Abstract
IntroductionHigh-risk surgical patients are at increased risk of fungal infections and candidaemia. Evidence from observational and small randomised controlled studies suggests that prophylactic fluconazole may be effective in reducing fungal infection and mortality. We evaluated the effects of prophylactic fluconazole on the incidence of candidaemia and hospital mortality in immunocompetent high-risk surgical patients.MethodsRandomised controlled studies involving the use of fluconazole in immunocompetent high-risk surgical patients from the Cochrane Controlled Trial Register (2005, issue 1) and from the EMBASE and MEDLINE databases (1966–30 April 2005), without any language restriction, were included. Two reviewers reviewed the quality of the studies and performed data extraction independently.ResultsSeven randomised controlled studies with a total of 814 immunocompetent high-risk surgical patients were considered. The use of prophylactic fluconazole was associated with a reduction in the proportion of patients with candidaemia (relative risk [RR] = 0.21, 95% confidence interval [CI] = 0.06–0.72, P = 0.01; I2 = 0%) and fungal infections other than lower urinary tract infection (RR = 0.39, 95% CI = 0.24–0.65, P = 0.0003; I2 = 0%), but was associated with only a trend towards a reduction in hospital mortality (RR = 0.82, 95% CI = 0.62–1.08, P = 0.15; I2 = 7%). The proportion of patients requiring systemic amphotericin B as a rescue therapy for systemic fungal infection was lower after prophylactic use of fluconazole (RR = 0.35, 95% CI = 0.17–0.72, P = 0.004; I2 = 0%). The proportion of patients colonised with or infected with fluconazole-resistant fungi was not significantly different between the fluconazole group and the placebo group (RR = 0.66, 95% CI = 0.22–1.96, P = 0.46; I2 = 0%).ConclusionThe use of prophylactic fluconazole in immunocompetent high-risk surgical patients is associated with a reduced incidence of candidaemia but with only a trend towards a reduction in hospital mortality.
Highlights
High-risk surgical patients are at increased risk of fungal infections and candidaemia
The use of prophylactic fluconazole was associated with a reduction in the proportion of patients with candidaemia and fungal infections other than lower urinary tract infection (RR = 0.39, 95% confidence interval (CI) = 0.24–0.65, P = 0.0003; I2 = 0%), but was associated with only a trend towards a reduction in hospital mortality (RR = 0.82, 95% CI = 0.62– 1.08, P = 0.15; I2 = 7%)
The proportion of patients requiring systemic amphotericin B as a rescue therapy for systemic fungal infection was lower after prophylactic use of fluconazole (RR = 0.35, 95% CI = 0.17–0.72, P = 0.004; I2 = 0%)
Summary
High-risk surgical patients are at increased risk of fungal infections and candidaemia. Evidence from observational and small randomised controlled studies suggests that prophylactic fluconazole may be effective in reducing fungal infection and mortality. We evaluated the effects of prophylactic fluconazole on the incidence of candidaemia and hospital mortality in immunocompetent high-risk surgical patients. Candida spp. remain the commonest type of fungal infections in the ICUs and candidaemia accounts for 15% of all nosocomial bloodstream infections in the United States [1], with similar trends being reported worldwide [8]. The use of prophylactic antifungal therapy in ICU is controversial, evidence from observational studies suggests that antifungal prophylaxis is associated with a reduced risk of candidaemia [9]. The risk factors associated with candidaemia are prevalent in high-risk or critically ill surgical patients, and these include the presence of a central venous catheter, acute
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