INTRAABDOMINAL FUNGAL-INFECTIONS AFTER PANCREATIC TRANSPLANTATION - INCIDENCE, TREATMENT, AND OUTCOME

BACKGROUND: Intra-abdominal infections account for 15 percent of techn ical failures after pancreatic transplantation. Although some data are available about intra-abdominal bacterial infections, no study has an alyzed the incidence, treatment, and outcome of inh a-abdominal fungal infections. STUDY DESIGN: We retrospectively studied 445 consecutive pancreatic transplantations--45 percent were simultaneous pancreatic a nd renal, 24 percent pancreatic after renal, and 31 percent pancreatic transplantations alone--in patients with Type I diabetes mellitus. Do nors were cadavers in 92 percent and living relatives in 8 percent. Pr imary transplantations were done in 80 percent and retransplantation i n 20 percent. Of these 445 pancreatic transplantations, 90 percent wer e bladder-drained, 9 percent entericcdrained, and 1 percent duct-injec ted. Only symptomatic patients with documented culture-positive intra- abdominal fungal infections were included. RESULTS: Intra-abdominal fu ngal infections occurred after pancreatic transplantation in 41 (9.2 p ercent) of 445 patients. Donor age, but not recipient age, was a signi ficant risk factor. The rate of infections was higher for enteric-drai ned (21 percent) than for bladder-drained (10 percent) transplantation s; for organs donated by living relatives (16 percent) than for those from cadavers (9 percent); and for pancreatic after renal (12 percent) and simultaneous pancreatic-renal (11 percent) than for pancreatic-on ly (5 percent) recipients. The rate of intra-abdominal fungal infectio ns was 6 percent for recipients who were given antifungal prophylaxis (fluconazole, 400 mg/day for seven days after transplantation) compare d with 10 percent for those without prophylaxis. The one-year graft su rvival rate for recipients with infection was 17 percent compared with 65 percent for those without (p=0.0001); the survival rate was 70 per cent compared with 92 percent for patients with and without infection, respectively (p=0.0007). In 22 percent of recipients, the infection r esolved and graft function persisted; in 58 percent, the infection res olved after transplant pancreatectomy; and in 20 percent, death occurr ed despite transplant pancreatectomy. Recipients with sole fungal or f ungal and bacterial infection (n=41) were 50 percent less likely to re cover with a functioning graft and had a risk of death that was three times higher (p less than or equal to 0.05) than those with sole bacte rial infection (n=48). CONCLUSIONS: Intra-abdominal fungal infections after pancreatic transplants are associated with high morbidity and mo rtality rates, significantly higher than for sole bacterial infections . In addition to aggressive treatment: including transplant pancreatec tomy and reduction of immunosuppression, efforts must be made toward b etter prevention of intra-abdominal fungal infections.