Fluconazole improves survival in septic shock: a randomized double-blind prospective study.
OBJECTIVE
To demonstrate whether fluconazole reduces multiple organ failure and mortality in early septic shock (<24 hrs).


METHODS
A prospective randomized double-blind study.


METHODS
A medical and surgical adult intensive care unit in a tertiary referral center.


METHODS
Values were obtained from 71 general adult intensive care unit patients.


METHODS
During a 2.5-yr period, December 1998-June 2001, 71 patients with septic shock attributed to either nosocomial pneumonia (n = 37) or intra-abdominal sepsis (n = 34) were admitted to our intensive care unit and met the criteria of early septic shock and were entered into this study. All patients were randomized by our clinical pharmacist to receive daily either 200 mg of fluconazole in isotonic saline (fluconazole group = 32) or isotonic saline alone (placebo group = 39) intravenously during the course of their septic shock.


RESULTS
All patients were closely monitored with pulmonary artery catheters and parameters to calculate daily organ dysfunction and Acute Physiology and Chronic Health Evaluation II scores. There was a highly significant increase in 30-day survival in the fluconazole-treated patients compared with the placebo patients (78% vs. 46%). However, fluconazole was found to be more effective in patients with septic shock attributed to intra-abdominal sepsis than to nosocomial pneumonia. Increased survival in the intra-abdominal sepsis clinical category was mirrored by a significantly lower number of organ failures in the treated group compared with the placebo group whereas the number of organ failures in the fluconazole group attributed to nosocomial pneumonia were not significantly increased compared with the control group. The septic shock state was considered in all cases to be attributed to bacterial and not to disseminated yeast infection with the exception of one patient in the control group who was admitted with candidemia. The mechanisms by which fluconazole exerts its protective effect against septic shock in patients is far from clear. However, fluconazole has been shown to enhance bactericidal activity of neutrophils and also to inhibit transmigration and adhesion of neutrophils in capillaries of distant organs.


CONCLUSIONS
The development of organ failure and mortality in septic shock was significantly reduced by fluconazole given intravenously. The mechanism of action of fluconazole in reducing multiple organ dysfunction in this group of patients may be attributed to the ability of fluconazole to increase recruitment, improve bactericidal activity of neutrophils, and to contain microorganisms locally.
Jacobs
Sydney
S
Department of Anesthesia and Intensive Care, Riyadh Armed Forces Hospital, Saudi Arabia. sydney@nesma.net.sa
Price Evans
David A
DA
Tariq
Mohammed
M
Al Omar
Nasser Fawzan
NF
D000328:Adult; D000368:Aged; D000935:Antifungal Agents / Q000009:adverse effects / Q000627:therapeutic use*; D003428:Cross Infection / Q000188:drug therapy / Q000401:mortality; D004311:Double-Blind Method; D005260:Female; D015725:Fluconazole / Q000009:adverse effects / Q000627:therapeutic use*; D017052:Hospital Mortality; D006801:Humans; D007262:Infusions, Intravenous; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000401:mortality / Q000517:prevention & control; D010538:Peritonitis / Q000188:drug therapy / Q000401:mortality; D018410:Pneumonia, Bacterial / Q000188:drug therapy / Q000401:mortality; D011446:Prospective Studies; D012772:Shock, Septic / Q000188:drug therapy* / Q000401:mortality; D016896:Treatment Outcome
D000935:Antifungal Agents; D015725:Fluconazole