IFI in the era of antifungal prophylaxis’ implies a uniform implementation of antifungal prophylaxis in solid organ transplant recipients.  However there is considerable heterogeneity in practice based on a number of factors including:

• Type of organ transplanted
• Local fungal epidemiology
• The incidence of IFI
• Prior fungal colonization
• Individual risk factors – rejection, CMV infection, hypogammaglobulinaemia

Antifungal prophylaxis choices include:-

• No prophylaxis
• Yeast-active agent
• Mould-active agent
• i-v, oral or nebulized route

Strategies include:-

• Universal prophylaxis (all transplant recipients receive antifungal prophylaxis)
• Pre-emptive therapy (antifungal therapy commenced following the isolation of a fungus with no evidence of invasive disease)

The choice of strategy will have a significant impact of the nature and type of IFI that occurs.  The timely use of diagnostic techniques such as Aspergillus PCR and the detection of galactomannan allows the implementation of targeted pre-emptive therapy and therefore reduces overall antifungal exposure.  However the utility of biomarkers for screening has yet to be confirmed in the solid organ transplant setting.

Widespread implementation of antifungal prophylaxis comes at a price.  Drug interactions, medication toxicity, financial cost and the emergence of resistant strains of yeast and moulds need to be weighed against the potential reduction in IFI.  If azole antifungal therapy is administered there is general agreement that therapeutic drug monitoring is an important component of optimal patient management and should be available in real time to have an impact on dosing decision making.