Risk Factors for Invasive Fungal Infections in Heart Transplant Recipients

Purpose Heart transplant (HT) recipients are at risk for invasive fungal infection (IFI), a potentially fatal complication. However, data on predictors of IFI in this patient population are sparse. Our goal was to identify pretransplant and posttransplant risk factors for IFI after HT. Additionally, we sought to assess overall survival and one-year mortality among patients with or without IFI. Methods We conducted a retrospective, case-control study in consecutive HT recipients at a single center between 2/1/2014-3/31/2020. Electronic medical records were reviewed to collect the following: demographics, peri-operative and operative characteristics, IFI diagnosis, and mortality. We included IFI cases that were classified as probable or proven according to EORTC/MSG criteria. Statistically significant variables in the univariate analysis were introduced into a multivariate logistic regression model using backward stepwise selection to identify predictors of IFI. The impact of IFIs on overall survival and one-year mortality were assessed using Kaplan-Meier estimation. Results We identified 25 cases of IFI among 248 HT recipients, occurring at median 79 days (IQR 15-303 days) following HT. Significant risk factors for IFI on multivariate analysis included an increased length of postoperative intensive care unit (ICU) stay (OR 1.07, 95% CI 1.02-1.12), pretransplant hemodialysis (OR 3.83, 95% CI 1.05-12.58), and African American race (OR 3.18, 95% CI 1.08-8.79). The cumulative incidence of IFI was 10.1%. IFI was associated with death (HR 3.28, 95% CI 1.41-7.64, p=.004) and 1-year mortality (HR 7.16, 95% CI 2.48-20.65, p<0.001). Conclusion Identification of local risk factors will allow us to develop a targeted antifungal prophylaxis protocol. Hemodialysis and longer ICU stays have been associated with IFI in other studies as well but the association with African American race is new and must be validated. Optimal strategies addressing antifungal prophylaxis and risk reduction for IFI need to be addressed to improve patient outcomes and survival. Heart transplant (HT) recipients are at risk for invasive fungal infection (IFI), a potentially fatal complication. However, data on predictors of IFI in this patient population are sparse. Our goal was to identify pretransplant and posttransplant risk factors for IFI after HT. Additionally, we sought to assess overall survival and one-year mortality among patients with or without IFI. We conducted a retrospective, case-control study in consecutive HT recipients at a single center between 2/1/2014-3/31/2020. Electronic medical records were reviewed to collect the following: demographics, peri-operative and operative characteristics, IFI diagnosis, and mortality. We included IFI cases that were classified as probable or proven according to EORTC/MSG criteria. Statistically significant variables in the univariate analysis were introduced into a multivariate logistic regression model using backward stepwise selection to identify predictors of IFI. The impact of IFIs on overall survival and one-year mortality were assessed using Kaplan-Meier estimation. We identified 25 cases of IFI among 248 HT recipients, occurring at median 79 days (IQR 15-303 days) following HT. Significant risk factors for IFI on multivariate analysis included an increased length of postoperative intensive care unit (ICU) stay (OR 1.07, 95% CI 1.02-1.12), pretransplant hemodialysis (OR 3.83, 95% CI 1.05-12.58), and African American race (OR 3.18, 95% CI 1.08-8.79). The cumulative incidence of IFI was 10.1%. IFI was associated with death (HR 3.28, 95% CI 1.41-7.64, p=.004) and 1-year mortality (HR 7.16, 95% CI 2.48-20.65, p<0.001). Identification of local risk factors will allow us to develop a targeted antifungal prophylaxis protocol. Hemodialysis and longer ICU stays have been associated with IFI in other studies as well but the association with African American race is new and must be validated. Optimal strategies addressing antifungal prophylaxis and risk reduction for IFI need to be addressed to improve patient outcomes and survival.