Association Between Perioperative Use of Fourth- Versus First-Generation Cephalosporins and Early Bacterial Infections, Chronic Lung Allograft Dysfunction-Free Survival, and 1- and 5-Year Survival: A Cohort Study.

BACKGROUND: Improving the prevention of bacterial lung infections in the first month after lung transplantation is important for improving postoperative chronic lung allograft dysfunction (CLAD) and survival. Although clinical practice guidelines for antimicrobial prophylaxis in surgery recommend the use of cefazolin for heart and lung transplantations, the supporting evidence is largely based on cardiac procedures, and currently no formal recommendations to guide antimicrobial regimens in the specific context of lung transplantation exist. METHODS: Data from 148 inpatients who underwent lung transplantation and were treated with cefozopran or cefepime (fourth-generation cephalosporins) or cefazolin (first-generation cephalosporin) at Kyoto University Hospital between January 2006 and September 2024 were extracted. We compared the incidence of bacterial infections within 30 days after lung transplantation, CLAD-free survival, and 1- and 5-year survival between patients receiving fourth- and first-generation cephalosporins. RESULTS: The incidence of bacterial pneumonia was significantly lower in patients treated with a fourth-generation cephalosporin than in those treated with a first-generation cephalosporin (8.9% vs 29.2%, respectively; hazard ratio: 0.299; 95% confidence interval: 0.127-0.707). Moreover, hospital readmission due to bacterial infection, decrease in measured forced expiratory volume in 1 s from baseline, CLAD-free survival, and 1- and 5-year survival were significantly better in patients treated with a fourth-generation cephalosporin than in those treated with a first-generation cephalosporin. CONCLUSIONS: Our findings suggest that perioperative fourth-generation cephalosporin use may effectively prevent early bacterial infections and subsequent decline in pulmonary function, improving CLAD-free survival and 1- and 5-year survival compared with first-generation cephalosporin use.