title: EPICO 3.0. Antifungal prophylaxis in solid organ transplant recipients.
abstract: BACKGROUND
  Although over the past decade the management of invasive fungal infection has improved, considerable controversy persists regarding antifungal prophylaxis in solid organ transplant recipients.
  
  
  OBJECTIVE
  To identify the key clinical knowledge and make by consensus the high level recommendations required for antifungal prophylaxis in solid organ transplant recipients.
  
  
  METHODS
  Spanish prospective questionnaire, which measures consensus through the Delphi technique, was conducted anonymously and by e-mail with 30 national multidisciplinary experts, specialists in invasive fungal infections from six national scientific societies, including intensivists, anesthetists, microbiologists, pharmacologists and specialists in infectious diseases that responded to 12 questions prepared by the coordination group, after an exhaustive review of the literature in the last few years. The level of agreement achieved among experts in each of the categories should be equal to or greater than 70% in order to make a clinical recommendation. In a second term, after extracting the recommendations of the selected topics, a face-to-face meeting was held with more than 60 specialists who were asked to validate the pre-selected recommendations and derived algorithm.
  Echinocandin antifungal prophylaxis should be considered in liver transplant with major risk factors (retransplantation, renal failure requiring dialysis after transplantation, pretransplant liver failure, not early reoperation, or MELD>30); heart transplant with hemodialysis, and surgical re-exploration after transplantation; environmental colonization by Aspergillus, or cytomegalovirus (CMV) infection; and pancreas and intestinal transplant in case of acute graft rejection, hemodialysis, initial graft dysfunction, post-perfusion pancreatitis with anastomotic problems or need for laparotomy after transplantation. Antifungal fluconazole prophylaxis should be considered in liver transplant without major risk factors and MELD 20-30, split or living donor, choledochojejunostomy, increased transfusion requirements, renal failure without replacement therapy, early reoperation, or multifocal colonization or infection with Candida; intestinal and pancreas transplant with no risk factors for echinocandin treatment. Liposomal amphotericin B antifungal prophylaxis should be considered in lung transplant (inhalant form) and liver transplant with major risk factors. Antifungal prophylaxis with voriconazole should be considered in lung transplant, and heart transplant with hemodialysis, surgical re-exploration after transplantation, environmental colonization by Aspergillus, or CMV infection.
  
  
  CONCLUSIONS
  The management of antifungal prophylaxis in solid organ transplant recipients requires the application of knowledge and skills that are detailed in our recommendations and the algorithm developed therein. These recommendations, based on the DELPHI methodology, may help to identify potential patients, standardize their management and improve overall prognosis.
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain. Electronic address: zaragozar@ono.com.
authors.forename: Rafael
authors.initials: R
authors.lastname: Zaragoza
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: José María
authors.initials: JM
authors.lastname: Aguado
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Ricard
authors.initials: R
authors.lastname: Ferrer
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Alejandro H
authors.initials: AH
authors.lastname: Rodríguez
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Emilio
authors.initials: E
authors.lastname: Maseda
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Pedro
authors.initials: P
authors.lastname: Llinares
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Santiago
authors.initials: S
authors.lastname: Grau
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Patricia
authors.initials: P
authors.lastname: Muñoz
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Jesús
authors.initials: J
authors.lastname: Fortún
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Mercedes
authors.initials: M
authors.lastname: Bouzada
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Juan Carlos Del
authors.initials: JC
authors.lastname: Pozo
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
authors.forename: Rafael
authors.initials: R
authors.lastname: León
authors.affiliation: Servicio de Medicina Intensiva, Coordinador Unidad de Sepsis, Hospital Universitario Dr. Peset, Avda Gaspar Aguilar, 90, Valencia, Spain.
mesh_terms: D000465:Algorithms; D000935:Antifungal Agents / Q000627:therapeutic use*; D006801:Humans; D009181:Mycoses / Q000517:prevention & control*; D016377:Organ Transplantation; D011183:Postoperative Complications / Q000382:microbiology* / Q000517:prevention & control*; D011292:Premedication; D011446:Prospective Studies
chemical_list: D000935:Antifungal Agents
keywords: Anfotericina B liposómica; Echinocandin; Equinocandina; Fluconazol; Fluconazole; Liposomal amphotericin B; Profilaxis; Prophylaxis; Solid organ transplant; Trasplante de órgano sólido; Voriconazol; Voriconazole