible and repeated as needed.

4. Antifungal therapy should be adjusted based on susceptibility testing at a reference laboratory. Although clinically validated antifungal susceptibility breakpoints are lacking, it is reasonable for therapy to be guided by general antifungal susceptibility patterns.

5. Clinicians should closely monitor for renal toxicity with AmB products. If using such agents, treatment should generally be with a lipid formulation of AmB (LF‐AmB; ie, liposomal or lipid complex formulations) as these have less toxicity.

6. Clinicians should closely monitor for Q‐T interval prolongation, drug interactions, hepatotoxicity, and neuropsychiatric side effects with azoles.

7. Therapeutic drug monitoring of voriconazole should be considered to guide dose adjustments, especially in patients receiving higher doses or corticosteroids, although data for emerging fungal infections are lacking. Target voriconazole trough levels between 1.5‐4.5 mcg/mL are associated with the optimal balance of maximizing efficacy and minimizing toxicity. Based on very limited data in the prophylactic, setting the target posaconazole trough levels should be at least 0.7 mcg/mL. Routine monitoring of posaconazole levels may be unnecessary. We recommend checking serum trough levels when using the liquid formulation, in special populations (eg, patients with very high BMI, questionable drug absorption and those with cystic fibrosis) and when clinical response is suboptimal. It is unclear whether therapeutic drug levels are useful for isavuconazole.

8. Adjuvant therapy with interferon‐gamma and/or granulocyte-macrophage colony stimulating factor may be considered with caution in cases refractory to standard antifungal therapy.