The effect of empiric and prophylactic treatment with fluconazole on yeast isolates in a surgical trauma intensive care unit.

Abstract

To assess the effect of aggressive antifungal prophylaxis and empiric antifungal therapy using fluconazole on the mycotic microbiology and associated infectious complications in a surgical intensive care unit. Retrospective review of a cohort of critically ill surgical patients treated during an 11-month period. Surgical intensive care unit, university hospital, state-designated level I trauma center. All patients treated with fluconazole during the study. Positive fungal cultures obtained after commencement of antifungal prophylaxis or antifungal treatment with fluconazole. Overall and infectious mortality rates for patients with positive cultures were also measured. Of 72 surgical patients who were treated with fluconazole; 16 (22%) had secondary mycoses. Fourteen (88%) of these patients were receiving fluconazole as antifungal prophylaxis or as empiric treatment of suspected but unproved infection. The predominant organisms isolated from these 16 patients were Candida glabrata (41%) and Candida parapsilosis (41%). Overall mortality for this group was 44%, and infectious mortality was 38%. The infectious mortality rate was significantly higher than the rate found in patients who were successfully treated with fluconazole for primary mycoses, and who did not have secondary infections with resistant organisms (mortality, 9%; P < .01, chi 2). Emergence of resistant species after treatment with fluconazole does occur in surgical patients, and suggests that the development of a secondary fungal infection with a resistant organism may be associated with a poor prognosis.