Efficacy and safety of antifungal prophylaxis in surgical intensive care unit patients: A systematic review and meta-analysis of randomized controlled trials.

Invasive fungal infections (IFIs) are serious complications among surgical intensive care unit (ICU) patients, leading to substantial morbidity and mortality. Antifungal prophylaxis and pre-emptive strategies are employed to reduce the risk of such infections, although their effectiveness and safety remain subjects of debate. The present systematic review and meta-analysis included randomized controlled trials evaluating antifungal prophylaxis or pre-emptive therapy in surgical ICU patients. Searches in the PubMed, Scopus, Google Scholar and Science Direct databases up to February 2025 identified 11 eligible studies. Pooled analyses demonstrated that antifungal prophylaxis significantly reduced the risk of IFIs [risk ratio (RR)=0.63; 95% CI, 0.50-0.78; P<0.0001]. While azoles were effective, polyenes and echinocandins did not show a significant effect. No significant effect on overall mortality was observed (RR=0.99; 95% CI, 0.75-1.31; P=0.9186), and there was no increased risk of severe adverse events (RR=0.98; 95% CI, 0.70-1.36) or liver dysfunction (RR=0.91; 95% CI, 0.31-2.65). The analysis did not reveal strong evidence of publication bias as evaluated by funnel plots. Overall, the results indicated that antifungal prophylaxis appeared to be effective in reducing the risk of IFIs in surgical ICU patients without elevating the risk of serious side effects. The implementation of this therapy should be targeted toward high-risk populations, considering the antifungal type, local resource availability and antimicrobial management parameters. The evidence of prophylaxis therapy in low-risk population is limited, since the majority of included studies in the present meta-analysis analyzed high-risk populations.