Background: Pediatric intestinal transplant (ITx) patients are at high risk of invasive fungal infections because of multiple predisposing risk factors.

Aim: To report on a single center experience with fungal infections following ITx.

Material/methods: Data on fungal infections in ITx patients were obtained from the Liver unit database and hospital laboratory systems (ICE and Telepath). Our local protocol is to use prophylactic i.v. antifungal for 2 weeks, followed by oral non-absorbable antifungal for 6 months following transplant for selective decontamination of digestive tract. If medical or surgical complications occur, duration of i.v. and oral prophylactic antifungal was extended. Any patient with unexplained fever despite antibiotic use for 48 hrs was discussed with microbiology team, and a comprehensive sepsis work-up (including blood cultures, urine cultures, drain cultures, stool MC and S), change of central lines, radiological imaging was performed.

Results: 93 patients in our cohort of p-SBT since the start of the SBT program in 1993 until August 2016 were included in the study. 49/93 (52%) patients had candida grown from any body site at some point after ITx and 4/93 (4.3%) patients had grown Aspergillus, both were sterile sites. Of the 49/93 growing candida from any body site, 12/49 (24%) had non-albican candida. Only 4/12 were further identified to species level. Two were C. parapsilosis, 1 was C glabrata and was 1 C.lucitaniae.

10/49 had grown Candida from a normally sterile body site (urine was excluded from ‘normally sterile body site’ analysis). 1/10 grew from bile (C. albicans) and 6/10 (2 C. albicans, 3 non-albican candida, 1 C lusitaniae from peritoneal fluid, 3/10 children had candida grown from blood cultures (2 -non candia albicans and 1- candida albicans). Only one of the three candidemia was within first 12 months of SBT procedure. The other two grew at 46 and 36 months after their transplant. There was no mortality related directly to candidemia, but there was one mortality directly related to aspergillus infection.

Discussion: The incidence of  fungal infections is low in our ITx patients from sterile body sites as compared to other reports in the literature. This is most likely due to a combination of factors : prolonged use of appropriate antifungal prophylaxis, meticulous central venous line care and judicious use of antimicrobial drugs. 1/4 children with candida from ‘any body’ site had ‘non-albican’ candida, which influences the choice of empirical antifungal treatment of infection.

Conclusion: Fungal infections can be prevented following intestinal transplantation with a high index of suspicion and an appropriate prophylactic regime.

Multidisciplinary intestinal transplant team at Birmingham Children's Hospital.