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Volume 331:1325-1330 November 17, 1994 Number 20 Next

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ABSTRACT

Background Amphotericin B has long been the standard treatment for candidemia, but its use is complicated by its toxicity. More recently, fluconazole, a water-soluble triazole with activity against candida species and little toxicity, has become available. We conducted a multicenter randomized trial that compared amphotericin B with fluconazole as treatment for candidemia.

Methods To be eligible, patients had to have a positive blood culture for candida species, a neutrophil count 500 per cubic millimeter, and no major immunodeficiency. Patients were randomly assigned to receive either amphotericin B (0.5 to 0.6 mg per kilogram of body weight per day) or fluconazole (400 mg per day), each continued for at least 14 days after the last positive blood culture. Outcomes were assessed by a group of investigators blinded to treatment assignment.

Results Of the 237 patients enrolled, 206 met all entry criteria. The most common diagnoses were renal failure, nonhematologic cancer, and gastrointestinal disease. There was no statistically significant difference in outcome: of the 103 patients treated with amphotericin B, 81 (79 percent) were judged to have been treated successfully, as were 72 of the 103 patients treated with fluconazole (70 percent; P = 0.22; 95 percent confidence interval for the difference, -5 to 23 percent). The bloodstream infection failed to clear in 12 patients in the amphotericin group and 15 in the fluconazole group; the species most commonly associated with failure was Candida albicans. There were 41 deaths in the amphotericin group and 34 deaths in the fluconazole group (P = 0.20). Intravascular catheters appeared to be the most frequent source of candidemia. There was less toxicity with fluconazole than with amphotericin B.

Conclusions In patients without neutropenia and without major immunodeficiency, fluconazole and amphotericin B are not significantly different in their effectiveness in treating candidemia.

Source Information

From the University of Texas Medical School at Houston, Houston (J.H.R.); Laboratory of Clinical Investigation, National Institute of Allergy and Infectious Diseases, Bethesda, Md. (J.E.B.); Boston University Medical Center Hospital, Boston (A.M.S.); University of Alabama, Birmingham (P.G.P.); University of North Carolina, Chapel Hill (C.M.V.); Harbor-UCLA Medical Center, Torrance, Calif. (J.E.E.); Bowman Gray School of Medicine, Winston-Salem, N.C. (R.G.W.); University of Virginia, Charlottesville (W.M.S.); New England Deaconess Hospital, Boston (A.W.K.); and Roerig-Pfizer, New York (A.P.D., M.J.L., C.D.W.). Additional contributing authors include Harold C. Neu, M.D., John J. Stern, M.D., Carmelita U. Tuazon, M.D., Robert H. Rubin, M.D., Bryan P. Simmons, M.D., Jack D. Sobel, M.D., Michael F. Parry, M.D., James M. Horton, M.D., Issa E. Ephthimios, M.D., Allan R. Tunkel, M.D., Ph.D., Ronald A. Greenfield, M.D., Winkler G. Weinberg, M.D., David S. McKinsey, M.D., and Corstiaan Brass, M.D.Presented in part at the 33rd Interscience Conference on Antimicrobial Agents and Chemotherapy, New Orleans, October 18-20, 1993 (abstract no. 805) and at the 12th Congress of the International Society for Human and Animal Mycology, Adelaide, Australia, March 13-18, 1994 (abstract no. S11.1).

Address reprint requests to Dr. Rex at the University of Texas Medical School, 6431 Fannin 1728 JFB, Houston, TX 77030.

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N Engl J Med 1995; 332:1100-1102, Apr 20, 1995. Correspondence

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