*Purpose: Invasive candidiasis (IC) represents the most common fungal infection in lung transplant recipients (LTR) early post-transplant. Universal antifungal prophylaxis is frequently employed, which may be associated with IC due to more resistant Candida species.

*Methods: We performed a single-center retrospective cohort study in LTR from 2012-2017. We reviewed the results of all positive cultures for Candida post-lung transplant to identify episodes of IC. As per protocol, LTR receive universal prophylaxis with systemic triazole for 18 months and initial aerosolized amphotericin B (AmB). Proven and probable IC were defined by criteria established by Mycoses Study Group, the European Confederation of Medical Mycology and the International Society for Heart and Lung Transplantation.

*Results: 523 LTR were reviewed. 16 (3%) patients developed a total of 22 breakthrough episodes of IC (19 proven and 3 probable). 11 (69%) patients were double lung transplant; 1 heart-lung. Median time from transplant to first episode of IC was 33 days (IQR 11-139). Candidemia was the most common presentation (12/22, 54.5%), followed by deep necrotic surgical site infection (18.2%), empyema (13.6%), mediastinitis (4.5%), intra-abdominal collection (4.5%) and necrotizing pneumonia (4.5%). No case of proven or probable tracheobronchitis or anastomosis infection was documented. With regard to infecting organism, C. glabrata was most common (13/22, 59%), followed by C. albicans (6/22, 27%), C. tropicalis (1), C. krusei (1), and C. kefyr (1). 3 bloodstream infections appeared to be secondary to intra-abdominal collection (1), empyema (1), and sternal abscess (1). Despite universal prophylaxis, breakthrough episodes of IC occurred while on itraconazole (18/22), AmB alone (2/22), voriconazole (1/22), and posaconazole (1/22). Azole levels prior to IC were documented only in 6 episodes and 5/6 (83%) were sub-therapeutic. 9/13 (69%) C. glabrata isolates showed fluconazole resistance (MIC≥64); 4 (31%) were susceptible dose dependent (MIC≤32). 1 LTR had 2 episodes of candidemia secondary to C. glabrata intermediate to micafungin (MIC 0.12). Ninety-day mortality for LTR with IC was 10/16 (62.5%) with 70% of them in LTR who had IC caused by non-albicans species.

*Conclusions: Overall prevalence of IC in the setting of universal prophylaxis is low. However, breakthrough episodes with more resistant non-albicans Candida species and the resultant high mortality are concerning. Transplant center-specific data on IC epidemiology are critical to delineate the duration and choice of antifungal prophylactic agent.

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