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In a study of 292 critically ill adult surgical and trauma patients, admitted to hospital for at least

48 hours, patients were randomised to no antimycotic therapy, clotrimazole, 10 mg three times a day, ketoconazole, 200 mg/day or nystatin, 2 000 000 units 6-hourly. In this group treatment with three or more antibiotics, APACHE II >10, and ventilatory support for more than 48 hours significantly predicted yeast colonisation and sepsis. The four groups did not differ significantly with regard to yeast colonisation (23%, 18%, 12% and 15%, respectively), yeast sepsis (3%, 1%, 2% and 7% respectively), or mortality (15%, 14%, 6% and 20% respectively).10

In another group of ill high-risk surgical patients, an RCT on 49 patients revealed candidiasis in two patients who received intravenous fluconazole 400 mg/day and in seven patients who received placebo (P=0-06). Fluconazole was well tolerated, and adverse events occurred at similar frequencies in both treatment groups.11

An RCT addressed the safety and efficacy of fluconazole therapy in 143 liver-transplant recipients. Seventy-six patients received oral fluconazole, 100 mg/day, and 67 received nystatin 4 x106 units/day) for the first 28 days after transplantation. Candida colonisation occurred in 25% and 53% of patients in the fluconazole and nystatin groups, respectively (P = 0-04), and 13% and 34% of patients respectively had Candida infections (P= 0-022). Of these patients, 10-5% in the fluconazole group and 25-3% in the nystatin group had superficial Candida infections (P= 0-024). Invasive candidiasis developed in two patients in the fluconazole group (2-6%) and six in the nystatin group (9-0%) (P=0-12). No increased hepatotoxicity, ciclosporin interaction or emergence of clinically relevant resistant Candida strains was attributable to fluconazole.12

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