Fungal Infections

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Fungal infections are a major cause of morbidity and mortality in transplant recipients. The reported incidence ranges from 5% in renal allograft recipients to almost 50% in liver recipients. While most of these infections occur in the first six months after transplantation, fungal infections are occasionally seen several years post-transplantation. The reported mortality for such infections exceeds 30%. Recent advances have been made in the area of antifungal therapy, and the impact of these new therapies on the morbidity and mortality of fungal infections in transplant recipients is currently unknown.

Candida Species overview

The most common source of Candida infection is gut translocation or, alternatively, intravascular catheters. The risk factors associated with invasive fungal infection include: the use of high-dose corticosteroids, the administration of broad-spectrum antimicrobials, episodes of allograft rejection requiring increased immunosuppression, and allograft dysfunction. In the case of liver transplantation, the presence of a Roux-en-Y choledocojejunostomy, CMV infection, the administration of OKT3, and re-transplantation are additional risk factors (Table 16.3).

Recipients of renal allografts are at risk for UTIs with these organisms because of underlying medical conditions, such as diabetes mellitus, and the use of indwelling urinary drainage catheters. Pancreas-kidney recipients also are at additional risk because urinary pH changes associated with exocrine secretion drainage favor bladder colonization with Candida.

Clinical Presentation

Candida infections can present in multiple ways including intravascular catheter infections with sepsis and fever, intra-abdominal abscesses, urinary tract infections. Mediastinitis can complicate heart and lung transplantation.

The diagnosis is made by isolating Candida species from culture of appropriate clinical specimens. In the setting of documented or suspected candidemia, fundo-

Table 16.3. Risk factors associated with invasive fungal infections

• Receipt of high-dose corticosteroids

• Receipt of broad-spectrum antimicrobial agents

• Multiple rejection episodes requiring heightened immunosuppression

• Allograft dysfunction

• Concomitant infection with immunosuppressive viruses (namely, CMV)

scopic eye examination may reveal endophthalmitis or lesions suggestive of septic emboli. The role of surveillance cultures for the diagnosis of fungal infections is unknown, as many patients colonized with Candida never demonstrate clinical infection.

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