Antifungal agents for preventing fungal infections in solid organ transplant recipients.
BACKGROUND
Invasive fungal infections (IFIs) are important causes of morbidity and mortality in solid organ transplant recipients.


OBJECTIVE
This study aims to systematically identify and summarise the effects of antifungal prophylaxis in solid organ transplant recipients.


METHODS
The Cochrane Central Register of Controlled Trials (Issue 3, 2003), MEDLINE (1966-June 2003), and EMBASE (1980-June 2003) were searched. Reference lists, abstracts of conference proceedings and scientific meetings (1998-2003) were handsearched. Authors of included studies and pharmaceutical manufacturers were contacted.


METHODS
Randomised controlled trials (RCTs) in all languages comparing the prophylactic use of any antifungal agent or regimen with placebo, no antifungal, or another antifungal agent or regimen.


METHODS
Two reviewers independently applied selection criteria, performed quality assessment, and extracted data using an intention-to-treat approach. Differences were resolved by discussion. Data were synthesised using the random effects model and expressed as relative risk (RR) with 95% confidence intervals (95% CI).


RESULTS
Fourteen unique trials with 1497 randomised participants were included. Antifungal prophylaxis did not reduce mortality (RR 0.90, 95% CI 0.57 to 1.44). In liver transplant recipients, a significant reduction in IFIs was demonstrated for fluconazole (RR 0.28, 95% CI 0.13 to 0.57). Although less data were available for itraconazole and liposomal amphotericin B, indirect comparisons and one direct comparative trial suggested similar efficacy. Fluconazole prophylaxis did not significantly increase invasive infections or colonisation with fluconazole-resistant fungi. In renal and cardiac transplant recipients, neither ketoconazole nor clotrimazole significantly reduced invasive infections. Overall, the strength and precision of comparisons however were limited by a paucity of data.


CONCLUSIONS
For liver transplant recipients, antifungal prophylaxis with fluconazole significantly reduces the incidence of IFIs with no definite mortality benefit. Given a 10% incidence of IFI, 14 liver transplant recipients would require fluconazole prophylaxis to prevent one infection. In transplant centres where the incidence of IFIs is high, or in situations where the individual risk is great, antifungal prophylaxis should be considered.
Playford
E G
EG
Infection Management Services, Princess Alexandra Hospital, Ipswich Rd, Woolloongabba, QLD, Australia, 4102. geoffrey_playford@health.qld.gov.au
Webster
A C
AC
Sorell
T C
TC
Craig
J C
JC
D000935:Antifungal Agents / Q000627:therapeutic use*; D015725:Fluconazole / Q000627:therapeutic use; D006801:Humans; D016867:Immunocompromised Host; D016031:Liver Transplantation / Q000401:mortality; D009181:Mycoses / Q000401:mortality / Q000517:prevention & control*; D016377:Organ Transplantation / Q000401:mortality; D016032:Randomized Controlled Trials as Topic
D000935:Antifungal Agents; D015725:Fluconazole