Preemptive treatment of fungal infection: has its time arrived in liver transplantation?

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http://www3.interscience.wiley.com/cgi-bin/abstract/117924752/ABSTRACT?CRETRY=1 & SRETRY=0

Liver Transplantation Volume 14, Issue 3 , Pages 380 - 384

Published Online: 27 Feb 2008

Copyright © 2008 American Association for the Study of Liver Diseases

Liver Transplantation Worldwide

Preemptive treatment of fungal infection: has its time arrived in liver transplantation?

D. Perkins, M.D.

Liver Transplantation Worldwide, University of Washington Medical Center, Seattle, WA

Abstract

Background

Invasive fungal infection remains a major challenge in liver transplantation and the mortality rate is high. Early diagnosis and treatment are required for better results.

Patients

We prospectively measured plasma (1 3)-d glucan (BDG) levels in 180 living donor liver transplant recipients for 1 year after surgery. Fungal infection was defined as proposed by the European Organization for Research and Treatment of Cancer/Mycoses Study Group. Preemptive treatment (intravenous fluconazole and trimethoprim-sulfamethoxazole) was started when the BDG level was greater than 40 pg/ml.

Results

Twenty-four patients (13%) were diagnosed with invasive fungal infection. The responsible pathogens included Candida spp. in 14 cases, Aspergillus fumigatus in 5, Cryptococcus neoformans in 3, and Pneumocystis jiroveci in 2. Preemptive treatment was performed in 22% of patients (n = 40). Renal impairment and mild gastrointestinal intolerance due to the drugs were observed in 28% (11/40) of patients during treatment. Among them 14 patients were diagnosed with fungal infection including seven candidiasis, five aspergillosis, and two Pneumocystis jiroveci pneumonia. The sensitivity and specificity of BDG for overall fungal infection was 58% and 83%, respectively, with a positive predictive value of 35% and a negative predictive value of 93%, and a positive likelihood ratio of 3.41 and a negative likelihood ratio of 1.98. The overall mortality for fungal infection in our series was 0.6%.

Conclusion

Although the sensitivity and positive predictive value were low, the low mortality rate after fungal infection and the mild side effects of the preemptive treatment might justify our therapeutic strategy. Based on the effectiveness, this strategy warrants further investigation.

Digital Object Identifier (DOI)10.1002/lt.21438