Early Invasive Fungal Infections in Liver Transplant Recipients Receiving Risk‐Stratified Echinocandin Prophylaxis: A Descriptive Single‐Center Cohort Study

BACKGROUND: Invasive fungal infection (IFI) remains a cause of morbidity and mortality after liver transplantation; guidelines recommend targeted antifungal prophylaxis in recipients with specific risk factors. METHODS: We retrospectively studied adult liver transplant recipients (LTR) at a single center, 2017-2023. High-risk recipients received a planned 14-day course of echinocandin prophylaxis, caspofungin in 97.6%. The primary endpoint was IFI within 30 days of transplantation, a window spanning the planned prophylaxis and the 2 weeks after it. Secondary endpoints were fungal etiology and factors associated with IFI. We also examined the temporal distribution of early aspergillosis across the whole institutional registry to 2025. RESULTS: Of 286 recipients, 85 (29.72%) were high risk. IFI was more frequent in high-risk than non-high-risk LTR (8/85, 9.41% vs. 4/201, 1.99%; p = 0.0077); most were breakthrough (7/8) mold infections. In exploratory analyses, IFI was associated with high-risk status (unadjusted odds ratio: 5.12, 95% CI: 1.50-17.49), MELD > 30 (4.67, 1.25-17.41) and diabetes (4.64, 1.37-15.79); with 12 events, these estimates are imprecise, and no multivariable model was fitted. Among 452 transplants performed in 2017-2025, seven developed early aspergillosis across four calendar years, with no significant variation in annual incidence (p = 0.146), never more than two cases in any 90-day window (Monte Carlo p = 0.82) and none among the 117 transplants of the following 28 months. CONCLUSION: Early IFI under risk-stratified echinocandin prophylaxis concentrated in the sickest recipients and was dominated by mold disease. No clear temporal pattern suggestive of a sustained common-source outbreak was identified, although environmental transmission cannot be excluded.