Invasive Fungal Infections After Intestine Transplantation: Epidemiology and Outcomes

BACKGROUND: Invasive fungal infections (IFIs) represent a major complication after intestine transplantation, with reported incidence rates between 40% and 49%. These infections are associated with high morbidity and allograft loss. This study evaluates the impact of post-transplant IFIs on graft outcomes in intestine transplant recipients. METHODS: We conducted a retrospective cohort study of 152 patients who underwent intestine transplantation from 2008 to 2022. The primary outcome was IFI, defined as proven or probable by EORTC/MSGERC criteria. The secondary outcome was a composite of allograft failure or death. Analyses were conducted using multivariable Cox proportional hazards models, with non-baseline variables incorporated as time-dependent exposures. RESULTS: Among 152 intestine transplant recipients, 56 (36.8%) developed post-transplant IFI. Median time to IFI was 83.5 days (IQR 19.5-444.2), with Candida infections occurring early and non-Candida infections occurring later. Candida species accounted for 73% of IFIs, most commonly C. glabrata, C. albicans, and C. parapsilosis, with 29.3% showing fluconazole resistance. Most infections were intra-abdominal and bloodstream. Redo transplantation (HR 2.44, 95% CI 1.20-4.95; p = 0.014), anastomotic leak (HR 2.23, 95% CI 1.02-4.90; p = 0.045), and augmented immunosuppression (HR 4.73, 95% CI 1.94-11.53; p < 0.001) were independent predictors of Candida IFI. IFI was associated with a markedly increased risk of allograft loss or death (HR 3.67, 95% CI 2.30-5.83; p < 0.001). CONCLUSIONS: Post-transplant IFIs are common and associated with allograft loss or mortality in intestine transplant recipients. Early recognition and aggressive management of IFIs remain critical to improving transplant outcomes.