Risk Stratification for Targeted Antifungal Prophylaxis in Adult Liver Transplant Recipients Open Access

Background. Guidelines recommend targeted antifungal prophylaxis in high-risk liver transplant recipients (LTR) with ≥2 risk factors. Our center administers antifungal prophylaxis with ≥1 risk factor. The aim of this study was to assess adherence with our antifungal prophylaxis protocol in adult LTR and examine the epidemiology of invasive candidiasis (IC) in our program.

Methods. We performed a single center retrospective cohort study of adult LTR from January 2011 to December 2014. Chart review was performed to collect demographic and clinical data. In our protocol, high-risk LTR had ≥1 of the following risk factors: re-transplant, fulminant hepatic failure, >10 units of packed red blood cells, operative time >10 hours, re-operation after transplant, or renal replacement therapy prior to transplant. The primary endpoint was IC within 90 days of transplant.

Results. Our cohort consisted of 364 LTR. Among 189 high-risk LTR, 143 (76%) received antifungal prophylaxis, and of 175 low-risk LTR, 144 (83%) did not receive antifungal prophylaxis. Prophylaxis was given for a median of 9 (IQR, 7–20) days. LTR were more likely to receive prophylaxis as the number of risk factors increased (P_trend < 0.001). Overall adherence to our protocol was 79%. Five of 189 (2.6%) high-risk LTR developed IC, including 2.8% (4/143) among those who received prophylaxis and 2.2% (1/46) among those who did not receive prophylaxis. Among LTR with only one risk factor, IC was observed in 1/65 with prophylaxis and 1/31 without prophylaxis. The other 3 LTR who developed IC despite prophylaxis had ≥3 risk factors. None of the 175 low-risk LTR developed IC although 31 (17.7%) received antifungal prophylaxis. There was a proportional increase in the risk of IC with each additional risk factor (P_trend < 0.001). There was no difference in mortality in patients receiving prophylaxis versus those who did not, regardless of IC risk factors.

Conclusion. The rate of IC in our cohort was lower than previously published rates, and there was no difference in the IC rate among high-risk LTR with or without prophylaxis. Although this may be explained by prophylaxis in LTR with only one risk factor, our study suggests that risk stratification to guide targeted antifungal prophylaxis in high-risk LTR may need to be re-examined.

Disclosures. All authors: No reported disclosures.

Author notes