Early Invasive Fungal Infections in Liver Transplant Recipients Receiving Risk-Stratified Echinocandin Prophylaxis: A Descriptive Single-Center Cohort Study

Background: Invasive fungal infection (IFI) remains a cause of morbidity and mortality after liver transplantation; guidelines recommend targeted antifungal prophylaxis in recipients with specific risk factors. Methods: We retrospectively studied adult liver transplant recipients (LTR) at a single center, 2017–2023. High-risk recipients received a planned 14-day course of echinocandin prophylaxis, caspofungin in 97.6%. The primary endpoint was IFI within 30 days of transplantation, a window spanning the planned prophylaxis and the 2 weeks after it. Secondary endpoints were fungal etiology and factors associated with IFI. We also examined the temporal distribution of early aspergillosis across the whole institutional registry to 2025. Results: Of 286 recipients, 85 (29.72%) were high risk. IFI was more frequent in high-risk than non-high-risk LTR (8/85, 9.41% vs. 4/201, 1.99%; p = 0.0077); most were breakthrough (7/8) mold infections. In exploratory analyses, IFI was associated with high-risk status (unadjusted odds ratio: 5.12, 95% CI: 1.50–17.49), MELD > 30 (4.67, 1.25–17.41) and diabetes (4.64, 1.37–15.79); with 12 events, these estimates are imprecise, and no multivariable model was fitted. Among 452 transplants performed in 2017–2025, seven developed early aspergillosis across four calendar years, with no significant variation in annual incidence (p = 0.146), never more than two cases in any 90-day window (Monte Carlo p = 0.82) and none among the 117 transplants of the following 28 months. Conclusion: Early IFI under risk-stratified echinocandin prophylaxis concentrated in the sickest recipients and was dominated by mold disease. No clear temporal pattern suggestive of a sustained common-source outbreak was identified, although environmental transmission cannot be excluded.