The combination of oral amphotericin B with azoles prevents the emergence of resistant Candida species in neutropenic patients

The role of antifungal prophylaxis remains controversial and concerns exist that the use of azoles may potentiate the emergence of resistant Candida s pecies. We used a strategy of combining the latest azole/triazole with oral amphotericin B to reduce this risk. We analysed data on Candida colonizati on and candidaemia in neutropenic patients from four prophylaxis periods (1 985/6: ketoconazole and amphotericin B suspension; 1991/2 & 1997: fluconazo le and amphotericin B suspension; 1998/9: itraconazole) to look for evidenc e of the emergence of potentially resistant species. Overall, the percentag e of patients colonized with Candida fell significantly (69.3%, 57.5%, 43.2 % and 46%, respectively, P < 0.001) due to a decrease in colonization with C. albicans (49%, 23.1%, 22.2% and 25.2%, respectively, P < 0.001). However , in 1998/9, increased colonization, particularly with C. glabrata in the l ower gastrointestinal tract, was noted to coincide with the omission of ora l amphotericin B. Despite an increasing population of 'high risk' patients, the incidence of candidaemia has not changed significantly (2%, 1.4%, 1.2% and 2% respectively). However, species causing candidaemia have changed, w ith resistant organisms now predominating. Our findings support the use of azole prophylaxis although, in view of the trends noted when itraconazole w as used alone, we would recommend the additional use of oral amphotericin B .