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Bronchiolitis obliterans syndrome (BOS) may develop after either lung or haematopoietic stem cell transplantation (HSCT), with similarities in histopathological features and clinical manifestations. However, there are differences in the contributory factors and clinical trajectories between the two conditions. BOS after HSCT occurs due to systemic graft-versus-host disease (GVHD), whereas BOS after lung transplantation is limited to the lung allograft. BOS diagnosis after HSCT is more challenging, as the lung function decline may occur due to extrapulmonary GVHD, causing sclerosis or inflammation in the fascia or muscles of the respiratory girdle. Treatment is generally empirical with no established effective therapies. This review provides rare insights and commonalities of both conditions, which are not well elaborated elsewhere in contemporary literature, and highlights the importance of cross disciplinary learning from experts in other transplant modalities. Treatment algorithms for each condition are presented, based on the published literature and consensus clinical opinion. Immunosuppression should be optimised, and other conditions or contributory factors treated where possible. When initial treatment fails, the ultimate therapeutic option is lung transplantation (or re-transplantation in the case of BOS after lung transplantation) in carefully selected candidates. Novel therapies under investigation include aerosolised liposomal cyclosporine, Janus kinase inhibitors, antifibrotic therapies and (in patients with BOS after lung transplantation) B-cell-directed therapies. Effective novel treatments that have a tangible impact on survival and thereby avoid the need for lung transplantation or re-transplantation are urgently required. ispartof: ERJ OPEN RESEARCH vol:8 issue:3 ispartof: location:England status: published

Infection remains a common cause of death throughout the lifespan of a lung transplant recipient. The increased susceptibility of lung transplant recipients is multifactorial including exposure of the graft to the external environment, impaired mucociliary clearance, and high levels of immunosuppression. Long-term outcomes in lung transplant recipients remain poor compared with other solid organ transplants largely due to deaths from infections and chronic allograft dysfunction. Antibacterial, antifungal, and antiviral prophylaxis may be used after lung transplantation to target a number of different opportunistic infections for varying durations of time. The first-month posttransplant is most commonly characterized by nosocomial infections and donor-derived infections. Following the first month to the first 6 months after transplant-a period of intense immunosuppression-is associated with opportunistic infections. While immunosuppression is reduced after the first year posttransplant, infection remains a risk with community-acquired and rarer infectious agents. Clinicians should be vigilant for infection at all time points after transplant. The use of patient-tailored prophylaxis and treatments help ensure graft and patient survival.

Patients with connective tissue disease (CTD) and advanced lung disease are often considered suboptimal candidates for lung transplantation (LTx) due to their underlying medical complexity and potential surgical risk. There is substantial variability across LTx centers regarding the evaluation and listing of these patients. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization aims to clarify definitions of each disease state included under the term CTD, to describe the extrapulmonary manifestations of each disease requiring consideration before transplantation, and to outline the absolute contraindications to transplantation allowing risk stratification during the evaluation and selection of candidates for LTx.

Background Reduced BMI is an absolute contraindication for lung transplantation (LTx) at most centers in the United States. The objective of this study was to quantify post-LTx survival of moderate to severely underweight patients with cystic fibrosis (CF) (BMI Methods Using United Network for Organ Sharing Registry data (undergoing transplant from June 2005-November 2015), Kaplan-Meier estimates of median posttransplant survival were calculated for all patients with CF, COPD, and idiopathic pulmonary fibrosis (IPF), as well as low and normal weight CF subgroups. Cox regression modeling stratified according to transplant center assessed risk of posttransplant mortality in recipients with CF and a BMI Results Median posttransplant survival (95% CI) for CF, COPD, and IPF was 7.9 (7.2-8.6), 5.9 (5.6-6.2), and 5.5 (5.2-5.8) years, respectively. Although an absolute decrease was noted in posttransplant survival for recipients with CF and a BMI Conclusions Transplant recipients with CF and a BMI

Bronchoalveolar lavage (BAL) is a key clinical and research tool in lung transplantation (LTx). However, BAL collection and processing are not standardized across LTx centers. This International Society for Heart and Lung Transplantation-supported consensus document on BAL standardization aims to clarify definitions and propose common approaches to improve clinical and research practice standards. The following 9 areas are covered: (1) bronchoscopy procedure and BAL collection, (2) sample handling, (3) sample processing for microbiology, (4) cytology, (5) research, (6) microbiome, (7) sample inventory/tracking, (8) donor bronchoscopy, and (9) pediatric considerations. This consensus document aims to harmonize clinical and research practices for BAL collection and processing in LTx. The overarching goal is to enhance standardization and multicenter collaboration within the international LTx community and enable improvement and development of new BAL-based diagnostics. ispartof: JOURNAL OF HEART AND LUNG TRANSPLANTATION vol:39 issue:11 pages:1171-1190 ispartof: location:United States status: published

Improved predictive models are needed in lung transplantation in the setting of a proposed allocation system that incorporates longer-term post-transplant survival in the United States. Allocation systems require accurate mortality predictions to justly allocate organs.Utilizing the United Network for Organ Sharing database (2005-2017), we fit models to predict 1-year mortality based on the Lung Allocation Score (LAS), the Chan, et al, 2019 model, a novel "clinician" model (a priori clinician selection of pre-transplant covariates), and two machine learning models (Least Absolute Shrinkage and Selection Operator; LASSO and Random Forests) for predicting 1-year and 3-year post-transplant mortality. We compared predictive accuracy among models. We evaluated the calibration of models by comparing average predicted probability vs observed outcome per decile. We repeated analyses fit for 3-year mortality, disease category, including donor covariates, and LAS era.The area under the cure for all models was low, ranging from 0.55 to 0.62. All exhibited reasonable negative predictive values (0.87-0.90), but the positive predictive value for was poor (all0.25). Evaluating LAS calibration found 1-year post-transplant estimates consistently overestimated risk of mortality, with greater differences in higher deciles. LASSO, Random Forests, and clinician models showed no improvement when evaluated by disease category or with the addition of donor covariates and performed worse for 3-year outcomes.The LAS overestimated patients' risk of post-transplant death, thus underestimating transplant benefit in the sickest candidates. Novel models based on pre-transplant recipient covariates failed to improve prediction. There should be wariness in post-transplant survival predictions from available models.

The lung allocation score prioritizes candidates for a lung transplant in the United States. As the country adopts the continuous distribution framework for organ allocation, we must reevaluate lung allocation score assumptions to maximize transplant benefit.We used Scientific Registry of Transplant Recipients data to study the impact of these changes: (1) updating cohorts; (2) transitioning from 1- to 5-year posttransplant survival; (3) using time-varying effects for non-proportional hazards; and (4) weighting waitlist and posttransplant area under the curve differently. Models were compared using Spearman correlations and C-statistics. The thoracic simulation allocation model characterized transplant rates and proportions of recipient subgroups under the current and new systems.Posttransplant areas under the curve models were estimated with recipients aged ≥12 from January 1, 2014, to December 31, 2018. All models had similar C-statistics and Spearman correlations, indicating similar predictive performance and posttransplant area under the curve rankings. Five-year posttransplant area under the curve across age and diagnosis groups varied more than 1-year groups. Using the thoracic simulation allocation model, 1- and 5-year posttransplant model under the curve models showed similar transplant rates and recipient characteristics under the current system, but under continuous distribution, 5-year posttransplant area under the curve resulted in increased transplant rates with more recipients younger and in diagnosis groups B and C.Incorporating equally weighted waitlist and posttransplant models using 5-year posttransplant survival detected the largest variability in survival under the continuous distribution system, which could improve long-term survival in the United States.

Cystic fibrosis (CF) is the indication for transplantation in approximately 15% of recipients worldwide, and Cystic Fibrosis Lung Transplant Recipients (CFLTRs) have excellent long-term outcomes. Yet, CFLTRs have unique comorbidities that require specialized care. The objective of this document is to provide recommendations to CF and lung transplant clinicians for the management of perioperative and underlying comorbidities of CFLTRs and the impact of transplantation on these comorbidities. The Cystic Fibrosis Foundation (CFF) organized a multidisciplinary committee to develop CF Lung Transplant Clinical Care Recommendations. Three workgroups were formed to develop focused questions. Following a literature search, consensus recommendations were developed by the committee members based on literature review, committee experience and iterative revisions, and in response to public comment. The committee formulated 32 recommendation statements in the topics related to infectious disease, endocrine, gastroenterology, pharmacology, mental health and family planning. Broadly, the committee recommends close coordination of care between the lung transplant team, the cystic fibrosis care center, and specialists in other disciplines with experience in the care of CF and lung transplant recipients. These consensus statements will help lung transplant providers care for CFLTRs in order to improve post-transplant outcomes in this population.

Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital's use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is "the right drug at the right time and the right dose for the right bug for the right duration." A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.

Background Lung transplantation (LTx) is frequently considered for patients with cystic fibrosis (CF) when the FEV 1 reaches 1 Methods We conducted a retrospective cohort study using the CF Foundation Patient Registry from January 1, 2003 to December 31, 2013. Adult patients (≥ 18 years) with FEV 1 Results There were 3,340 patients with an FEV 1 1 Conclusions Median survival was > 6.5 years for patients with CF and an FEV 1 1

Purpose The Organ Procurement and Transplantation Network (OPTN) US lung allocation policy was altered in 2017 by changing the first geographic unit of lung allocation from the donation service area (DSA) to a 250 nautical mile (NM) radius around the donor hospital. Methods OPTN data on lung candidates and recipients age gt; 11 was analyzed pre (11/26/2015- 11/24/2017) and post allocation policy change (11/25/2017- 11/24/2019). Cohorts were compared to study the differences. Results An increase was seen in the match lung allocation score (LAS) at transplant from pre to post era (mean pre=47.25 vs. post=49.79, p Conclusion Under the current system, lungs are being placed to sicker candidates with similar short-term post-transplant outcomes compared to the older allocation system. The next step for the lung allocation system in the US is a move to the Continuous Distribution framework to avoid hard boundaries in geography and other clinical classifications. The OPTN Lung Transplantation Committee is using these results and additional analyses to make evidence-based decisions for allocating lungs under the new framework.

Purpose Outcomes of lung transplant recipients (LTR) hospitalized for COVID-19 and comparisons to non-lung solid organ transplant recipients (SOTR) are incompletely described. Methods Using a multicenter prospective registry of SOTR, we examined 28-day outcomes (mortality [primary outcome], intensive care unit (ICU) admission, mechanical ventilation, and bacterial pneumonia) among both LTR and non-lung SOTR hospitalized with laboratory-confirmed COVID-19 diagnosed between March 1, 2020 and September 21, 2020. Data were analyzed using Stata (StataCorp, College Station, TX); chi-square tests were used to compare categorical variables and multivariable logistic regression was used to assess risk factors for mortality. Results The cohort included 72 LTR and 392 non-lung SOTR (Table 1). Overall, 28-day mortality trended higher in LTR vs. non-lung SOTR (27.8% vs. 19.9%, P=0.136). Other 28-day outcomes were similar between LTR and non-lung SOTR: ICU admission (45.8% vs. 39.1%, P=0.28), mechanical ventilation (32.9% vs. 31.1%, P=0.78), and bacterial pneumonia (15.3% vs. 8.2%, P=0.063). Congestive heart failure, diabetes, age >65 years, and obesity (BMI >= 30) were independently associated with mortality in non-lung SOTR, but not in LTR (Table 2). Conclusion In this large prospective cohort comparing lung and non-lung SOTR hospitalized for COVID-19, there were high but not significantly different rates of short-term morbidity and mortality. Baseline comorbidities appeared to drive mortality in non-lung SOTR but not LTR. Further studies are needed to identify risk factors for mortality among LTR.

Background Lung transplantation is an intervention that improves survival for adult patients with cystic fibrosis (CF). Some patients with CF are never referred for lung transplant evaluation despite meeting physiologic criteria for referral. Methods We performed a retrospective analysis of adult patients (≥18years of age) in the Cystic Fibrosis Foundation Patient Registry (CFFPR), eligible for their first evaluation for lung transplantation during the years 2001–2008 based on FEV1 Results Within the CFFPR, 1240 patients met eligibility criteria. Eight hundred and nine (65.2%) were referred for lung transplant evaluation, and 431 (34.8%) were not referred. In a multivariable model, Medicaid insurance (OR 1.79, 95% CI 1.29–2.47), older age (per 5year increase; OR 1.25, 95% CI 1.13–1.39), lack of high school graduate education (OR 2.27, 95% CI 1.42–3.64), and Burkholderia cepacia complex sputum culture positivity (OR 2.48, 95% CI 1.50–4.12) were associated with non-referral, while number of pulmonary exacerbations (OR 0.93, 95% CI 0.87–0.99) and supplemental oxygen use (OR 0.59, 95% CI 0.43–0.81) were associated with increased referral. Conclusions Despite meeting lung function criteria for lung transplant evaluation, 35% of patients with CF had not yet been referred to a lung transplant center. Predictors of non-referral included markers of low socioeconomic status, older age and B. cepacia complex sputum culture. Further work is needed to understand the outcomes for non-referred patients in order to refine referral recommendations in this population.

Purpose The OPTN added fields to the deceased donor registration (DDR) form on 3/31/2015 and to the transplant recipient registration (TRR) form on 2/28/2018 to capture the utilization of ex vivo lung perfusion (EVLP) on donor lungs prior to transplantation (Tx) in the US. The aim is to examine the data fields currently being collected, summarize the use of EVLP over time, and to compare early transplant outcomes between EVLP lungs and lungs where EVLP was not considered. Methods All adult deceased donors with at least one lung recovered for Tx from 4/1/15- 6/30/19 were analyzed. The prevalence of EVLP was examined over time and by recovering OPO. Post-transplant 1-year recipient survival (Tx between 4/1/15-6/30/18) was compared between donors of lungs with EVLP vs. no EVLP. Results For adult deceased donors (N=10,167), 19,295 lungs were recovered for the purpose of Tx. EVLP was intended in of 785 lungs and 485 (61.8%) of EVLP donor lungs were Tx. Since data collection began the use of perfusion has increased from 1.7% (N=16) of lungs to 7.4% (N=97) in the most recent quarter (Figure 1). Approximately 65% of the lungs perfused were from non-DCD donors and 35% from DCD donors. 51 of the 58 OPOs have recovered at least one lung that has been perfused. Over time the discard rate for perfused lungs has decreased from approximately 50% in the earliest quarter to approximately 25% in the most recent quarter. 1-yr patient survival between groups (EVLP, n=136; non-EVLP, n=7,169) was not significantly different (p= 0.06). Conclusion The number of donor lungs perfused prior to Tx in the US has grown over the past 4 years to approximately 7% of all recovered donor lungs. Geographically, the use of EVLP varied greatly across OPOs. Early recipient outcomes did not differ statistically between EVLP intended donor lungs compared to conventional donation.

Purpose In 2016, the Organ Procurement and Transplantation Network (OPTN) developed a methodology to measure equity in access to deceased donor kidney transplantation that has since been applied to liver and, most recently, lung. The holistic approach is designed to measure disparities related to geographic, demographic, clinical, and socioeconomic factors while adjusting for factors used to prioritize candidates for allocation, as well as to quantify system-level equity by a single number that can be tracked over time. Methods For OPTN data on active lung candidates we fit 36 separate Poisson rate models over rolling 6-month periods examined quarterly from 1/2010 to 6/2019, adjusting for 15 candidates covariates. Disparity was quantified as the Winsorized standard deviation (SD) of of predicted transplant rates (on log scale) among lung registrations, after “discounting” for desired, policy-induced disparities such as the lung allocation score by holding these factors constant. Risk-adjusted, factor-specific disparities were calculated as the SD of the log(transplant rate), holding all other factors constant. Results Despite 3 policy modifications over the time period, the overall disparity metric has remained very stable (fig1). Donation service area (DSA) was the factor most independently associated with disparities in access to lung transplant in each period. Other factors that rose to the top, but well below DSA, include gender, ethnicity, diagnosis group, and age. Conclusion Even after removing DSA as a unit of allocation for lung in 2017, DSA still is the factor contributing the most to inequities. This methodology will be used for monitoring the impact on equity of future policy changes, such as the anticipated transition to “Continuous Distribution” for lungs.

Purpose Resilience can be defined as a patient's capacity to adapt to or recover from adverse experiences. We hypothesize that resilience may be an important factor associated with lung transplant outcomes. Our objective was to describe resilience in lung transplant candidates and examine resilience as a potential predictor of lung transplant outcomes. Methods Adult lung transplant candidates on the waiting list between 9/16/2015 to 10/1/2019 at six transplant centers were mailed prospective questionnaires which included the validated Connor-Davidson Resilience Scale (RISC-10). Non-responders were declared non-participators after three recruitment attempts by mail. Demographics and transplant-related outcomes were recorded. Results Survey metrics were excellent with 56.9% participation (N = 199) and Conclusion In lung transplant candidates, resilience was comparable to population norms. However, one in six lung transplant candidates had low resilience. Addressing stress may be a potential target for improving resilience in future studies.

Airway complications remain a major cause of morbidity and mortality after cardiothoracic transplantation. The reported incidence of airway ischemic complications varies widely, contributed to by the lack of a universally accepted grading system and standardized definitions. Furthermore, the majority of the existing classification systems fail to integrate the wide range of possible bronchial complications that may develop after lung transplant. Hence, a Working Group was created by the International Society for Heart and Lung Transplantation with the aim of elaborating a universal definition of adult and pediatric airway complications and grading system. One such area of focus is to understand the problem in the context of a more standardized consensus of classifying airway ischemia. This consensus definition will have major clinical, therapeutics, and research implications.

Summary of Objectives Bronchoalveolar lavage (BAL) is a key tool for clinical monitoring and research in lung transplantation (LTx). However, BAL collection and processing are not standardized across LTx centers, resulting in significant variability of practices. This ISHLT-supported consensus statement on BAL standardization aims to clarify definitions and propose common approaches to improve: a) clinical and research practice standards, b) comparison and validation of research data, and c) collaboration between centers. Methods After an open invitation to ISHLT members, an international workgroup of 68 LTx specialists from 10 countries (75% North America, 16% Europe, 9% Australia/Asia) was created and divided into 9 subgroups covering the following topics: 1) bronchoscopy procedure and BAL collection, 2) sample handling in the bronchoscopy department, 3) sample processing for clinical microbiology, 4) clinical cytology, 5) research and 6) microbiome, 7) sample inventory and tracking, 8) donor bronchoscopy and 9) pediatric considerations. The workgroup designed and administered an online survey to capture practices of BAL collection and processing in LTx, according to the 9 subgroup topics. Results from 112 of 159 invited LTx centers (response rate 70%) indicate significant inter-center discrepancies in the definitions and methodology of BAL collection and processing. A systematic literature analysis performed by the workgroup identified 525 relevant articles; a specifically designed questionnaire was used to a) identify relevant articles for each subgroup and b) assess the quality of published BAL methodology. Endpoints Based on the large-scale international survey and a systematic literature review, the ISHLT BAL Standardization Workgroup is currently preparing consensus statements relevant to the 9 subgroup topics above. The statements will be subjected to three rounds of voting by the workgroup according to the Delphi method (consensus goal >80% of responders within two integers of the median). This abstract will be updated in March 2019 with key excerpts from finalized statements, which will be presented at the ISHLT 2019 annual meeting and submitted for publication. This consensus document will be instrumental for the harmonization of clinical and research practices and will help improve the performance of the international LTx community in this regard.

Purpose The OPTN/UNOS added fields to the deceased donor registration form on 3/31/2015 and the transplants recipient registration (TRR) form on 2/28/2018 to collect data on the utilization of ex vivo lung perfusion (EVLP) on donor lung. The steadily increasing use of EVLP, early outcomes, and new data collected on the TRR are summarized. Methods To determine trends in the use of EVLP, all deceased donor lungs recovered from 4/1/2015- 6/30/2018 were analyzed and divided into an EVLP and non-EVLP cohort. TRR data was available for recipients receiving a transplant between 2/28/2018- 6/30/2018. One year lung recipient survival was compared for the cohort spanning 4/1/2015- 6/30/2017. Results EVLP was utilized on 447 of 14,269 recovered lungs procured from 7,524 deceased donors. Of the 447 with EVLP utilized, 165 (34.6%) were DCD donors and 270 (56.6%) were transplanted. A total of 49 out of 58 (84%) OPOs perfused at least 1 lung. By examining the use of EVLP by annual quarters, the earliest quarter had 16 lungs perfused (1.7%) while the most recent quarter had 70 lungs perfused (5.8%). The discard rate for EVLP lungs was statistically higher than lungs that were not perfused (43.4% vs. 4.4%, p Conclusion Since April 2015, the use of EVLP has increased to the current reported level of almost 6% of deceased donor lungs recovered for transplant in the US. The majority of EVLP lungs are perfused at the recovery site by transplant programs and there is no evidence of a negative impact on one year recipient survival. Continued data collection on donor lung perfusion on both the DDR and TRR will allow the OPTN to better understand the utilization of this evolving technology.

Purpose On November 24, 2017, in an emergency action, the OPTN changed lung allocation policy by removing the donor service area (DSA) as the first unit of allocation for deceased donor lungs and replaced it with a 250 nautical mile (NM) circle around the donor hospital. Methods OPTN data on adult lung candidates and recipients was analyzed pre (11/25/2016- 8/24/2017) and post policy change (11/25/2017- 8/24/2018, 9 months). Comparisons were made to study the differences between cohorts. Results Comparison between the pre era (N=1,806) and the post era (N=1,843) cohorts revealed a significant increase in the match LAS at transplant (mean pre=47.24 vs. post=49.68, p Conclusion As expected, there was an increase in the distance traveled from transplant center to donor hospital to provide organs to candidates with a higher severity of illness. The waiting list mortality for LAS 60-70 decreased while transplant rate only decreased significantly for LAS 40-50. Lung utilization has not changed but an increase in the use of EVLP is noted. Continued evaluation is needed to understand the full effects of this policy change.

Purpose of review Lung transplantation is an important therapeutic treatment for many patients with life-threatening pulmonary diseases; however, long-term survival is still relatively limited compared with other solid organ transplants. Over the last year, several articles have been published helping to increase our knowledge of infections in lung transplant recipients. In particular, important new information has been published recently regarding cytomegalovirus (CMV) and fungal infections following lung transplantation. Recent findings Recent studies indicate prolonged (≥12 months) antiviral prophylaxis for CMV after lung transplant may be beneficial in high-risk transplant recipients. Epidemiologic studies show invasive fungal infections are increasingly being recognized following solid organ transplantation, particularly with Aspergillus and Candida species. Pulmonary infections with CMV and Aspergillus are likely contributors to the development of bronchiolitis obliterans syndrome (BOS). Summary Lung transplantation has many potential posttransplant complications with infection being a major contributor. More information has become available regarding CMV prophylaxis, CMV treatment, pulmonary fungal infection epidemiology, and the role of both CMV and Aspergillus on the development of BOS, which helps toward the goal of increasing long-term survival in lung transplant recipients.

Fungal pneumonia is increasingly common, particularly in highly immunosuppressed patients, such as solid organ or hematopoietic stem cell transplant recipients, and the diagnosis is evolving. Although standard techniques such as microscopy and culture remain the mainstays of diagnosis, relatively recent advances in serological and molecular testing are important additions to the field. This article reviews the laboratory tools used to diagnose fungal respiratory disease.

Infections complications following lung transplantation are associated with significant morbidity and mortality. Management of infections is most challenging in patients with cystic fibrosis (CF), but all lung transplant recipients are at heightened risk for opportunistic infections. Particularly in CF, pretransplant infections with PSEUDOMONAS AERUGINOSA, other highly resistant bacteria (e.g., STENOTROPHOMONAS, BURKHOLDERIA), and mycobacteria play a major role in recipient selection and post-lung transplant outcomes. Understanding the clinical impact and management strategies for each of these different pathogens is critical to maximizing the benefit of lung transplantation. In the review, we discuss each of these infections both as pretransplant risk factors as well as posttransplant pathogens and the individual issues that arise with each infection.

Background Prior studies reveal that a significant proportion of patients with cystic fibrosis (CF) and advanced lung disease are not referred for lung transplant (LTx) evaluation. We sought to assess expert CF physician perspectives on the timing of LTx referral and investigate their LTx knowledge. Methods We developed an online anonymous survey that was distributed by the Cystic Fibrosis Foundation (CFF) to the medical directors of all CFF-accredited care centers in the United States in 2015. The survey addressed only adult patients (≥18 years old) and was sent to 119 adult CF physicians, 86 CFF-affiliated CF physicians (who see adults and children, but have smaller program sizes than adult or pediatric centers), and 127 pediatric CF physicians (who see some adults, but mostly children). The focus of the questions was on CFF-care center characteristics, physician experience and indications/contraindications to referral for LTx evaluation. Results There were 114/332 (34%) total responses to the survey. The response rates were: 57/119 (48%) adult physicians, 12/86 (14%) affiliate physicians and 43/127 (34%) pediatric physicians; 2 physicians did not include their CFF center type. Despite the poor ability of FEV1