Nonkidney Organ Transplant Recipients
Abdominal Organ Transplants
Candida has been isolated in ~4% of the preservation fluids from liver transplant recipients. Antifungal prophylaxis is commonly employed in liver transplant recipients at risk for invasive fungal infections. Preservation fluid cultures should be taken into consideration when determining the need for prophylaxis. Cultures of blood, urine and drainage fluids should be performed prior to initiating empiric therapy when Candida is identified in preservation fluid cultures or following organ procurement complicated by intestinal contamination. Microbiology of the donor duodenal contents in pancreas transplants suggests frequent contamination with Candida. Opening of the donor duodenum during the back bench procedure was associated with aggressive Candida arteritis following pancreatic transplantation. Therefore, some centers recommend instillation of amphotericin B through a nasogastric tube positioned into the donor duodenum during organ procurement. Additionally, most centers do not open or aspirate the donor duodenum contents during cold storage preservation.
Thoracic Transplants
Candida species are frequent oropharyngeal colonizers and are commonly detected in donor respiratory tract cultures. Antifungal prophylaxis for ~3 months is commonly employed following lung transplantation. If routine prophylaxis is not employed and if the donor's respiratory sample yields Candida, empiric therapy should be considered and continued until bronchoscopy has confirmed the integrity of the bronchial anastomosis. A longer course may be considered in the recipients of bilateral or right lung transplants and in patients receiving depleting induction agents as these factors pose a risk for anastomotic infection. The choice of antifungal agent should be guided by the Candida species (Table 1).
Preservation fluid contamination and donor-derived Candida infections are unusual following cardiac transplantation. A review of over 100 donor left atrium and postpreservation fluid cultures demonstrated positive cultures in 58% (including 2 with Candida) with no adverse clinical outcomes.
Key Recommendations
Liver transplant recipients in whom Candida species are identified in the preservation fluid cultures or in patients with surgeries complicated by intestinal contamination during organ recovery should receive empiric antifungal therapy for 2 weeks.
Limited data are available regarding donor-derived fungal infections in pancreas transplantation. If the donor preservation fluid is positive for yeast and in the absence of routine employment of antifungal prophylaxis, treatment should be initiated as outlined for kidney transplant recipients.
Antifungal therapy should be employed if donor bronchopulmonary secretions yield Candida until a repeat bronchoscopy is performed 1 week posttransplant to evaluate the anastomosis.