A Cochrane review 1 included 17 trials involving a total of 3798 patients and 381 deaths. In two large three-armed trials results for amphotericin B were combined with results for nystatin in a "polyene" group. Because nystatin is an ineffective drug in these circumstances, this approach creates a bias in favour of fluconazole. Furthermore, most patients were randomised to oral amphotericin B, which is poorly absorbed and poorly documented. There were no significant differences in effect between fluconazole and amphotericin B, but the confidence intervals were wide.
Comment: The quality of evidence is downgraded by study quality (several methodological limitations), by inconsistency (heterogeneity in interventions), by imprecise results (wide confidence intervals), and by publication bias. The authors' conclude: Amphotericin B has been disfavoured in several of the trials through their design or analysis. Since intravenous amphotericin B is the only antifungal agent for which there is evidence suggesting an effect on mortality [Evidence Level: C] and is considerably cheaper than fluconazole, it should be preferred.
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