Factors Associated with Candidemia After Living Donor Liver Transplantation: A Case–Control Study

<b>Background</b>: Liver transplant recipients are highly susceptible to invasive fungal infections, particularly candidemia, due to intensive immunosuppressive therapy and postoperative complications. However, few studies have comprehensively examined postoperative antimicrobial and immunosuppressive factors in this context. <b>Aim</b>: This study aimed to identify perioperative and postoperative factors associated with the development of candidemia in living donor liver transplant (LDLT) recipients, with a particular focus on antimicrobial and immunosuppressive regimens during initial hospitalization. <b>Methods</b>: A retrospective case-control analysis was conducted involving 36 LDLT recipients who developed candidemia (candidemia group) and 72 matched controls without candidemia (non-candidemia group) between January 2019 and November 2023. Demographic and clinical variables were compared using univariate and multivariate logistic regression analyses to identify independent associations. A post hoc power analysis demonstrated a high statistical power (97.3%) to detect large effect sizes. <b>Results</b>: Univariate analysis revealed significant associations with prolonged intubation (<i>p</i> < 0.001), bile leaks (<i>p</i> < 0.001), relaparotomy (<i>p</i> < 0.001), chronic renal disease (<i>p</i> = 0.011), hepatocellular carcinoma (<i>p</i> = 0.011), and the use of antimicrobials including meropenem (<i>p</i> = 0.048), linezolid (<i>p</i> = 0.005), tigecycline (<i>p</i> = 0.045), third-generation cephalosporins (<i>p</i> = 0.003), anidulafungin (<i>p</i> < 0.001), fluconazole (<i>p</i> = 0.006), mycophenolate (<i>p</i> = 0.011), and total parenteral nutrition (TPN) (<i>p</i> = 0.049). CMV prophylaxis (<i>p</i> < 0.001) and CMV-PCR positivity (<i>p</i> = 0.015) were also significantly associated with candidemia. Multivariate logistic regression analysis identified prolonged intubation (OR = 1.07; <i>p</i> = 0.019), bile leaks (OR = 10.9; <i>p</i> = 0.002), anidulafungin use (OR = 4.70; <i>p</i> = 0.032), fluconazole use (OR = 35.8; <i>p</i> = 0.005), and absence of CMV prophylaxis (OR = 11.7; <i>p</i> = 0.021) as independent factors associated with increased odds of candidemia. <b>Conclusions</b>: Prolonged intubation, bile leaks, antifungal exposure, and lack of CMV prophylaxis are independently associated with higher odds of candidemia after LDLT. Targeted prophylaxis, prudent antimicrobial stewardship, and timely biliary intervention may reduce fungal morbidity and mortality in post-transplant patients.