Transplant Patients at Risk for Fungal Infection

Intestinal and multivisceral transplantation—and any organ transplant actually—increases risk for infection since immunosuppressants are critical post-surgery. Fungal infections ranging from mild skin rashes to deadly fungal pneumonia can be a problem, and may lead to increased morbidity and mortality in these patients. A review in the June 2015 issue of Current Opinion in Organ Transplantation covers recent advances in diagnosis and management of fungal infections among transplant patients.

Intestinal and multivisceral transplant recipients contract Candida most often, with more than 80% of invasive infections attributed to this organism. Risk increases when any of 4 conditions are present: intestinal barrier disruptions, compromised surgical procedure, use of central venous catheters, or prolonged use of broad spectrum antibiotics. Most intra-abdominal Candida infections (40%) are diagnosed in the first month after transplantation. Candidemia, on the other hand, is often related to prolong central venous catheter access or multiple courses of antibiotics, and tends to occur 6 or more months after transplantation. Blood cultures sensitivity is low—bordering on 70%—and once antifungals are administered, it is even less sensitive.

Administering antifungal prophylaxis with fluconazole (400mg/day) or liposomal amphotericin B (3—5 mg/kg per day) for at least 4 weeks in the post-transplant period or until anastomosis heals may prevent candidiasis. Patients and nursing staff need to be very careful with central lines, and use alcohol lock therapy (instillation of an alcohol/ethanol solution into the lumen of the catheter for 4 hours daily) when necessary.

Aspergillus is emerging as a pathogen of concern, but data are limited. This is also the cases with the mucorales, Cryptococcus and endemic mycoses. Researchers are collecting data on changes in incidences and likely timing of infection for these fungi. Risk factors for invasive aspergillosis increases as immunosuppression related to induction therapy with T-cell-depleting antibodies increases. CMV infection, neutropenia, renal failure, prolonged ICU stay, and re-transplantation also increase risk. Voriconazole is the drug of choice for all Aspergillus infections. Alternatives include amphotericin B, posaconazole, and the echinocandins. When necessary, surgical management can be used. Prophylactic therapies have not been identified or developed for Aspergillus.

This article’s strength is its presentation of treatment options for various types of infection in tables.