Abstract
Objective To study in cancer patients with neutropenia whether antifungal agents given prophylactically or empirically decrease morbidity and mortality.
Data sources Medline search 1996 to September 1997, using a comprehensive search strategy. Unpublished trials from conference proceedings and industry contact.
Study selection Randomised trails comparing amphotericinB, AmBisome, fluconazole, ketoconazole, miconazole or itraconazole with placebo or no treatment.
Results 25 trials comprising 2912 randomised patients were included of whom 444 died. Prophylactic or empiric treatment with antifungals had no effect on mortality (odds ratio 0.92 [0.75–1.14]). Amphotericin decreased mortality significantly (OR 0.58 [0.37–0.93]) but the studies were small and the difference in the number of deaths was only 15. Antifungal treatment decreased the incidence of invasive fungal infection significantly (OR 0.49 [0.36–0.66]) and also decreased fungal colonisation and use of additional (escape) antifungal therapy. The NNT to prevent one case of fungal invasion to occur in surviving patients is 59 (CI 37–131).
Conclusions There was no convincing effect on mortality and only a modest effect on fungal invasion. We therefore question the current widespread practices of routine prophylactic or empirical therapy with antifungal agents on cancer patients with neutropenia and suggest that these agents are restricted to patients with proven infection and to patients in randomised controlled trials. A large, definitive, placebo controlled trial of amphotericin B should be performed.
Gotzsche P C, Johansen H K. Routine versus selective antifungal administration for control of fungal infections in patients with cancer (Cochrane Review). In. The Cochrane Library, Issue 2, 1999, Oxford: Update Software
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Address for reprints: Peter Gotzsche The Nordic Cochrane Centre, Righospitalet, dept. 711218B Tagensvej DK-2200 Copenhagen, Denmark
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Clarkson, J., Worthington, H. Routine use of antifungals in cancer treatment questioned. Evid Based Dent 1, 16 (1999). https://doi.org/10.1038/sj.ebd.6490040
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DOI: https://doi.org/10.1038/sj.ebd.6490040