In my own experience as an ophthalmologist if I am going to prescribe systemic antibiotics - oral or IM or IV I am always start antifungals simultaneosly with antibiotic. My preference is Fluconazole 100 mg once a week, which is enough for 7 days of antibiotic use. In case of 10 days or 2 we the patient will receive additional capsule of Fluconazole.

One thing needs to be considered is how prevalent is the fungal infection in your area or unit. It is always true that antifungal prophylaxis is beneficial when the prevalence is high. But if you rarely see any case then it will be very hard to see the benefit.

limiting exposure time to antibiotics would probably be the best "prophylaxis" for fungal infections. In my experience, less than 0.1% of patients started on antibiotics with a well thought regimen and a clear duration complicated with fungal infections, with none systemic (in my experience)

prophylaxis in severe imunodopression like granulomatous disease is another question

Look at your local data of prevalence of fungal infections (not carriers!) to see if antifungal prophylaxis is cost-efficient. Study the connection of fungal infections and antibiotic administration and see whether the ATBs were really necessary, then may be the administration was too long, especially for broad spectrum agents.

Immunocompetent patients do not get fungal infections, at least not systemic, controlled with local antifungals. catheter related colonization may occur which are controlled by catheter removal.

Immunocompromised patients, patients receiving chemotherapy, transplant recipients may be eligible.

Febrile neutropenia is another discussion.

I believe immunologic status of a given patient is of paramount importance. In an immuno competent patient, the best option is always good antimicrobial stewardship, limiting spectrum and duration of antibiotherapy to what is strictly necessary. Unless invasive fungal infections prevalence is high (as it could be in some environments, as ICUs and oncology wards) antifungal prophylaxis can be actually deleterious, as C. albicans resistance to azoles is rising and other Candida species are naturally resistant to fluconazole. My advice would be to review your local data concerning invasive fungal infections and decide based on the patient, not on his therapy.

We use our modified predictive rule made by combination of Ostrosky-Zeichner et al. (2007) and Paphitou et al.(2005):

Group A

Broad-spectrum antibiotics - 3 points

central venous catheter (day 1–3 of ICU stay) - 3 points

Group B:

mechanical ventilation - 2 point

diabetes - 2 point

Group C:

total parenteral nutrition (day 1–3 of ICU stay) - 1 point

dialysis (day 1–3 of ICU stay) - 1 point

major surgery (day –7 to 0 of ICU stay) - 1 point

pancreatitis (day –7 to 0 of ICU stay) - 1 point

steroids (day –7 to 3 of ICU stay) - 1 point

other immunosuppressive agents (day –7 to 0 of ICU stay) - 1 point

Group D:

presence of Candida spp. in any clinical specimen - 3 points

If present any of Group A criteria + one of Group B + ((Two of Group C) or (one of Group B + Group В) = we consider prophylaxis of candidiasis