Prevention of systemic mycoses in patients who are not neutropenic: should we do it? Can we do it?
It has been well documented that serious fungal infections may cause death in 5% to 10% of patients in certain high risk groups, such as those undergoing lung, pancreas, or liver transplantation. Patients in intensive care units, such as those with underlying severe disease, multi-organ fungal infection, those with catheters, those on broad spectrum antibacterial agents, and those in renal failure are also at risk and may be candidates for antifungal prophylaxis. However, recommendations regarding the use of antifungal drugs for prophylaxis in non-neutropenic patients are unclear. Several clinical trials in transplant recipients have supported the use of fluconazole for prophylaxis, particularly in liver transplantation, though the data are too few to permit generalized conclusions for all organ transplant recipients. There is also a trial in which antifungal prophylaxis has been successful after gut perforation. However, there are also reports in which high doses of fluconazole have not reduced fungal infection. The appropriate circumstances for prophylaxis are still undergoing definition. It is the author's opinion that effective prophylaxis will become more problematic in the future. In a year or two, once the drug becomes generic, the price of fluconazole will fall dramatically. A sharp increase in use is likely to occur, and is likely to be followed by increasing fluconazole resistance in both Candida albicans and non-albicans colonization and infections. The situation is similar to the consequences of widespread fluconazole use in AIDS patients. The best methods to delay resistance include strict handwashing, careful control of antibacterials, restricting fluconazole use to those situations where it has been most clearly shown to be beneficial, and carefully monitoring patients in intensive care units.
University of Texas Health Science Center, Division of Infectious Diseases, San Antonio, Texas 78284, USA.
J R
JR
Graybill
D000935:Antifungal Agents / Q000627:therapeutic use*; D002986:Clinical Trials as Topic; D015725:Fluconazole / Q000627:therapeutic use*; D016469:Fungemia / Q000517:prevention & control*; D006801:Humans; D009503:Neutropenia / Q000150:complications; D012307:Risk Factors
D000935:Antifungal Agents; D015725:Fluconazole