Early results of targeted prophylaxis for coccidioidomycosis in patients undergoing orthotopic liver transplantation within an endemic area

Coccidioidomycosis (CM) is an endemic fungal infection of the desert southwestern United States. In immunocompromised hosts, such as transplant recipients, this infection is often a severe, disseminated disease with high mortality. A history of coccidioidal infection or positive serologic results increases the risk of CM after transplantation. At our institution, all liver transplant candidates with either positive history or serologic results for coccidioidal infection receive fluconazole in order to prevent recurrent infection after transplantation. Patients with neither a history of coccidioidal infection nor positive serologic results do not receive prophylaxis but are followed serologically every 3 months. From June 1999 to October 2001, 81 liver transplantations were performed at our institution in 76 patients with end-stage liver disease. Four of these 76 patients received prophylactic fluconazole in order to prevent CM. None of these 4 patients had reactivation of CM. A new coccidioidal infection developed after orthotopic liver transplantation in 1 of 72 patients (1.4%). Close surveillance and targeted prophylaxis are safe and effective alternatives to universal prophylaxis for CM in patients undergoing liver transplantation in an endemic area.