Dealing with Difficult Bugs Before Lung Transplantation

Many individuals with respiratory failure who are candidates for lung transplantation present with colonization or infection of the respiratory tract. Pathogens may be found within the context of suppurative lung disease (cystic fibrosis, bronchiectasis) or, more rarely, in patients with other nonsuppurative diseases. The presence of multiresistant bacteria and some fungal species need a specific and complex management plan, and, in some case, can be a contraindication to transplantation. The need for prolonged immunosuppression in lung transplant recipients can further increase the risk of uncontrolled infection. Multiresistant bacteria can impact the postoperative outcome of transplant recipients. Burkholderia cenocepacia is a contraindication to transplantation in most centers, but some experienced centers have reported favorable postoperative outcomes. Mycobacterium abscessus requires a careful handling of the chest cavity during the transplant operation and can require prolonged intravenous treatment postoperatively. Aspergillus and other fungal species can cause localized lung disease and can be handled well with medical management before and after the transplant. However, lung transplantation should be very cautiously considered in cases of disseminated disease or uncontrolled pulmonary spread. Phage therapy is a promising new approach that may aid in the treatment of these difficult infections.