Baddour et al Infective Endocarditis in Adults 1465 A 2-phase treatment of fungal IE has evolved. The initial or induction phase consists of control of infection. Treatment includes a combination of a parenteral antifungal agent, usu- ally an amphotericin B containing product, and valve sur- gery. Valve surgery should be done in most cases of fungal IE. Results of a meta-analysis that included 879 cases of Candida IE demonstrated a marked reduction in death (prevalence odds ratio, 0.56; 95% confidence interval, 0.16 1.99) among those who underwent adjunctive valve surgery.244 In addition, patients who were treated with combination therapy including amphotericin B and flucytosine had reduced mortality com- pared with those who received antifungal monotherapy. Antifungal therapy usually is given for >6 weeks. After completion of this initial therapy, long-term (lifelong) sup- pressive therapy with an oral azole is reasonable.243,244,246 Suppressive therapy has been used in 2 populations. First, because of the high relapse rate of fungal IE and the prolonged delay (years in some cases) in relapse, oral azoles have been administered after combined medical and surgical induction therapy. In a second population with fungal IE, lifelong oral antifungal suppressive therapy has been given to patients who respond clinically to induction medical therapy but are not deemed appropriate surgical candidates for valve replacement for attempted infection cure. Anecdotal case series243,245 indi- cate that IE has been successfully suppressed for months to years. A meta-analysis that included 64 reported patients with Candida IE who did not undergo valve surgery because they were deemed to be unacceptable surgical candidates supports the notion that fluconazole suppressive therapy is useful; 20 of 21 patients (95%) who were ultimately treated with long-term suppressive therapy survived during follow-up, which was 6 Recommendations 1. 