Association of fungal infection and increased mortality in liver transplant recipients

BACKGROUND: Invasive fungal infection is associated with increased morbidit y and mortality following orthotopic liver transplantation (OLTx). Understa nding the risk factors associated with fungal infection may facilitate iden tification of high-risk patients and guide appropriate initiation of antifu ngal therapy. OBJECTIVES: The aim of this study was to determine the incidence of fungal infections, identify the most common fungal pathogens, and determine the ri sk factors associated with fungal infections and mortality in OLTx recipien ts. METHODS: Medical records from 96 consecutive OLTx in 90 American veterans ( 88 males, 2 females; mean age 48 years, range 32 to 67) performed from Janu ary 1994 to December 1997 were retrospectively reviewed for fungal infectio n in the first 120 days after transplantation. Infection was defined by pos itive cultures from either blood, urine (<105 CFU/mL), cerebrospinal or per itoneal fluid, and/or deep tissue specimens. Superficial fungal infection a nd asymptomatic colonization were excluded from study. All patients receive d cyclosporine, azathioprine, and prednisone as maintenance immunosuppressi ve therapy. Fungal prophylaxis consisted of oral clotrimazole (10 mg) troch es, five times per day during the study period. RESULTS: Thirty-five patients (38%) had documented infection with one or mo re fungal pathogens, including Candida albicans (25 of 35; 71%), C torulops is (7 of 35; 20%), C tropicalis (2 of 35; 6%), non-C albicans (2 of 35; 6%) , Aspergillus fumigatus (4 of 35; 11%), and Cryptococcus neoformans (1 of 3 5; 3%). The crude survival for cases with or without fungal infection was 6 8% and 87%, respectively (P < 0.0001), The median intensive cave unit stay and overall duration of hospitalization were significantly longer for patie nts with fungal infection (P < 0.01). The mean time interval from transplan tation to the development of fungal infection was 15 days (range 4 to 77) w ith a mean survival time from fungal infection to death of 21 days (range 3 to 64). Fungal infections occurred significantly more often in patients wi th renal insufficiency (serum creatinine > 2.5 mg/dL), biliary/vascular com plications, and retransplantation, CONCLUSIONS: Fungal infections weve associated with increased morbidity and mortality following OLTx, with Candida albicans being the most common path ogen. Treatment strategies involving antifungal prophylaxis for high-risk p atients and earlier initiation of antifungal therapy in cases of presumed i nfection ave warranted. (C) 2000 by Excerpta Medica, Inc.