Prophylaxis, pre-emptive or empirical antifungal therapy: which is best in non-lung transplant recipients?

Renal, liver, heart and lung transplantation are now considered to be the standard therapeutic interventions in patients with end-stage organ failure. Infectious complications following solid organ transplantation (SOT) are relatively common owing to the transplant recipient's overall immunosuppressed status. The incidence of invasive mycoses following SOT ranges from 5% to 42% depending on the organ transplanted. Moreover, invasive fungal infections (IFIs) account for significant morbidity and mortality in SOT, ranging between 25% and 95% depending on the type of fungus and its organ localisation. The frequency, incidence and clinicoepidemiological characteristics of IFIs in patients who are recipients of non-pulmonary solid organ transplantation (NP-SOT) are very different from those that occur in patients with lung transplantation and haematopoietic stem cell transplantation. Candida and Aspergillus spp. are the cause of most infections. These fungal infections are associated with high overall mortality rates. Different strategies (prophylaxis, pre-emptive treatment, empirical therapy, antifungal combinations, routes of administration) have been tested to improve the prognosis of these invasive mycoses in SOT. To achieve this objective it is essential to have new antifungal drugs with a higher spectrum of activity against the fungal pathogens, both classical and emerging, and showing improvements in pharmacokinetic and pharmacodynamic characteristics, ease of administration and acceptability, and lower rates of adverse effects. This article will review the risk factors for IFIs in NP-SOT recipients and the available antifungal strategies for management. In addition, it will evaluate the role of prophylactic therapy in this group of patients.