Fungal infections after liver transplantation: outcomes and risk factors revisited in the MELD era Saliba F, Delvart V, Icha € ı P, Kassis N, Botterel F, Mihaila L, Azoulay D, Adam R, Castaing D, Bretagne S, Samuel D. Fungal infections after liver transplantation: outcomes and risk factors revisited in the MELD era. Abstract: Antifungal prophylaxis is recommended in high-risk patients, but risk criteria remain unclear and the predictive value of Model of End- Stage Liver Disease (MELD) score is unknown. In a retrospective, single- center analysis of 667 liver transplants, potential risk factors for fungal infection were assessed, including MELD score. Antifungal prophylaxis was administered in 198 patients (29.4%). During follow-up (mean 43.6  29.6 months), 263 patients (39.4%) developed  1 episode of fungal infection, and 187 (28.0%) patients developed a probable or proven invasive fungal infection requiring systemic antifungal treatment. Patients receiving antifungal prophylaxis had a lower incidence of fungal infection (29.8% vs. 43.5% without prophylaxis, p < 0.001) and invasive fungal infection (17.7% vs. 32.4%, p < 0.001). One-yr patient survival was 91%, 85% and 69%, respectively, in patients with no fungal infection, fungal colonization and treated invasive fungal infection (p < 0.001); graft survival was 88%, 85% and 66% (p < 0.001). Multivariate analysis indicated that MELD score of 20–30 or  30 was associated with a 2.0-fold or 4.3-fold increase in relative risk of fungal infection, respectively, and a 2.1-fold or 3.1-fold increase in relative risk of invasive fungal infection. In conclusion, liver transplant patients with a MELD score  20, and particularly patients with a score  30, are candidates for antifungal prophylaxis. Faouzi Saliba a,b,c , Val  erie Delvart a , Philippe Icha € ı a,c , Najiby Kassis d , Franc ßoise Botterel e , Liliana Mihaila d , Daniel Azoulay a,b,c , Ren  e Adam a,b,c , Denis Castaing a,b,c , St  ephane Bretagne e and Didier Samuel a,b,c a AP-HP H^ opital Paul Brousse, Centre H epato- Biliaire, b Universit e Paris-Sud, UMR-S 785, c Inserm, Unit e 785, d AP-HP H^ opital Paul Brousse, Service de microbiologie and e AP- HP H^ opital Henri Mondor, Service de microbiologie, Villejuif, France Key words: Aspergillus – Candida – fungal infection – Model of End-Stage Liver Disease – prophylaxis Corresponding author: Prof. Faouzi Saliba, H^ opital Paul Brousse, Centre H epato-Biliaire, 12 avenue Paul Vaillant Couturier, 94800 Villejuif, France. Tel.: +33 1 45 59 64 12; fax: +33 1 45 59 38 57; e-mail: faouzi.saliba@pbr.aphp.fr Conflict of interest: The authors have no conflicts of interest to declare. Accepted for publication 6 March 2013 Although the incidence of invasive fungal infection following liver transplantation has declined since the mid-1990s (1–3), such infections still develop in approximately 5–20% of patients (4) and represent a significant burden in terms of mortality and mor- bidity (5). Candida and Aspergillus infections account for 70–90% of invasive fungal infections in solid organ transplant recipients (4, 6), with liver transplant patients showing a particularly high sus- ceptibility to Candida species (7, 8). Candidiasis and aspergillosis typically occur early post-trans- plant (4, 8), the time at which the intensity of immunosuppressive regimens is highest and the immune status of the recipient is weakened by illness, the surgical procedure and the hospital microbiological environment. Despite the absence of a real consensus, short-term antifungal prophy- laxis is currently recommended after liver trans- plantation in patients considered to be at high risk for fungal infection (9, 10). The criteria for identifying high-risk recipients, however, remain unclear. In the mid-1990s, a series of analyses identified a range of possible risk fac- tors for invasive infections, including pre-trans- plant or early post-transplant colonization (2, 11, 12), poor pre-transplant renal function (2, 11), a complex transplant procedure as indicated by high use of blood products, choledochojejunostomy anastomosis or long surgical time (1, 2, 11, 12), and a difficult post-operative course with extended stay in the intensive care unit (ICU) or bacterial infection (1, 12). One of these studies (11) and a E454 © 2013 John Wiley & Sons A/S. Clin Transplant 2013: 27: E454–E461 DOI: 10.1111/ctr.12129