Fungal infections following liver transplantation

Abstract

With increasing morbidity and mortality from chronic liver disease and acute liver failure, the need for liver transplantation is on the rise. Most of these patients are extremely vulnerable to infections as they are immune-compromised and have other chronic co-morbid conditions. Despite the recent advances in practice and improvement in diagnostic surveillance and treatment modalities, a major portion of these patients continue to be affected by post-transplant infections. Of these, fungal infections are particularly notorious given their vague and insidious onset and are very challenging to diagnose. This mini-review aims to discuss the incidence of fungal infections following liver transplantation, the different fungi involved, the risk factors, which predispose these patients to such infections, associated diagnostic challenges, and the role of prophylaxis. The population at risk is increasingly old and frail, suffering from various other co-morbid conditions, and needs special attention. To improve care and to decrease the burden of such infections, we need to identify the at-risk population with more robust clinical and diagnostic parameters. A more robust global consensus and stringent guidelines are needed to fight against resistant microbes and maintain the longevity of current antimicrobial therapies.

Prophylaxis of Fungal Infections in Transplant Patients:What has Changed in Recent Years?

“…Thus, fluconazole is still the most viable option in the public system. [46][47][48][49]55 In LgT, recent and past studies suggest using azoles as the prophylactic agents. Similarly, a recent study places azoles as first-line antifungal agents in 80% of cases, echinocandins in approximately 18.3%, and amphotericin B in only 1.5%.…”

“…As for liposomal amphotericin, although this drug does not alter the cytochrome P450 system, its nephrotoxicity has been and continues to be a major concern. [46][47][48][49][50]52 It is also important to note that there is still no consensus on the need for antifungal prophylaxis in all transplant patients. Several programs do not routinely use antifungals perioperatively in these patients, and one study showed a similar incidence of IFI in the absence of prophylaxis.…”

“…Still, that fluconazole would be preferred due to its cost-effectiveness and safety profile. 48 Still on LvT, research by Kang et al showed that micafungin could be used as an alternative to fluconazole, with no difference between the two in terms of IFI presence, time to IFI development, fungus-free survival, and adverse reactions. The research also found similar clinical success rates of 95.65% and 96.10% in the micafungin and fluconazole groups, respectively.…”

Profilaxia de Infecções Fúngicas em Pacientes Transplantados: O que Mudou nos Últimos Anos?

“…47 Ademais, um trabalho mais recente de revisão gerido por Khalid et al sugeriu que a eficácia do fluconazol era semelhante à da anfotericina lipossomal, porém que o fluconazol seria preferencial devido ao seu custo-benefício e perfil de segurança. 48 Ainda sobre o TF, uma pesquisa de Kang et al mostrou que a micafungina poderia ser usada como alternativa ao fluconazol, não havendo diferença entre ambos em termos de presença de IFI, tempo para desenvolvimento de IFI, sobrevida livre de fungos e reações adversas. A pesquisa ainda verificou semelhantes taxas de sucesso clínico de 95,65% e 96,10%, nos grupos de micafungina e fluconazol, respectivamente.…”

“…Assim, o fluconazol ainda parece ser a opção mais viável no sistema público. [46][47][48][49]55 No TP, tanto estudos recentes como estudos passados sugerem o uso de azóis como os agentes profiláticos. Da mesma forma, um estudo recente coloca os azóis como agentes antifúngicos de primeira linha em 80% dos casos, já as equinocandinas em aproximadamente 18,3% e a anfotericina B somente em 1,5%.…”