*Purpose: Invasive fungal infection (IFI) after liver transplant (LT) is associated with significant morbidity and mortality. The optimal antifungal prophylaxis regimen has not been defined. This study assessed the efficacy of a tiered-approach antifungal prophylaxis regimen in a randomly selected sample of liver transplant recipients (LTR) within 100 days of transplant.

*Methods: This retrospective study examined incidence and type of IFIs, susceptibilities, rejection, and mortality in LTRs between 6/1/14-1/31/20. Our institution uses risk factors (RF) (Table 1) to determine the antifungal agent used for prophylaxis. If 1-2 RF are present, pts receive fluconazole 200-400 mg daily based on renal function; if >2 RF are present, pts receive caspofungin 70 mg load, then 50 mg daily. Prophylaxis is initiated post-LT until improvement in clinical status and/or upon transfer out of the ICU.

*Results: Demographics are illustrated in Table 2. No significant differences were seen in demographic data between those with and without IFIs including MELD score and CMV risk status. 63% of LTR received IFI prophylaxis with a mean duration of 5.7 days of fluconazole and 8.5 days of caspofungin. There were 8 IFI identified despite protocol adherence in these patients (Table 3). There was no significant difference in rates of rejection in LTR with IFI compared to no IFI. No deaths occurred in the 100 days post-transplant. Mortality in the 6 months post-LT was higher in LTR who developed IFIs compared to those who did not (12.5% vs 0%, p=0.001). Pts with IFI were more likely to have had RRT within 48 hours pre-LT and/or within 7 days post-LT (75% vs. 33.7%, p=0.026).

*Conclusions: Our incidence of IFI (8%) in LTR was comparable to the incidence in the reported literature of 4-7%, thus illustrating effectiveness of the antifungal prophylaxis protocol at our center. Given the higher rates of IFI in LTR who received RRT in the 48 hours pre-LT and/or 7 days post-LT, modifying the current protocol to include post-operative RRT as an additional risk factor for IFI should be considered. More studies with larger sample sizes are needed to identify the optimal IFI prophylaxis regimen.

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