*Purpose: Invasive fungal infections (IFI) increase morbidity and mortality after lung transplant. Despite this, anti-fungal prophylaxis (AFP) in lung transplant recipients (LTR) varies by prophylactic strategy (i.e. universal or pre-emptive), drug choice and duration. Our objective was to systematically review the impact of AFP on the development of IFI in LTR.

*Methods: MEDLINE, EMBASE and Scopus were searched (2001 to Aug 4, 2018) using terms such as, “antifungal”, “transplant”, and “prophylaxis”. Cohort studies or randomized control trials of adult LTR that pertained to the use of anti-fungal agents for the prevention of IFI were included. We excluded any basic science or animal studies, case report or case series, review articles, non-original research, duplicate studies, pediatric or survey studies. Studies were Two trained reviewers independently assessed articles for inclusion with a third reviewer adjudicating disagreements. The Newcastle Ottawa Scale was used for quality assessment. Number of IFIs, prophylactic medication, duration of medication, and follow-up time were extracted from each study.

*Results: Of the 1550 references retrieved, 21 cohort studies and 1 randomized control trial were included. These studies included 1973 LTR. Four cohorts/ groups (251 LTR) evaluated pre-emptive prophylaxis, 22 cohorts/groups (1541 LTR) evaluated universal prophylaxis, and 3 studies (181 LTR) included cohorts with no prophylaxis. Pre-emptive prophylaxis was initiation of (1 study) or a change in (3 studies) antifungal agent following Aspergillus spp. airway colonization. The combined incidence of IFI was 1.9 vs. 3.1 cases per transplant-year for pre-emptive and universal AFP, respectively (p=0.83). With universal prophylaxis, 6 cohorts used 2 agents (4 inhaled amphotericin plus triazole, 2 echinocandin plus triazole). Of the remaining 16 cohorts/groups, 7 (337 LTR) used single agent triazoles, and 9 (956 LTR) used nebulized amphotericin monotherapy. The combined rate of IFI was 2.88 and 3.36 cases per transplant-year with triazole and nebulized amphotericin monotherapy, respectively (p=0.94). Duration of anti-fungal prophylaxis varied, and ranged from ‘until hospital discharge’ to ‘lifelong’ prophylaxis. Reported post-transplant follow-up ranged from ‘post-transplant hospitalization’ to 36 months.

*Conclusions: AFP strategy, medication class, and duration varied between studies. The incidence of IFI was similar with pre-emptive compared to universal prophylaxis, and triazole monotherapy compared to nebulized amphotericin monotherapy.

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