Strategies to prevent invasive mycoses have gained wide interest due to the poor response rates observed in the treatment of these infections in heavily immunosuppressed patients. The prophylactic use of antifungal agents has been shown in randomized controlled trials to reduce the incidence of invasive infections and improve survival (Fig. 2) (56,57). Fluconazole prophylaxis has been endorsed as an appropriate infection-control measure during the pre-engraftment period in patients undergoing hematopoietic stem cell transplantation in consensus guidelines (58). Two double-blind, placebo controlled studies have demonstrated decreases in invasive fungal infections during the pre-engraftment period with the use of this strategy (Fig. 2) (56,57). In both studies patients randomized to fluconazole had lower rates of invasive fungal infections as well as reductions in fungal-related mortality. Reductions in invasive fungal infections was primarily due decreases in the incidence of invasive canidiasis. Unfortunately, the use of fluconazole prophylaxis is not without consequences. An autopsy study including 355 allogeneic transplant recipients, half who received fluconazole and half no prophylaxis, reported an increase in the rates of Aspergillus and Zygomycete infections in patients who received prophylaxis (59). Whether this was due to selective pressure resulting from the lack of activity that fluconazole has against these organisms or increased risk of invasive mould infections due to prolonged survival is unknown.
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