The Answer Is In: Fluconazole Prophylaxis Is Not Beneficial for Intensive Care Unit Patients without Neutropenia

The prevention of hospital infections in high-risk environments, such as intensive care units (ICUs), is a major goal of the patient safety movement. Fungal infections in the ICU—particularly candidemia—are especially troubling because they disproportionately affect the highest-risk patients and therefore inflict major morbidity and mortality. Although preventing these infections is a worthy goal, the specific strategy of using chemoprophylaxis has remained controversial, because we have an incomplete understanding of the risks, benefits, and costs of this approach, despite the availability of well-tolerated systemic antifungal drugs, such as fluconazole (1). The absence of conclusive evidence invites clinicians to make their own conclusion about the merit of this approach. As a result, 1 of 2 groups of patients (those who receive or do not receive prophylactic fluconazole) may be at avoidable risk—we just do not know which group. We need a high-quality study about this practice.

The first line of defense against candidemia is infection control. Policies that can reduce bloodstream infections (for example, checklists for assuring good aseptic technique when placing central venous catheters) increase patient safety. Administering antifungal drugs to patients when they have risk factors but no clinical evidence for serious fungal infection could be an appealing choice if efficacy of this preemptive strategy outweighed the toxicity and cost. At the time of initiation of treatment, empirical therapy (addressing an infection that is suspected to be present on clinical or laboratory grounds) and prophylaxis (treatment without evidence of actual infection but in a person with defined risk factors) can look alike. Prophylaxis, however, will continue either for a defined duration or until the risk factors have been reduced or eliminated. On the other hand, empirical therapy is meant to continue only if the presence of infection has been confirmed.

Several previous trials make a good case for prophylaxis. …