Invasive candidiasis in liver transplant patients: Incidence and risk factors in a pediatric cohort

Abstract

Prolonged OR, re-transplantation, and high-volume intraoperative transfusion have been associated with increased risk for IC in adult LT recipients. Antifungal prophylaxis is recommended for adult patients with these risk factors. There are limited data on the incidence of and risk factors for IC in pediatric LT recipients. A retrospective cohort study of all pediatric LT patients at the CHOP between 2000 and 2012 and the CHP between 2004 and 2012 was performed to define the incidence of IC within 30 days of LT. A 3:1 matched case-control study with incidence density sampling was performed. Conditional logistic regression analyses were used to explore risk factors associated with IC. Among 397 recipients, the incidence of IC was 2.5%. Bivariate analyses showed that ICU admission prior to transplant, OR > 10 h, intraoperative volume infusion of >300 mL/kg, and broad-spectrum antibiotics were significantly associated with IC. In a multivariate model, only ICU admission remained significantly associated with IC. Antifungal prophylaxis was not significantly protective against IC. The low incidence of IC and lack of an identified protective effect from antifungal prophylaxis suggest that prophylaxis in pediatric LT recipients should not be routinely recommended to prevent IC events in the first 30 days post-transplant.

Risk factors for early invasive fungal infections in paediatric liver transplant recipients

“…Our 12.3% incidence of IFIs is in accordance with the incidence in the adult liver transplant population, in which rates of 8.4%‐17.7% have been reported . In contrast, two studies in the United States observed a lower incidence of IFIs in paediatric liver transplant recipients; 2.5% invasive candidiasis during the 30‐day posttransplantation period in two institutions during 2000‐2012 and 4.7% IFIs in a single center during 180 days posttransplantation in 2000‐2013 . The differences in the incidence of IFIs may be attributed to the antifungal prophylaxis administered in these studies (16%‐40%) or to the disparities between institutions (ie, different peritransplantation antibiotic prophylaxis regimens, different surgical techniques).…”

“…Two single retrospective cohort studies of paediatric liver transplant recipients reported on the incidence of early invasive fungal or candida infections, 4.7% and 2%, respectively, with only one study aimed at identifying high‐risk paediatric patients . Knowledge accrued regarding risk factors and relevant time frames can contribute towards devising rational antifungal prophylactic and treatment strategies in these patients.…”

“…Two single retrospective cohort studies of paediatric liver transplant recipients reported on the incidence of early invasive fungal or candida infections, 4.7% and 2%, respectively, with only one study aimed at identifying high-risk paediatric patients. 10,11 Knowledge accrued regarding risk factors and relevant time frames can contribute towards devising rational antifungal prophylactic and treatment strategies in these patients. Therefore, the aim of this study was to investigate the incidence and risk factors of IFIs in paediatric liver transplant recipients during the early posttransplantation period (≤3 months) and build a model which could predict IFIs on an individual basis in order to lay the foundation for developing rational antifungal prophylactic and treatment strategies.…”

Relationship between transfusion volume and outcomes in children undergoing noncardiac surgery

“…Massive blood transfusion in pediatric victims of combat trauma, defined as RBC transfusion volumes ≥40 mL/kg, has been identified as an independent predictor of multiple organ failure, systemic inflammatory response syndrome, increased infection, and increased mortality . Studies in pediatric liver transplant recipients show a similar trend . In pediatric heart transplant recipients, escalating RBC transfusion volumes administered during surgery were independently associated with worse clinical outcomes; transfusion volumes >60 mL/kg were associated with increased risk of a major adverse event, including postoperative sepsis, use of extracorporeal membrane oxygenation, open chest, dialysis, and graft failure …”

Recognition and Clinical Presentation of Invasive Fungal Disease in Neonates and Children

“…For children who had undergone lung transplantation, colonization before transplantation, transplant rejection, cytomegalovirus mismatch, tacrolimus treatment, and older age increased the risk of developing IFD [ 31 ]. In a recently published US study of 397 children who were undergoing liver transplantation, the only significant risk factor for IC identified with multivariate analysis was admission to an ICU before transplantation [ 32 ]. Children who undergo a renal transplant are considered to be at low risk for IFD; candidemia related to intravascular catheter use is the most common presentation [ 33 , 34 ].…”