*Purpose: No consensus exists regarding systemic antifungal prophylaxis in liver transplant recipients (LTRs) in terms of optimal duration, choice of agent, or risk factors to determine appropriate candidates. Our objective was to characterize the adherence to antifungal prophylaxis guidelines at our center and the subsequent incidence of invasive fungal infections (IFIs) within 90 days of transplant.

*Methods: All LTRs transplanted at our center from 4/2016 to 4/2018 were included in a single-center, retrospective chart review. Exclusion criteria included multi-organ transplantation, HIV positivity, active treatment with an antifungal, and positive donor cultures. Our institutional guidelines for antifungal prophylaxis included re-transplantation, re-operation, Roux-en-y hepaticojejunostomy, operative course > 8 hours, > 40 units of blood products intraoperatively, renal replacement therapy peri/post operatively, and fungal colonization. IFIs were defined by the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group definitions.

*Results: 204 LTRs met inclusion criteria. The population was primarily male (76%) with a median age of 59 years (IQR: 52 to 64). 71 LTRs (35%) received antifungal prophylaxis for a median duration of 7 days (IQR: 5 to 15). Of those who received prophylaxis, 34 LTRs (48%) had > 1 indication per institutional guidelines. Of those who did not receive prophylaxis, 26 LTRs (20%) had 1 or more missed indications. Fluconazole was the most commonly used antifungal agent (93%), followed by caspofungin (7%). Only 3 IFIs occurred within 90 days post-transplant, and all occurred in patients who lacked risk factors in the immediate post-transplant setting, as defined by our guidelines, and therefore did not receive antifungal prophylaxis. All 3 IFIs were in LTRs who developed co-morbidities post-transplant that increased their risk for fungal infections (Table 1).

*Conclusions: The incidence of IFIs in our liver transplant cohort is low despite short duration of prophylaxis as well as preferential use of fluconazole, a narrow spectrum antifungal. There were no IFIs in LTRs with risk factors who did not receive antifungal prophylaxis. These findings suggest the need to revisit guidelines for IFI prophylaxis in LTRs.

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