Endemic Fungal Infections In Solid Organ Transplant Recipients

Growth of B. dermatitidis from clinical specimens and/or direct visualization of morphologically consistent yeast forms in sputum, BAL fluid, and tissue specimens establishes the diagnosis. (Moderate, Strong)

The Blastomyces antigen EIA, performed on serum, urine, BAL fluid, and CSF, provides a non‐invasive diagnostic tool for rapid diagnosis and monitoring treatment response. (Low, Strong)

Serologic Blastomyces antibody assays and the (1‐3)‐β‐D‐glucan assay are not diagnostically useful. (Moderate, Strong)

Azole monotherapy may be considered for mild, localized infections. Itraconazole (200 mg twice daily) remains first line. (Moderate, Strong)

For moderate, severe, and/or disseminated infection, initial therapy with lipid formulation amphotericin is recommended for a minimum of 1‐2 weeks or until clinical improvement is demonstrated, followed by step‐down azole therapy to complete 12 months of therapy. (Moderate, Strong)

The preferred treatment of CNS blastomycosis is lipid formulation amphotericin for 4‐6 weeks, followed by voriconazole (200‐400 mg twice daily) for at least 12 months. Alternative stepdown therapy with fluconazole 800 mg daily is recommended in the setting of voriconazole intolerance. (Moderate, Strong)

Therapeutic monitoring of azole serum drug levels is highly recommended during therapy. (Moderate, Strong)

Limited data suggest that serial urine Blastomyces antigen EIA monitoring may be useful to follow response to therapy. Suppressive therapy following successful treatment may be considered. (Low, Weak)

Symptom assessment and chest radiography are the recommended screening for transplant candidates with potential Blastomyces exposure. (Low, Strong)

Primary antifungal prophylaxis for blastomycosis after transplant is not recommended, but transplant recipients should avoid at‐risk environmental exposures. (Low, Strong)