*Purpose: The purpose of this study is to evaluate the need for nystatin prophylaxis for oropharyngeal (OPC) and esophageal Candidiasis (EC) in adult kidney transplant recipients (KTRs), given that available guidelines currently recommend prophylaxis for 1-3 months after kidney transplant.

*Methods: A single-center retrospective analysis was conducted of adult KTRs transplanted from March 2011 to November 2018, who had 6 months of follow-up available. Compared were those who received nystatin versus no Candida prophylaxis. Patients were excluded if they were a multi-organ transplant, received an alternative antifungal for prophylaxis, lacked 6 months of follow-up, or were treated with other antifungals prior to diagnosis of OPC or EC. The primary outcome was the incidence of OPC and EC at 6 months post-transplant. Secondary outcomes included presence of and time to fungal infection after transplant and incidence of Candidiasis, Candiduria, or invasive fungal infections.

*Results: The study population included 103 KTRs, of which 53 (52%) received nystatin. Baseline characteristics were similar between groups with the exception of a higher incidence of deceased donor transplants among those in the no prophylaxis group (72% vs. 49%; p = 0.0174). The majority of patients were 51 year old (IQR 41-62 years), Hispanic (64%), dialysis patients (81%), who did not have diabetes at the time of transplant (62%) and received lymphocyte-depleting induction (76%). The average prednisone dose at discharge was 20 mg (IQR 10-25 mg) in both groups. Post-transplant, 14% of patients received corticosteroid doses > 1 mg/kg and 7% received lymphocyte-depleting agents within a year post-transplant. The nystatin group received prophylaxis for a median of 4 days (IQR 4-6 days). No OPC or EC occurred within 6 months from transplant in either group. Overall incidence of Candidiasis, Candiduria, and invasive fungal infections were 0%, 2%, and 1%, respectively. Incidence was not significantly different between groups.

*Conclusions: In adult KTRs, the use of nystatin for antifungal prophylaxis versus no prophylaxis demonstrated no incidence of OPC nor EC. In light of the current nystatin suspension shortage, these findings offer a solution. This data suggest that the use of nystatin for antifungal prophylaxis may no longer be warranted in the era of modern-day immunosuppression. However, further research is warranted to evaluate rates in patients with additional known risk factors not adequately depicted in this study such as prior colonization, neutropenia, prolonged antibiotic use, and viral co-infection.

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