title: Targeted versus universal antifungal prophylaxis among liver transplant recipients.
abstract: Guidelines recommend targeted antifungal prophylaxis for liver transplant (LT) recipients based on tiers of risk, rather than universal prophylaxis. The feasibility and efficacy of tiered, targeted prophylaxis is not well established. We performed a retrospective study of LT recipients who received targeted prophylaxis (n = 145; voriconazole [VORI; 54%], fluconazole [8%], no antifungal [38%]) versus universal VORI prophylaxis (n = 237). Median durations of targeted and universal prophylaxis were 11 and 6 days, respectively (p < 0.0001). The incidence of invasive fungal infections (IFIs) in targeted and universal groups was 6.9% and 4.2% (p = 0.34). Overall, intra-abdominal candidiasis (73%) was the most common IFI. Posttransplant bile leaks (p = 0.001) and living donor transplants (p = 0.04) were independent risk factors for IFI. IFIs occurred in 6% of high-risk transplants who received prophylaxis and 4% of low-risk transplants who did not receive prophylaxis (p = 1.0). Mortality rates (100 days) were 10% (targeted) and 7% (universal) (p = 0.26); attributable mortality due to IFI was 10%. Compliance with prophylaxis recommendations was 97%. Prophylaxis was discontinued for toxicity in 2% of patients. Targeted antifungal prophylaxis in LT recipients was feasible and safe, effectively prevented IFIs and reduced the number of patients exposed to antifungals. Bile leaks and living donor transplants should be considered high-risk indications for prophylaxis.
authors.affiliation: Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA; Antibiotic Management Program, University of Pittsburgh Medical Center, Pittsburgh, PA.
authors.forename: G A
authors.initials: GA
authors.lastname: Eschenauer
authors.forename: E J
authors.initials: EJ
authors.lastname: Kwak
authors.forename: A
authors.initials: A
authors.lastname: Humar
authors.forename: B A
authors.initials: BA
authors.lastname: Potoski
authors.forename: L G
authors.initials: LG
authors.lastname: Clarke
authors.forename: R K
authors.initials: RK
authors.lastname: Shields
authors.forename: R
authors.initials: R
authors.lastname: Abdel-Massih
authors.forename: F P
authors.initials: FP
authors.lastname: Silveira
authors.forename: P
authors.initials: P
authors.lastname: Vergidis
authors.forename: C J
authors.initials: CJ
authors.lastname: Clancy
authors.forename: M H
authors.initials: MH
authors.lastname: Nguyen
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D000935:Antifungal Agents / Q000627:therapeutic use*; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology* / Q000382:microbiology; D006085:Graft Survival; D006801:Humans; D016867:Immunocompromised Host; D008107:Liver Diseases / Q000150:complications* / Q000382:microbiology / Q000601:surgery; D016031:Liver Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D014019:Tissue Donors; D066027:Transplant Recipients; D014481:United States / Q000453:epidemiology
chemical_list: D000935:Antifungal Agents
keywords: Antibiotic: antifungal; antibiotic prophylaxis; clinical research/practice; complication: infectious; fungal; infection and infectious agents; infectious disease; liver transplantation/hepatology; liver transplantation: living donor; pharmacology