Overview of transplant mycology

PURPOSE: The epidemiology, clinical manifestation, diagnosis, and management of invasive mycoses in transplant patients are described. SUMMARY: The incidence of and mortality from invasive mycoses have increased in transplant patients. Candida and Aspergillus are the two most common fungal pathogens in this patient population. The use of immunosuppressive and myeloablative therapies and other factors increases the risk of invasive mycoses. A high index of suspicion and clinical clues are needed for the diagnosis of Candida and Aspergillus infections because reliable diagnostic techniques are not available and the patient presentation is nonspecific. Targeted prophylaxis for patients at high risk for morbidity and mortality and early, aggressive treatment using broad-spectrum antifungal agents are recommended. Prophylaxis using itraconazole reduces the risk of treatment failure due to resistant pathogens compared with fluconazole. Voriconazole might prove advantageous compared with fluconazole and itraconazole for prophylaxis because of its extended spectrum and predictable blood levels. Caspofungin seems as effective as and less toxic than amphotericin B for this use. Voriconazole is more effective than amphotericin B for the treatment of aspergillosis. Caspofungin is comparable to voriconazole in efficacy as salvage treatment after failure to respond to other antifungal agents. CONCLUSION: Caspofungin plus voriconazole and other combination therapies often are used for the treatment of aspergillosis yet data to support such use are yet to be produced. The investigational agents posaconazole, micafungin, and anidulafungin appear promising as salvage treatment of various invasive mycoses.