The incidence of fungal infections in pancreas transplant recipients in the absence of systemic antifungal prophylaxis

Abstract

Background: There is a lack of high-level evidence identifying meaningful outcomes and the place in therapy for systemic perioperative antifungal prophylaxis (ppx) in pancreas transplant recipients. As our program does not routinely utilize systemic perioperative antifungal ppx in pancreas transplant recipients, we assessed the incidence of post-transplant infectious complications. Methods: This was a single-center, retrospective cohort study of consecutive adult pancreas transplant recipients between 01/2016 and 04/2018 to describe the incidence of fungal infections. Patients with a history of previous simultaneous pancreas-kidney (SPK) transplant, HIV, or unexplained use of antifungal ppx after transplantation were excluded. The primary outcome was the incidence of fungal infections within 3 months after transplantation. Results: After screening 60 patients, 56 met inclusion criteria. Within 3 months posttransplantation, two (3.6%) patients had a positive fungal culture requiring systemic antifungal treatment. The sources for infection in both cases were intra-abdominal fluid cultures, positive for Candida albicans. Both patients were treated with fluconazole. Allograft-related outcomes included a 6-month pancreas graft survival of 91.1% and pancreas transplant rejection incidence of 10.7%. Conclusion: In this single-center experience, pancreas transplant recipients not receiving systemic antifungal ppx had similar infectious and graft-related outcomes to what is reported in literature. K E Y W O R D S fungal infection, pancreas transplantation, perioperative, prophylaxis

Candida Infections in Solid Organ Transplantation

“…The lack of antifungal prophylaxis did not affect the incidence of IC [76]. Similar to Bartoletti, in a recent singlecenter study, Shaik et al showed that enteric-drained pancreas transplant recipients who did not receive systemic antifungal prophylaxis had similar infectious complications, including an incidence of invasive candidiasis of 3.6%, which is similar to previously reported rates [75].…”

“…The incidence of IC following pancreas transplantation ranges from 2.7% to 20% [1,[75][76][77][78][79]. There are no differences in the incidence of invasive candidiasis between different types of pancreas transplants (simultaneous pancreas-kidney, pancreas transplant alone, pancreas after kidney) [80].…”

First World Consensus Conference on pancreas transplantation: Part II – recommendations

“…A selective policy of antifungal prophylaxis in patients at higher risk for invasive fungal infection is justified. Most centers use a protocolized short duration, systemic antifungal prophylaxis strategy 312,[314][315][316][317][318][319][320][321]. Experts recommended the use of antimycotic prophylaxis, as per center protocol, to mitigate the risk of invasive fungal infections.5.10.4 | Antimicrobial prophylaxisPancreas transplantation is associated with a high risk of bacterial infection.…”

Risk factors for intra‐abdominal fungal infection after simultaneous pancreas‐kidney transplantation: A single‐center retrospective experience

“…Initial empiric therapy recommended echinocandin, whereas fluconazole is an acceptable alternative in patients not critically ill and/or considered unlikely to have a fluconazole‐resistant Candida species 28 . These recommendations are also confirmed in the guidelines from the American Society of Transplantation Infectious Diseases Community of Practice, published in 2019 28 . Treatment of intra‐abdominal candidiasis should also include source control with appropriate drainage and/or debridement.…”

“…In 2016, the IDSA published guidelines to standardize the use of antifungal therapy in patients presenting clinical evidence of intra‐abdominal infection and high‐risk factors for candidiasis, including recent abdominal surgery, anastomotic leaks, or necrotizing pancreatitis 24 . Initial empiric therapy recommended echinocandin, whereas fluconazole is an acceptable alternative in patients not critically ill and/or considered unlikely to have a fluconazole‐resistant Candida species 28 . These recommendations are also confirmed in the guidelines from the American Society of Transplantation Infectious Diseases Community of Practice, published in 2019 28 .…”