There is a growing awareness of the increasing role of fungal infections in morbidity and mortality of intensive care unit (ICU) patients. The use of the azoles in prophylaxis for fungal infection inimmunocompromised patients is well described and has proven efficacy. In addition, there is an increasing body of work that azole prophylaxis may be of benefit in certain patient populations as well. In both patient populations, infections caused by Candida species are thought to develop from endogenous colonization, yet the value of fungal surveillance cultures in critically ill patients is uncertain and lacks a high positive predictive value.

Fungal infections may develop in up to 30% to 35% of patients with necrotizing pancreatitis, with Candida albicans being the most frequently isolated fungal species by far. Two recent studies showed a significant decrease in fungal infections in a fluconazole prophylaxis group compared with a control group. In patients with septic shock from abdominal nonpancreatic sources, use of empiric fluconazole showed a decreased incidence of candidemia and fungal-related deaths in three recent studies, although reduction in overall mortality was less certain. Some caution has been voiced concerning the prophylactic use of fluconazole in “moderately ill” immunocompetent patients because of the risk of developing drug-resistant (resistant to azole drugs) fungal strains, especially Candida glabrata, although Swoboda et al. have reported no shift to nonalbicans pathogens with a decreased risk of mortality using prophylaxis.