Clinical aspects of invasive candidiasis in solid organ transplant recipients

Increasingly potent immunosuppressive agents have dramatically reduced the incidence of rejection of transplanted organs while increasing patients' susceptibility to opportunistic infections. Invasive fungal infections (IFIs) following solid organ transplantation, despite having a lower incidence than bacterial and viral infections, remain a major cause of morbidity and mortality. Fungal infections in patients with different types of solid organ transplant have different incidences, underlying pathogenetic mechanisms and modes of clinical presentation. Two genera, Aspergillus and Candida, are responsible for the vast majority of fungal infections in solid organ transplant recipients accounting for more than 80% of IFIs. Candidaemia is the most frequent clinical manifestation of Candida spp. infection, regardless of the transplanted organ and typically occurs within 1 month of transplantation. Management of fungal infections varies widely among different transplant centres. Large multicentre, randomized controlled trials evaluating risk factors, diagnosis, prophylaxis and treatment strategies for fungal infection in organ transplant recipients are lacking. Consequently, a uniform consensus on each of these does not exist, and clinical practice has evolved mainly from case series, anecdotal experiences and single-centre trials. Targeted prophylaxis is recommended for high-risk liver, pancreas and small bowel patients. Management of established infection is based on guidelines in the general population and should take into consideration prior prophylaxis, severity of infection and the possibility of drug-drug interactions in these immunosuppressed patients.