Routine versus selective antifungal administration for control of fungal infections in patients with cancer

Systemic fungal infection is considered to be an important cause of morbidity and mortality in cancer patients, particularly those with neutropenia. Antifungal drugs are often given prophylactically, or to patients with persistent fever.

The objective of this review was to assess the effect of antifungal drugs in cancer patients with neutropenia.

We searched the Cochrane Controlled Trials Register (October 1997), MEDLINE (to September 1997) and the reference lists of articles. We searched the proceedings of the ICAAC, General Meeting of the ASM (from 1990 to 1995), and the 7th European Congress of Clinical Microbiology and Infectious Diseases (1995) and contacted researchers in the field.

Randomised trials of amphotericin B, AmBisome, fluconazole, ketoconazole, miconazole, or itraconazole compared with placebo or no treatment in cancer patients with neutropenia.

Two reviewers independently assessed trial eligibility, methodological quality and abstracted data.

Twenty-five trials involving 2912 patients were included. In 19 trials, prophylactic or later treatment with antifungal drugs had no effect on mortality (odds ratio 0.92, 95% confidence interval 0.75 to 1.14). Only amphotericin showed a significant benefit (odds ratio 0.58, 95% confidence interval 0.37 to 0.93) based on seven trials, but the studies were small and the difference in number of deaths was only 15. Overall it would be necessary to treat 59 patients (95% confidence interval 37 to 131) with an antifungal drug to prevent one case of fungal invasion in surviving patients, although only amphotericin and fluconazole showed a clear beneficial effect. Antifungal treatment decreased fungal colonisation and the need for additional antifungal therapy, but there was heterogeneity across the trials.

Routine prophylactic or later therapy with antifungal drugs in cancer patients with neutropenia does not appear to have a beneficial effect on mortality and only a modest effect on fungal invasion.