Antifungal agents for preventing fungal infections in non-neutropenic critically-ill patients

Playford, E. G., Webster, A., Sorrell, T. and Craig, J. (2006) Antifungal agents for preventing fungal infections in non-neutropenic critically-ill patients. Cochrane Database of Systematic Reviews, 1: 1-48.


Author Playford, E. G.
Webster, A.
Sorrell, T.
Craig, J.
Title Antifungal agents for preventing fungal infections in non-neutropenic critically-ill patients
Journal name Cochrane Database of Systematic Reviews   Check publisher's open access policy
ISSN 1469-493X
Publication date 2006
Sub-type Critical review of research, literature review, critical commentary
DOI 10.1002/14651858.CD004920.pub2
Issue 1
Start page 1
End page 48
Total pages 48
Place of publication U.K.
Publisher John Wiley & Sons
Collection year 2005
Language eng
Subject CX
321208 Primary Health Care
730305 Diagnostic methods
11 Medical and Health Sciences
Formatted abstract Background
Invasive fungal infections, important causes of morbidity and mortality in critically ill patients, may be preventable with the prophylactic administration of antifungal agents.

Objectives
This study aims to systematically identify and summarize the effects of antifungal prophylaxis in non-neutropenic critically ill adult patients on all-cause mortality and the incidence of invasive fungal infections.

Search strategy
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, Issue 3, 2005), MEDLINE (1966 to 2 September 2005), and EMBASE (1980 to week 36, 2005). We also handsearched reference lists, abstracts of conference proceedings and scientific meetings (1998 to 2004), and contacted authors of included studies and pharmaceutical manufacturers.

Selection criteria
We included randomized controlled trials in all languages comparing the prophylactic use of any antifungal agent or regimen with placebo, no antifungal, or another antifungal agent or regimen in non-neutropenic critically ill adult patients.

Data collection and analysis
Two authors independently applied selection criteria, performed quality assessment, and extracted data using an intention-to-treat approach. We resolved differences by discussion. We synthesized data using the random effects model and expressed results as relative risk with 95% confidence intervals.

Main results
We included 12 unique trials (eight comparing fluconazole and four ketoconazole with no antifungal or a nonabsorbable agent) involving 1606 randomized patients. For both outcomes of total mortality and invasive fungal infections, almost all trials of fluconazole and ketoconazole separately showed a non-significant risk reduction with prophylaxis. When combined, fluconazole/ketoconazole reduced total mortality by about 25% (relative risk 0.76, 95% confidence interval 0.59 to 0.97) and invasive fungal infections by about 50% (relative risk 0.46, 95% confidence interval 0.31 to 0.68). We identified no significant increase in the incidence of infection or colonization with the azole-resistant fungal pathogens Candida glabrata or C. krusei, although the confidence intervals of the summary effect measures were wide. Adverse effects were not more common amongst patients receiving prophylaxis. Results across all trials were homogeneous despite considerable heterogeneity in clinical and methodological characteristics.

Authors' conclusions
Prophylaxis with fluconazole or ketoconazole in critically ill patients reduces invasive fungal infections by one half and total mortality by one quarter. Although no significant increase in azole-resistant Candida species associated with prophylaxis was demonstrated, trials were not powered to exclude such an effect. In patients at increased risk of invasive fungal infections, antifungal prophylaxis with fluconazole should be considered.
Q-Index Code CX
Additional Notes Article CD004920

Document type: Journal Article
Sub-type: Critical review of research, literature review, critical commentary
Collections: Excellence in Research Australia (ERA) - Collection
School of Biological Sciences Publications
 
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