*Purpose: The purpose of this study is to characterize the impact of antifungal discontinuation on immunosuppressant levels and incidence of acute rejection and fungal infections in lung transplant recipients.

*Methods: This single-center, retrospective cohort study with a nested case control will include adult recipients of a lung transplant (single-, double, heart-lung, or lung-liver) during the timeframe of February 3, 2020 to May 1, 2021. Use of posaconazole or voriconazole for fungal prophylaxis and a calcineurin inhibitor (tacrolimus or cyclosporine) for maintenance immunosuppression is also required. Data to be collected will include demographic information, transplant information, pharmacotherapy of immunosuppression and antifungal prophylaxis, dates and results of graft biopsies, and dates and results of fungal cultures. Data will be analyzed using descriptive statistics and univariate analysis.

*Results: One hundred and thirty six patients received a lung transplant during the study timeframe. Ninety eight (72.05%) met inclusion criteria and were included for analysis. Data were analyzed for two groups of patients – those who had the azole discontinued in the outpatient setting (N= 70, 71.43%) and those with discontinuation during a hospital admission (N= 28, 28.57%). A majority of patients (N=58, 82.86%) with outpatient azole discontinuation had preemptive calcineurin inhibitor dose adjustments. The average change in calcineurin inhibitor trough after discontinuation was a decrease of 1.20 ng/mL (SD 7.88) and an increase of 78 ng/mL (SD 81.83) for tacrolimus and cyclosporine, respectively. It took an average of 21.6 days (SD 22.09) and 2.29 dose adjustments (SD 1.90) after azole discontinuation for the calcineurin trough to reach predefined therapeutic levels (10 ng/mL tacrolimus and 200 ng/mL cyclosporine). Subtherapeutic calcineurin inhibitor troughs did not significantly impact the incidence of acute rejection or fungal infection.

*Conclusions: Azole antifungal discontinuation in the outpatient setting impacted the amount of time patients spent with subtherapeutic calcineurin inhibitor trough concentrations, despite seemingly small average changes in trough concentrations.

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