Therapeutic dilemma of fluconazole prophylaxis in intensive care

OBJECTIVE: To review the data concerning the use of prophylactic fluconazole in intensive care patients who are not immuno-compromised. DATA SOURCE: Literature identified through MEDLINE (1966-March 2001) and recent abstracts of data presented at scientific meetings. DATA SYNTHESIS: The use of fluconazole as a prophylactic antifungal agent is well documented in patients who are immuno-compromised or undergoing bone marrow or solid organ transplantation, with supportive results. Recently published data suggest that the use of fluconazole in high-risk surgical patients can be safe and effective for preventing certain candida infections. However, there is growing evidence that the use of fluconazole may be contributing to the higher prevalence of fluconazole-resistant fungal infections. CONCLUSIONS: The use of prophylactic fluconazole in nonneutropenic patients is controversial. Retrospective and surveillance studies of nosocomial fungal infections suggest that the use of fluconazole may be contributing to the shift in fungal flora causing these infections and that the isolates are more fluconazole resistant. Fluconazole prophylaxis in surgical patients may be justified in patients who are at the greatest risk of developing fungal infections, those requiring multiple intraabdominal surgeries, or those with recurrent gastrointestinal perforations or anastomotic leakages, but there is a lack of randomized controlled trials to recommend its widespread use at this time.