Key points are not available for this paper at this time.
The major issues in the management of fungal infection are prevention, diagnosis and treatment. Our main goal must remain prevention, but for a number of reasons prophylaxis against invasive fungal infection (IFI), in the neutropenic patient, remains controversial. We consider this aim to be desirable, given the high mortality rates associated with established infection, due in part to inadequacies and substantial delays in diagnosis. In a meta-analysis Bow et al (1997) , found a mortality rate of 47% in patients with invasive fungal infection. In a more recent prospective EORTC survey, Denning et al (1999) found that the 3-month mortality rate in patients with invasive aspergillosis was 64%. However, clinical trials of antifungal prophylaxis have failed to show a reduction in overall mortality in almost every case, other than those conducted in the highest risk patients. Fuel was recently added to the fire of this debate by the publication of a further meta-analysis on the role of prophylaxis and empirical treatment ( Gotzsche Tollemar et al, 1989a , b; Goodrich et al, 1991 ; Verfaille et al, 1991; Goodman et al, 1992 ; McWhinney et al, 1993 ; Winston et al, 1993 ; Fetscher et al, 1999 ; Salazar et al, 1999 ). The risk is dependent on the underlying disease, the treatment given and the prophylaxis used and is higher in older patients ( Kiwan Goodman et al, 1992 ). Myelosuppressive chemotherapy, for example DAT (daunorubicin, cytarabine and 6-thioguanine) in acute myeloblastic leukaemia (AML), leads to an average 3 weeks of neutropenia, with 2 weeks being severe ( and less with the amphotericin ( et al, ). In a substantial study in a reduction in IFI, with in the fluconazole compared with with the polyenes The of fluconazole to an for of the species is et al, in the from of the which has been by the introduction of an in studies of this have shown high with at in chemotherapy patients ( et al, in at ( et al, ) and in at 7 ( et al, 1998 ). In the study, the of was a that of and has antifungal data in patients. data in show a of at years and at years . are the for Aspergillus spp. reported as for prophylaxis by et al and for Candida species infections (C. albicans and non-albicans It is that higher blood in ( et al, 1999 although are as yet data and the of resistant trials have compared with a of In study of chemotherapy was the and was an but not of Aspergillus spp. infections with use vs. being in which was conducted in centres, used a with and reported very high rates ( et al, 1999 ). The study ( et al, 1999 ) of vs. fluconazole chemotherapy, and some of more than during neutropenic to the to d after the of prophylaxis, or Aspergillus spp. infections seen with itraconazole, with only C. albicans and fungal In with fungal Aspergillus C. Aspergillus spp. In the infections with fluconazole and with infections in chemotherapy patients. was a major because of In a study of chemotherapy amphotericin B used as a ( et al, 1998 ). There more IFI vs. Aspergillus spp. vs. and fungal vs. in the amphotericin than with itraconazole, but of these also reported with the their and trials reported a lower overall of fungal infection, a lower rate from fungal infection and a lower use of amphotericin B for IFI in patients given study that compared with fluconazole as in patients chemotherapy with or stem cell transplantation for the in of the blood of of The for of this ( et al, 1999 ). study the for and of the blood for The recent of both the oral and an of has in prophylaxis for most ( et al, 1999 ). The in by Goodman et al compared high-dose fluconazole with study, conducted during the neutropenic found a reduction in infection invasive infection vs. and vs. by of C. Aspergillus spp. and a as for IFI in the fluconazole et al conducted a of fluconazole at against in of or marrow Fungal infection in of patients was reduced compared with of seen in those receiving Candida albicans was seen in the fluconazole and infection, fungal colonization and the empirical use of amphotericin B at was in the fluconazole amphotericin B has been used at a low as a agent for prophylaxis ( et al, 1992 although study, using or a reduction in fungal infection from to in of ( et al, ). Patients peripheral blood stem cell with profound T-cell of the for prevention are at very high risk of IFI. to after amphotericin B has been used with in the mortality from to compared with an studies in support a role for this of amphotericin B, from reduced colonization to reduced IFI ( Tollemar et al, et al, 1999 ). with an has a substantial reduction in risk of invasive fungal infection in undergoing induction for leukaemia using on There was a reduction from an of of to in ( et al, ). in this study, the in was 47% in contrast to in and the in those with was Candida spp. the most common of infection, Aspergillus spp. infection was seen only in The of is the of an by the support for a role in prophylaxis from the of a reduction in the of fungal infection in a North of empirical ( et al, 1999 ). than some studies some studies have of et al conducted a study of the of high-dose fluconazole to and amphotericin B in patients. to be at high risk because of used for the treatment of disease and an prolonged of neutropenia. The of was but the rate of defined infection, including vs. was higher in the fluconazole amphotericin B was given more in the fluconazole and of IFI in There was on The study by of et al, ; et al, 1998 ). The of a targeted prophylaxis the of rapid diagnostic tests to that is likely to rescue patients who are this We have used in patients with for more than years ( McWhinney et al, 1993 ; . and 3 weeks on the seen in conventional ( et al, 1997 ) . et al (1999) in neutropenic patients with to for more than who a normal conventional time of d was by the use of are by ( et al, 1992 but we now to use amphotericin B or in the ( et al, 1998 ). of fungal has been used for years ( et al, ) and the is and for aspergillosis ( et al, ; et al, 1998 in our to be used to treatment. the Candida be as remains to be as a of Candida infection ( et al, ). The of a for fungal diagnosis has some years to is that of a which can be species by the use of ( et al, 1997 ). It is now to be used with for targeted ( et al, 1998 ). under is the ( ( & We that these can to a further on we use the combination of and to targeted and have empirical in in most The evidence for the of prophylaxis is in the but it is in other groups. The of invasive fungal infection is in the neutropenic patient, that we consider it to the use of both and empirical in the and, the rapid diagnostic methods are in the intermediate risk is not in the group. for failure to of prophylaxis is that the to be The should the range of likely have systemic and the of should be the upper and lower the and the upper tract by the of these we have recently to our of using a combination of oral amphotericin B or in the intermediate and who are in The use of empirical should with increased in the and be targeted to those with very invasive fungal In the we the of clinical trials of and antifungal with studies of of the and using We that this
Prentice et al. (Tue,) studied this question.