Evolution in the Management of Invasive Fungal Infections in Liver Transplant Recipients

Abstract

Invasive fungal infections (IFI) remain an important cause of morbidity and mortality, especially in hospitalized and immunocompromised or critically ill patients. The incidence of IFIs has been declining in liver transplant recipients (LTR). This is likely due to the evolving immunosuppressive drug regimens, improved surgical techniques and targeted antifungal prophylaxis. However, these still contribute to high mortality and are associated with high economic burden due to consumption of costly newer antifungal agents, longer hospital stay and need of intensive supportive care. Candida remains the most common fungal infection in LTR. Antifungal prophylaxis in LTR at high risk of developing IFI is widely agreed on, but there is no universal consensus on treatment selection and duration. Fluconazole and echinocandins are recommended for prophylaxis, but is increasingly associated with resistance. Risk factors for invasive candidiasis (IC) and invasive aspergillosis (IA) continue to evolve, and thus strategies for their prevention should be constantly updated and targeted. What is clear, however, is that antifungal prophylactic strategy should be selected by the transplant centre based on risk factors for IFIs in their patients, local epidemiology, the sensitivity profile of local fungal pathogens, and drug costs. The treatment with echinocandin is recommended for IC, although the risk of breakthrough infections for intra-abdominal candida infections should be recognised. The recommended treatment for IA is voriconazole. Although many non-culture methods are available for the diagnosis of IFI, there is a need for further evaluation of these tests in LTR and antifungal stewardship (AFS).