This study is a retrospective analysis of death, adverse events (AE), fungal infections, and hepatic function among recipients of liver transplantation at high risk of fungal infection who received prophylactic treatment with caspofungin. After reviewing data of 105 patients who had received isolated liver transplant between January 2003 and April 2007, we identified and analyzed 82 high-risk patients. Post-transplant patients at high risk for fungal infection are commonly defined by the presence of at least one of the following: (i) re-transplantation; (ii) re-operation; (iii) renal dysfunction. However, in our practice, patients are also considered at high risk for developing fungal infections if they present with the following: (iv) fever of unknown origin; (v) hypothermia; (vi) positive random culture for fungus at the time of transplant (bile and/or ascites); (vii) sepsis; (viii) use of vasopressors; (ix) re-intubation, during the first hospitalization after liver transplant; (x) prolonged intubation (>24 h), and (xi) acute respiratory distress syndrome, until negative fungal cultures are obtained. Exact conditional logistic regression was used to compare the risk of death, AEs, and fungal infections between patients who received caspofungin, other antifungal drugs, and no antifungal drugs. Analyses were then performed with SAS 9.1 (SAS Institute Inc., Cary, NC, USA). Patients were between 27 and 72 yr old (mean = 55), with two-thirds male and three-quarters Caucasian. Sixteen patients received caspofungin (11 preventively), and 32 received other antifungal (26 preventively). There were no proven fungal infections among the patients who received caspofungin, three infections among patients who received other antifungal (3/26 = 12%), and 14 infections among patients who were not preventively treated (14/45 = 31%). These infection rates were significantly different across the three groups (p = 0.029), with caspofungin and other antifungal preventive treatment comparable (p = 0.540), and both better than no preventive treatment at all (OR = 0.15, p = 0.049, for caspofungin versus no preventive treatment; OR = 0.29, p = 0.085, for other antifungal versus no preventive treatment). Caspofungin appears to be an effective preventive agent against fungal infections when used in recipients of liver transplant designated as high risk for fungal infection. Usage of caspofungin in these patients does not carry an apparent increase in risk of death or acute cellular rejection, although we observed a significantly higher risk of AEs, especially acute renal failure (p = 0.001), in patients who received this agent.
A 67-year-old male with a past medical history of chronic kidney insufficiency, splenectomy, and recurrent babesiosis infection was transferred to with jaundice and abdominal pain.The patient initially presented to an outside hospital (OSH) with generalized weakness, chills, and gastrointestinal symptoms and was found to have Babesia on peripheral blood smears. The patient received seven days of azithromycin and atovaquone, followed by three days of clindamycin and quinine sulfate. The patient was discharged home with improved symptoms and a negative peripheral blood smear. Less than 24 hours later he returned to the OSH with worsening myalgias and abdominal pain. Physical exam was significant for jaundice and hepatomegaly. Laboratory data revealed anemia, elevated creatinine, bilirubin of 30 mg/dL, and 1% parasitemia. At this point the patient was transferred for further management.Patient's past medical history was significant for chronic renal insufficiency, congestive heart failure, type 2 diabetes mellitus, coronary artery disease, and hypertension. Previous surgical procedures included splenectomy after a motor vehicle accident, below the knee amputation (BKA) of the right leg, and cholecystectomy. Patient denied alcohol or substance abuse, and quit smoking tobacco approximately 10 years ago. He is a retired carpenter and denied any recent history of travel. Medications on admission included digoxin, clopidogrel, isosorbide mononitrate, carvedilol, sucralfate, esomeprazole, metoclopramide, amlodipine, octreotide, and insulin lispro.On examination, patient looked fatigued, but in no acute distress. He was afebrile and had stable vital signs. Physical exam was significant for scleral icterus, ventral hernia and diffuse blanching, maculopapular rash on patient's hands and soles.Patient was admitted and started on treatment with clindamycin and quinine. The patient's blood smear showed Babesia species with a 1.7% parasitemia (figure 1). During the hospital stay, patient had an acute mental status change with asterixis. Laboratory data obtained at that time revealed elevated INR, bilirubin, and ammonia levels. Given the clinical findings, patient was started on lactulose for possible hepatic encephalopathy. Hepatitis serology was found to be negative. Dialysis was initiated in the setting of acute renal failure. Patient's clinical status continued to worsen, so red blood cell exchange transfusion was initiated in an attempt to reduce the parasite load and help clear the infection. Despite the exchange transfusion and continued antibiotic treatment, the patient continued to have hemolysis, paracitemia, renal failure, and hepatic failure. At that point hospice discussion was initiated and patient was eventually transferred to hospice home care.
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