Routine comprehensive Aspergillus screening of bronchoalveolar lavage samples in lung transplant recipients.

BACKGROUND: Invasive aspergillosis is a significant cause of morbidity and mortality in lung transplant recipients (LTRs). Early diagnosis may improve outcome, yet is challenging. We assessed the diagnostic yield of a routine, comprehensive, prospectively employed Aspergillus screening strategy in LTRs. METHODS: During a 6-month period, all bronchoalveolar lavage (BAL) samples (including post-transplant surveillance) obtained from LTRs at our center were routinely tested for Aspergillus PCR, galactomannan (GM), and fungal culture. Invasive aspergillosis (IA) was defined using EORTC/MSG and ISHLT criteria for proven and probable aspergillosis. RESULTS: Ninety-five consecutive BAL samples were tested. PCR, GM, and fungal culture were positive in 28.4%, 30.6%, and 7.4%, respectively. Five cases of IA (two proven, three probable) were identified. Fungal culture failed to detect 40% of IA cases, which were detected by a positive PCR and/or GM. However, the majority of positive PCR samples represented colonization (59.3%). Sensitivity of PCR, GM, and culture for IA was 80%, 60%, and 60%, respectively, and specificity was 74%, 71%, and 96%. CONCLUSIONS: In LTRs, a routine prospectively employed screening strategy in which all BAL samples were screened for Aspergillus PCR and GM, detected aspergillosis cases that were otherwise missed by a false-negative fungal culture, but resulted in more cases of colonization being detected. Clinical judgment is thus warranted to avoid unnecessary treatment of colonization.

Coronary artery bypass grafting after aprotinin: are we doing better?

OBJECTIVE: Cardiac surgery patients are treated with antifibrinolytic agents to reduce intra- and postoperative bleeding. Until 2007, lysine analogues (aminocaproic acid and tranexamic acid) and serine protease inhibitors (aprotinin) were recommended. In 2008, the U.S. Food and Drug Administration prohibited aprotinin use because of associated postoperative complications, including cerebrovascular accidents and renal failure. This work aimed at reevaluating the efficacy and safety of aprotinin versus tranexamic acid in patients undergoing elective coronary artery bypass surgery. METHODS: Two groups were enrolled in this study. Group A (n = 256), operated from January 2005 to August 2007, was treated with the half-Hammersmith aprotinin regime whereas group B (n = 104), operated after 2008, was treated with the full-dose tranexamic acid regime. All patients were of low-risk profile, and underwent an elective, on-pump coronary artery bypass surgery. The main outcome measures were safety, assessed in relation to thrombosis-related cardiac, cerebral, and renal events; and efficacy, investigated in terms of postoperative bleeding and infusions of blood products. RESULTS: Postoperatively, group B demonstrated greater bleeding during the operative and first postoperative days, and total bleeding (P values ≤ .001); a greater requirement of blood and/or blood products infusions (P = .024); higher postoperative acute renal failure rates (P = .028); lower platelet count (P = .002); and a higher postoperative increase in troponin levels (P < .0001). CONCLUSIONS: Among low-risk patients undergoing coronary artery bypass surgery, the half-Hammersmith aprotinin-based antifibrinolytic management proved to be more efficacious in terms of bleeding and consumption of blood products, with no evidence of associated increased rates of postoperative complications. Accordingly, the usage of aprotinin should be reconsidered for treatment among cohorts of low-risk cardiac patients.