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Arun S, Varghese M, Cherian T, Ramaswami P. Current Trends in Antifungal Prophylaxis for High-Risk Neonates in Neonatal Intensive Care Units in India: A Nationwide Survey. Cureus 2023; 15:e36136. [PMID: 36926274 PMCID: PMC10013975 DOI: 10.7759/cureus.36136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/15/2023] Open
Abstract
Background Prophylactic antifungals are often used in high-risk babies in neonatal intensive care units (NICUs) to reduce invasive fungal infections (IFIs). However, existing guidelines regarding prophylactic antifungal usage do not clearly define the high-risk population. This study aimed to assess the practices related to prophylactic antifungal use in NICUs in India. Methods For this cross-sectional study, an online structured questionnaire was completed by neonatologists who worked in level 3 NICUs in 12 states in India during the period June 2022 to August 2022. Results Data from 151 NICUs were analyzed. 71.7% of respondents were from private hospitals, and 28.3% were from government hospitals. Nearly one-fourth of the units (28.5%) used antifungal prophylaxis in all extremely low birth weight (ELBW) babies, while another one-fourth (25.8%) used a case-based approach. The remaining NICUs (45.7%) did not use prophylactic antifungals. Among the users, the preferred antifungal was fluconazole; 3 mg/kg and 6 mg/kg were the dosage regimens used. The commonly used interval for administering fluconazole was 72 hours (69.2% of units). The intravenous route was the preferred route of administration (84.1%). Factors that influenced the non-users were the low incidence of fungal infections in their NICUs and concern about the development of resistance. It was noted that the users felt strongly about the need for further recommendations from pediatric societies and more studies on the efficacy of antifungals. Conclusion There is considerable variation in the use of prophylactic antifungals across NICUs in India. Among the users, uniformity in the choice of antifungal and interval of administration was observed. Further recommendations from pediatric societies, including the definitions of neonates at-risk of fungal infections, are required to ensure consistency in practice and help clinicians decide whether or not to use prophylactic antifungals.
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Affiliation(s)
- Sumitha Arun
- Neonatology, Believers Church Medical College Hospital, Thiruvalla, IND
| | - Mereta Varghese
- Neonatology, Believers Church Medical College Hospital, Thiruvalla, IND
| | - Taliya Cherian
- Neonatology, Believers Church Medical College Hospital, Thiruvalla, IND
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Garrido F, Allegaert K, Arribas C, Villamor E, Raffaeli G, Paniagua M, Cavallaro G. Variations in Antibiotic Use and Sepsis Management in Neonatal Intensive Care Units: A European Survey. Antibiotics (Basel) 2021; 10:antibiotics10091046. [PMID: 34572631 PMCID: PMC8469483 DOI: 10.3390/antibiotics10091046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022] Open
Abstract
Management of neonatal sepsis and the use of antimicrobials have an important impact on morbidity and mortality. However, there is no recent background on which antibiotic regimens are used in different European neonatal intensive care units (NICUs). Our study aimed to describe the use of antibiotics and other aspects of early- and late-onset sepsis (EOS and LOS, respectively) management by European NICUs. We conducted an online survey among NICUs throughout Europe to collect information about antibiotic stewardship, antibiotic regimens, and general aspects of managing neonatal infections. NICUs from up to 38 European countries responded, with 271 valid responses. Most units had written clinical guidelines for EOS (92.2%) and LOS (81.1%) management. For EOS, ampicillin, penicillin, gentamicin, and amikacin were the most commonly used antibiotics. Analysis of the combinations of EOS regimens showed that the most frequently used was ampicillin plus gentamicin (54.6%). For LOS, the most frequently used antibiotics were vancomycin (52.4%), gentamicin (33.9%), cefotaxime (28%), and meropenem (15.5%). Other aspects of the general management of sepsis have also been analyzed. The management of neonatal sepsis in European NICUs is diverse. There was high self-reported adherence to the local clinical guidelines. There was homogeneity in the combination of antibiotics in EOS but less in LOS.
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Affiliation(s)
- Felipe Garrido
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
- Correspondence: ; Tel.: +34-661214947
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Cristina Arribas
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), School for Oncology and Developmental Biology (GROW), 6229 Maastricht, The Netherlands;
| | - Genny Raffaeli
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, NICU, 20122 Milan, Italy; (G.R.); (G.C.)
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, 20122 Milan, Italy
| | - Miren Paniagua
- Department of Pediatrics, Clínica Universidad de Navarra, 28027 Madrid, Spain; (C.A.); (M.P.)
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, NICU, 20122 Milan, Italy; (G.R.); (G.C.)
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Vieira VC, Costa RS, Lima RCG, Queiroz DB, de Medeiros DS. Prescription of off-label and unlicensed drugs for preterm infants in a neonatal intensive care unit. Rev Bras Ter Intensiva 2021; 33:266-275. [PMID: 34231807 PMCID: PMC8275084 DOI: 10.5935/0103-507x.20210034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/01/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate the use of off-label and unlicensed medications in preterm infants hospitalized in a neonatal intensive care unit. METHODS This nonconcurrent cohort study included preterm infants admitted to 3 neonatal intensive care units in 2016 and 2017 who were followed up during the neonatal period. The type and number of medications used were recorded for the entire period and classified based on the Anatomical Therapeutic Chemical. Descriptive and bivariate data analyses were performed to assess associations between the number of drugs used (total, off-label and unlicensed) and the explanatory variables of interest. RESULTS Four hundred preterm infants received 16,143 prescriptions for 86 different pharmaceuticals; 51.9% of these medications were classified as off-label and 23.5% as unlicensed. The most prescribed drugs were gentamicin and ampicillin (17.5% and 15.5% among off-label, respectively) and caffeine (75.5% among unlicensed). The results indicated significant associations between the use of off-label drugs and lower gestational age, low birth weight, lower 5-minute Apgar score, advanced resuscitation maneuver in the delivery room and death. The prescription of unlicensed drugs was associated with lower gestational age, low birth weight and 5-minute Apgar score below 7. CONCLUSION Neonates admitted to neonatal intensive care units are highly exposed to off-label and unlicensed medications. Further studies are needed to achieve greater safety and quality of drug therapy used in neonatology.
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Affiliation(s)
- Verônica Cheles Vieira
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia - Vitória da Conquista (BA), Brazil
| | - Renart Santos Costa
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia - Vitória da Conquista (BA), Brazil
| | | | - Daiane Borges Queiroz
- Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia - Vitória da Conquista (BA), Brazil
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Zhang D, Xie D, He N, Wang X, Dong W, Lei X. Prophylactic Use of Fluconazole in Very Premature Infants. Front Pediatr 2021; 9:726769. [PMID: 34660487 PMCID: PMC8517516 DOI: 10.3389/fped.2021.726769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/06/2021] [Indexed: 11/24/2022] Open
Abstract
Objective: To evaluate the efficacy, safety, and fungal sensitivity of prophylactic fluconazole use in very premature infants. Methods: We performed a retrospective historical comparative analysis of 196 very premature infants (113 in the prophylaxis group and 83 in the rescue group). The incidence of nosocomial fungal infection (NCFI) and pathogenic fungi, their drug sensitivity, and the minimum inhibitory concentration (MIC) of fluconazole were compared between the two groups. We also analyzed differences in short-term adverse outcomes, such as drug-induced liver or renal function disruption, fungal-attributable death, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC), between the groups. The effects of the prophylactic fluconazole strategy on NCFI and short-term adverse outcomes were assessed by multivariate logistic regression. Results: Candida albicans (46.7%) and Candida glabrata (43.3%) were the main culprit pathogens causing NCFI. The incidence of NCFI was significantly lower in the prophylaxis group than in the rescue group (15.9 vs. 45.8%, P < 0.001). However, fewer fungi were completely sensitive to fluconazole (40 vs. 85%, P < 0.05) and the MIC of fluconazole was higher [16.0 (3.5 ~ 16.0) vs. 3.0 (1.0 ~ 8.0) μg/ml, P < 0.001] in the prophylaxis group than in the rescue group. Compared with the rescue group, the prophylaxis group had a lower risk of NCFI (adjusted OR 0.25; 95% CI 0.11, 0.55). Additionally, the prophylaxis group had significantly lower risks of combined outcomes (one or more complications, such as BPD, ROP needing interventions, PVL/IVH (grade > 2), NEC stage ≥2, and fungal-attributable death) (adjusted OR 0.44; 95% CI 0.21, 0.92). There was no significant difference in serum alanine transferase (ALT), aspartate transaminase (AST), creatinine (Cr), or direct bilirubin (DBIL) levels between the two groups. Conclusions: Fluconazole prophylaxis reduced NCFI and improved combined clinical outcomes in very premature infants, with no increased risks of serious short-term adverse side effects; however, the MIC of fluconazole showed significant increases. Therefore, further optimization of preventive strategies is necessary to maintain the sensitivity of fluconazole against fungal isolates.
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Affiliation(s)
- Deshuang Zhang
- Division of Neonatology, Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Dongke Xie
- Department of Pediatric Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Na He
- Division of Neonatology, Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaoling Wang
- Division of Neonatology, Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenbin Dong
- Division of Neonatology, Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaoping Lei
- Division of Neonatology, Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, Luzhou, China.,Department of Perinatology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Synthesis, Optimization, Antifungal Activity, Selectivity, and CYP51 Binding of New 2-Aryl-3-azolyl-1-indolyl-propan-2-ols. Pharmaceuticals (Basel) 2020; 13:ph13080186. [PMID: 32784450 PMCID: PMC7464559 DOI: 10.3390/ph13080186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/29/2020] [Accepted: 08/05/2020] [Indexed: 12/14/2022] Open
Abstract
A series of 2-aryl-3-azolyl-1-indolyl-propan-2-ols was designed as new analogs of fluconazole (FLC) by replacing one of its two triazole moieties by an indole scaffold. Two different chemical approaches were then developed. The first one, in seven steps, involved the synthesis of the key intermediate 1-(1H-benzotriazol-1-yl)methyl-1H-indole and the final opening of oxiranes by imidazole or 1H-1,2,4-triazole. The second route allowed access to the target compounds in only three steps, this time with the ring opening by indole and analogs. Twenty azole derivatives were tested against Candida albicans and other Candida species. The enantiomers of the best anti-Candida compound, 2-(2,4-dichlorophenyl)-3-(1H-indol-1-yl)-1-(1H-1,2,4-triazol-1-yl)-propan-2-ol (8g), were analyzed by X-ray diffraction to determine their absolute configuration. The (−)-8g enantiomer (Minimum inhibitory concentration (MIC) = IC80 = 0.000256 µg/mL on C. albicans CA98001) was found with the S-absolute configuration. In contrast the (+)-8g enantiomer was found with the R-absolute configuration (MIC = 0.023 µg/mL on C. albicans CA98001). By comparison, the MIC value for FLC was determined as 0.020 µg/mL for the same clinical isolate. Additionally, molecular docking calculations and molecular dynamics simulations were carried out using a crystal structure of Candida albicans lanosterol 14α-demethylase (CaCYP51). The (−)-(S)-8g enantiomer aligned with the positioning of posaconazole within both the heme and access channel binding sites, which was consistent with its biological results. All target compounds have been also studied against human fetal lung fibroblast (MRC-5) cells. Finally, the selectivity of four compounds on a panel of human P450-dependent enzymes (CYP19, CYP17, CYP26A1, CYP11B1, and CYP11B2) was investigated.
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Mesek I, Nellis G, Lass J, Metsvaht T, Varendi H, Visk H, Turner MA, Nunn AJ, Duncan J, Lutsar I. Medicines prescription patterns in European neonatal units. Int J Clin Pharm 2019; 41:1578-1591. [PMID: 31625122 DOI: 10.1007/s11096-019-00923-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
Abstract
Background Hospitalized neonates receive the highest number of drugs compared to all other age groups, but consumption rates vary between studies depending on patient characteristics and local practices. There are no large-scale international studies on drug use in neonatal units. Objective We aimed to describe drug use in European neonatal units and characterize its associations with geographic region and gestational age. Setting A one-day point prevalence study was performed as part of the European Study of Neonatal Exposure to Excipients from January to June 2012. Method All neonatal prescriptions and demographic data were registered in a web-based database. The impact of gestational age and region on prescription rate were analysed with logistic regression. Main outcome measure The number and variety of drugs prescribed to hospitalized neonates in different gestational age groups and geographic regions. Results In total, 21 European countries with 89 neonatal units participated. Altogether 2173 prescriptions given to 726 neonates were registered. The 10 drugs with the highest prescription rate were multivitamins, vitamin D, caffeine, gentamicin, amino acids for parenteral nutrition, phytomenadione, ampicillin, benzylpenicillin, fat emulsion for parenteral nutrition and probiotics. The six most commonly prescribed ATC groups (alimentary tract and metabolism, blood and blood-forming organs, systemic anti-infectives, nervous, respiratory and cardiovascular system) covered 98% of prescriptions. Gestational age significantly affected the use of all commonly used drug groups. Geographic region influenced the use of alimentary tract and metabolism, blood and blood-forming organs, systemic anti-infectives, nervous and respiratory system drugs. Conclusion While gestational age-dependent differences in neonatal drug use were expected, regional variations (except for systemic anti-infectives) indicate a need for cooperation in developing harmonized evidence-based guidelines and suggest priorities for collaborative work.
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Affiliation(s)
- Inge Mesek
- Department of Microbiology, University of Tartu, Tartu, Estonia.
| | - Georgi Nellis
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Neonatal Unit, Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Jana Lass
- Department of Microbiology, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Tuuli Metsvaht
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Clinic of Anaesthesiology and Intensive Care, Paediatric Intensive Care Unit, Tartu University Hospital, Tartu, Estonia
| | - Heili Varendi
- Department of Paediatrics, University of Tartu, Tartu, Estonia.,Neonatal Unit, Children's Clinic, Tartu University Hospital, Tartu, Estonia
| | - Helle Visk
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Anthony J Nunn
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Jennifer Duncan
- Paediatric Medicines Research Unit (PMRU), Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
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Leroux S, Jacqz-Aigrain E, Elie V, Legrand F, Barin-Le Guellec C, Aurich B, Biran V, Dusang B, Goudjil S, Coopman S, Garcia Sanchez R, Zhao W, Manzoni P. Pharmacokinetics and safety of fluconazole and micafungin in neonates with systemic candidiasis: a randomized, open-label clinical trial. Br J Clin Pharmacol 2018; 84:1989-1999. [PMID: 29744900 DOI: 10.1111/bcp.13628] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/11/2018] [Accepted: 04/23/2018] [Indexed: 11/29/2022] Open
Abstract
AIMS The pharmacokinetics (PK) of fluconazole and micafungin differ in neonates compared with children and adults. Dosing instructions in product labels appear to be inconsistent with the emerging scientific evidence. Limited information is available on the safety profile of these agents in neonates. Our objective was to study the population PK and safety of both drugs, randomly administered in neonates with suspected or confirmed systemic candidiasis. METHODS Neonates were randomized 1:1 to fluconazole (loading dose 25 mg kg-1 ; maintenance dose 12 mg kg-1 day-1 or 20 mg kg-1 day-1 , respectively, for infants <30 weeks or ≥30 weeks' corrected gestational age) or micafungin (loading dose 15 mg kg-1 day-1 ; maintenance dose 10 mg kg-1 day-1 ). PK samples were taken on treatment days 1 and 5. Population parameters were determined using NONMEM and Monte Carlo simulations performed to reach predefined targets. Clinical and laboratory data, and adverse events were collected up to 36 weeks' corrected gestational age or hospital discharge. RESULTS Thirty-six neonates were enrolled. The median (range) gestational age was 28.2 (24.1-40.1) and 26.8 (23.5-40.0) weeks for fluconazole and micafungin, respectively. Based on 163 PK samples, the median population clearance (l h-1 kg-1 ) and volume of distribution (l kg-1 ) for fluconazole were: 0.015 [95% confidence interval (CI) 0.008, 0.039] and 0.913, and for micafungin were: 0.020 (95% CI 0.010, 0.023) and 0.354 (95% CI 0.225, 0.482), respectively. The loading dose was well tolerated. No adverse events associated with micafungin or fluconazole were reported. CONCLUSION Based on Monte Carlo simulations, a loading dose for fluconazole and dosing higher than recommended for both drugs are required to increase the area under the plasma drug concentration-time curve target attainment rate in neonates.
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Affiliation(s)
- S Leroux
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - E Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | | | - F Legrand
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - C Barin-Le Guellec
- EA4245, Faculté de Médecine, Université François Rabelais, Tours, France
| | - B Aurich
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - V Biran
- UMR 1141 INSERM, Université Paris 7-Diderot, Neonatal Intensive Care Unit, Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - B Dusang
- Neonatal Intensive Care Unit, CHU de La Réunion, Saint Pierre, La Réunion, France
| | - S Goudjil
- Neonatal Care Unit, CHU Amiens, Amiens, France
| | - S Coopman
- Centre d'Investigation Clinique, CIC1403, Lille University Hospital, Lille, France
| | | | - W Zhao
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center 1426 Robert-Debré Paediatric Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - P Manzoni
- Neonatal Intensive Care Unit, S. Anna Hospital, Torino, Italy
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Sakita KM, Faria DR, Silva EMD, Tobaldini-Valério FK, Kioshima ES, Svidzinski TIE, Bonfim-Mendonça PDS. Healthcare workers' hands as a vehicle for the transmission of virulent strains of Candida spp.: A virulence factor approach. Microb Pathog 2017; 113:225-232. [PMID: 29074432 DOI: 10.1016/j.micpath.2017.10.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/11/2017] [Accepted: 10/22/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although the majority of Candida infections are thought to come from endogenous sources, the healthcare workers' (HCWs) hands are being increasingly reported as vehicles for the transmission of pathogens. The aim of the present study was to evaluate the susceptibility of yeast isolated from the HCWs' hands and ICU (Intensive Care Unit) surfaces to antifungal agents and to determine the virulence potential and the genetic similarity between the same. METHODS The susceptibility of yeasts from the HCWs' hands (n = 57) and ICU surfaces (n = 98) to conventional antifungals (fluconazole, voriconazole, amphotericin B and micafungin) was evaluated using the broth microdilution assay accordance with CLSI M27-A3. Additionally, some virulence factors such as adhesion and biofilm capacity on abiotic surfaces and on endothelial cells were evaluated, as well as germ tube formation. The similarity among yeast isolates were evaluated by the RAPD technique using the P4, OPA18 and OPE18 primers. RESULTS Five species of Candida were found on the HCWs' hands (C. albicans, C. parapsilosis (sensu stricto), C. glabrata, C. tropicalis and C. krusei) and two on ICU surfaces (C. albicans and C. parapsilosis (sensu stricto)). The isolates from hands had higher resistance rates, with C. glabrata having the highest indices (100% FLU; 100% MFG). The similarity of C. albicans from HCWs and ICU surfaces was ≥80% according to the three primers analyzed. Candida spp. from hands had a greater potential for adhesion and biofilm formation on abiotic surfaces (p < 0.05). C. albicans from ICU surfaces had the greatest potential of adhesion on endothelial cells after 2 and 24 h, and presented high filamentation in SEM images and formed more and larger germ tubes (p < 0.05). CONCLUSION the present study showed the significant virulence potential of yeasts transmitted in the hospital environment for the first time. Additionally, healthy people working in the ICU can carry these yeasts, which are capable of surviving in hospital surfaces, on their hands, offering a risk to patients, especially those who are immunocompromised.
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Affiliation(s)
- Karina Mayumi Sakita
- Division of Medical Mycology, Teaching and Research Laboratory in Clinical Analyses, Department of Clinical Analysis of State University of Maringá, Paraná, Brazil
| | - Daniella Renata Faria
- Division of Medical Mycology, Teaching and Research Laboratory in Clinical Analyses, Department of Clinical Analysis of State University of Maringá, Paraná, Brazil
| | - Eliane Martins da Silva
- Division of Medical Mycology, Teaching and Research Laboratory in Clinical Analyses, Department of Clinical Analysis of State University of Maringá, Paraná, Brazil
| | - Flávia Kelly Tobaldini-Valério
- Division of Medical Mycology, Teaching and Research Laboratory in Clinical Analyses, Department of Clinical Analysis of State University of Maringá, Paraná, Brazil
| | - Erika Seki Kioshima
- Division of Medical Mycology, Teaching and Research Laboratory in Clinical Analyses, Department of Clinical Analysis of State University of Maringá, Paraná, Brazil
| | - Terezinha Inez Estivalet Svidzinski
- Division of Medical Mycology, Teaching and Research Laboratory in Clinical Analyses, Department of Clinical Analysis of State University of Maringá, Paraná, Brazil
| | - Patricia de Souza Bonfim-Mendonça
- Division of Medical Mycology, Teaching and Research Laboratory in Clinical Analyses, Department of Clinical Analysis of State University of Maringá, Paraná, Brazil.
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Performance of a Quantitative PCR-Based Assay and Beta-d-Glucan Detection for Diagnosis of Invasive Candidiasis in Very-Low-Birth-Weight Preterm Neonatal Patients (CANDINEO Study). J Clin Microbiol 2017; 55:2752-2764. [PMID: 28659321 PMCID: PMC5648711 DOI: 10.1128/jcm.00496-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/22/2017] [Indexed: 11/20/2022] Open
Abstract
An epidemiological, multicenter, noninterventional, observational case-control study was conducted to describe the performance of serum beta-d-glucan (BDG) and Candida PCR in blood, serum, and sterile samples for the diagnosis of invasive candidiasis (IC) in very-low-birth-weight (VLBW) preterm neonates and to compare these techniques with culture of samples from blood and other sterile sites. Seventeen centers participated in the study, and the number of episodes analyzed was 159. A total of 9 episodes of IC from 9 patients (7 confirmed and 2 probable) and 150 episodes of suspected sepsis from 117 controls were identified. The prevalence of IC was 5.7% (95% confidence interval [95% CI], 2.1 to 9.3). The mortality was significantly higher in episodes of IC (44.4%) than in the non-IC episodes (11.1%, P < 0.01). The sensitivity and specificity of the PCR performed on blood/serum samples were 87.5% and 81.6%, respectively. The sensitivity and specificity of the BDG results were lower (75.0% and 64.6%). For cases with negative culture results, the PCR and the BDG results were positive in 27 (17.4%) and 52 (33.5%) episodes, respectively. The presence of multiorgan failure, improvement with empirical antifungal therapy, thrombocytopenia, and Candida colonization were significantly associated (P < 0.01) with PCR or BDG positivity regardless of the results of the cultures. Serum BDG analysis and Candida PCR could be used as complementary diagnostic techniques to detect IC in VLBW neonates.
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Girardi A, Galletti S, Raschi E, Koci A, Poluzzi E, Faldella G, De Ponti F. Pattern of drug use among preterm neonates: results from an Italian neonatal intensive care unit. Ital J Pediatr 2017; 43:37. [PMID: 28412957 PMCID: PMC5392975 DOI: 10.1186/s13052-017-0354-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/30/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Drug use in preterm neonates admitted to Neonatal Intensive Care Unit (NICU) has been investigated, so far, in terms of unauthorized or off-label use; very little is known on the use of combinations of different active substances, which is frequently required in this population (prophylaxis of infections, treatment of concomitant diseases). The aim of this study was to describe the most common patterns of drug use in an Italian NICU, focusing on those with nephrotoxic potential. METHODS Medical records of preterm neonates (<37 weeks of gestational age) weighing less than 1,500 g at birth and admitted to an Italian NICU were scrutinized in a 3-year retrospective investigation. Analysis included drug exposure, duration of therapies, co-administration of drugs with potential renal side effects; also daily protein supplement was calculated from parenteral nutrition. RESULTS A cohort of 159 preterm neonates was selected; 68 were born weighing less than 1,000 g (extremely low birth weight infants, ELBW, Group A), 91 weighed between 1,000 and 1,500 g at birth (Group B). Compared to Group B, neonates of Group A were more likely to receive pharmacological treatments: the most used drugs were antibiotics (especially ampicillin and amikacin, p = .07 and p < .001, respectively), antifungals (especially fluconazole, p < .001), and diuretics (especially furosemide, p < .001). Analysis of co-administration of drugs with potential nephrotoxicity showed ampicillin and amikacin as the most reported combination (94.1% of Group A and 31.9% of Group B), the combination of furosemide with antibacterials (ampicillin or amikacin) was also frequently reported, with average period of combination shorter than 2 days. CONCLUSIONS ELBW infants were exposed to a higher number of drugs compared to other neonates and were more likely to receive associations of drugs with nephrotoxic potential (e.g. furosemide and amikacin), though only for short cycles. Further studies should evaluate the safety profile (especially potential renal side effects) related to most commonly used combinations.
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Affiliation(s)
- A Girardi
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - S Galletti
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - E Raschi
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - A Koci
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - E Poluzzi
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - G Faldella
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - F De Ponti
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy. .,Present Address: Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48 40126, Bologna, Italy.
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11
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Desselas E, Pansieri C, Leroux S, Bonati M, Jacqz-Aigrain E. Drug versus placebo randomized controlled trials in neonates: A review of ClinicalTrials.gov registry. PLoS One 2017; 12:e0171760. [PMID: 28192509 PMCID: PMC5305102 DOI: 10.1371/journal.pone.0171760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 01/25/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Despite specific initiatives and identified needs, most neonatal drugs are still used off-label, with variable dosage administrations and schedules. In high risk preterm and term neonates, drug evaluation is challenging and randomized controlled trials (RCT) are difficult to conduct and even more is the use of a placebo, required in the absence of a reference validated drug to be used as comparator. METHODS We analyzed the complete ClinicalTrials.gov registry 1) to describe neonatal RCT involving a placebo, 2) to report on the medical context and ethical aspects of placebo use. RESULTS Placebo versus drug RCT (n = 146), either prevention trials (n = 57, 39%) or therapeutic interventions (n = 89, 61%), represent more than a third of neonatal trials registered in the National Institute of Health clinical trial database (USA) since 1999. They mainly concerned preterm infants, evaluating complications of prematurity. Most trials were conducted in the USA, were single centered, and funded by non-profit organizations. For the three top drug trials evaluating steroids (n = 13, 9.6%), erythropoietin (EPO, n = 10, 6.8%) and nitric oxide (NO, n = 9, 6.2%), the objectives of the trial and follow-up were analyzed in more details. CONCLUSION Although a matter of debate, the use of placebo should be promoted in neonates to evaluate a potential new treatment, in the absence of reference drug. Analysis of the trials evaluating steroids showed that long-term follow-up of exposed patients, although required by international guidelines, is frequently missing and should be planned to collect additional information and optimize drug evaluation in these high-risk patients.
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Affiliation(s)
- Emilie Desselas
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Claudia Pansieri
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Stephanie Leroux
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
| | - Maurizio Bonati
- Department of Public Health, Laboratory for Mother and Child Health, IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hopital Robert Debré, Paris, France
- Clinical Investigation Center INSERM CIC1426, Hopital Robert Debré, Paris, France
- Université Paris 7 Diderot, Paris, France
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12
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Huizing MJ, Villamor-Martínez E, Vento M, Villamor E. Pulse oximeter saturation target limits for preterm infants: a survey among European neonatal intensive care units. Eur J Pediatr 2017; 176:51-56. [PMID: 27853941 PMCID: PMC5219014 DOI: 10.1007/s00431-016-2804-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/27/2016] [Accepted: 10/31/2016] [Indexed: 11/27/2022]
Abstract
UNLABELLED The optimum range of pulse oximeter oxygen saturation (SpO2) for preterm infants remains controversial. Between November 2015 and February 2016, we conducted a web-based survey aimed to investigate the current and former practices on SpO2 targets in European neonatal intensive care units (NICUs). We obtained valid responses from 193 NICUs, treating 8590 newborns ≤28 weeks per year, across 27 countries. Forty different saturation ranges were reported, ranging from 82-93 to 94-99%. The most frequently utilized SpO2 ranges were 90-95% (28%), 88-95% (12%), 90-94% (5%), and 91-95% (5%). A total of 156 NICUs (81%) changed their SpO2 limits over the last 10 years. The most frequently reported former limits were 88-92% (18%), 85-95% (9%), 88-93 (7%), and 85-92% (6%). The NICUs that increased their SpO2 ranges expected to obtain a reduction in mortality. A 54% of the NICUs found the scientific evidence supporting their SpO2 targeting policy strong or very strong. CONCLUSION We detected a high degree of heterogeneity in pulse oximeter SpO2 target limits across European NICUs. The currently used limits are 3 to 5% higher than the former limits, and the most extreme limits, such as lower below 85% or upper above 96%, have almost been abandoned. What is Known: • For preterm infants requiring supplemental oxygen, the optimum range of pulse oximeter oxygen saturation (SpO 2 ) to minimize organ damage, without causing hypoxic injury, remains controversial. What is New: • This survey highlights the lack of consensus regarding SpO 2 target limits for preterm infants among European neonatal intensive care units (NICUs). We detected 40 different SpO 2 ranges, and even the most frequently reported range (i.e., 90-95%) was used in only 28% of the 193 respondent NICUs. • A total of 156 NICUs (81%) changed their SpO 2 limits over the last 10 years. The currently used limits are 3 to 5% higher than the former limits, and the most extreme limits, such as lower below 85% or upper above 96%, have almost been abandoned.
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Affiliation(s)
- Maurice J. Huizing
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Eduardo Villamor-Martínez
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Máximo Vento
- Division of Neonatology, University & Polytechnic Hospital La Fe, Valencia, Spain
| | - Eduardo Villamor
- Department of Pediatrics, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands
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Abstract
BACKGROUND Fluconazole prophylaxis (FP) in premature infants is well studied and has been shown to decrease invasive candidiasis (ICs). IC in neonates has significant financial costs; determining the cost-benefit of FP may provide additional justification for targeting high-risk neonates. We aimed to determine the IC rate in premature infants at which FP is cost-beneficial. METHODS A decision tree cost-analysis model using cost of FP related to costs associated with IC was used. We searched PubMed for all papers that used intravenous FP and reported rates of IC in very low birth weight neonates. Average IC rates in those who received FP (2.0%; range, 0-6.1%) and in those who did not receive FP (9.2%; range, 0-20.5%) were used. Incremental hospital costs because of IC and for FP were retrieved from the literature. Sensitivity analysis was performed to determine the incremental cost of FP across the range of published IC rates. RESULTS The average cost per patient attributed to IC in patients receiving FP was $785 versus $2617 in those not receiving FP. Sensitivity analysis demonstrates the rate of IC would need to be <2.8% for FP to lose its cost-benefit. In Monte Carlo simulation, targeting infants <1000 g would lead to $50,304,333 in cost savings per year in the United States. CONCLUSIONS FP provides a cost-advantage across most IC rates seen in the youngest premature infants. Using a rate of 2.8% for their individual high-risk neonatal intensive care unit patients, providers can determine if FP is cost-beneficial in determining for whom to provide IC prophylaxis.
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Austin N, Cleminson J, Darlow BA, McGuire W. Prophylactic oral/topical non-absorbed antifungal agents to prevent invasive fungal infection in very low birth weight infants. Cochrane Database Syst Rev 2015; 2015:CD003478. [PMID: 26497202 PMCID: PMC7154334 DOI: 10.1002/14651858.cd003478.pub5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very preterm or very low birth weight infants. Uncertainty exists about the effect of prophylactic oral/topical non-absorbed antifungals to reduce mucocutaneous colonisation and so limit the risk of invasive fungal infection in this population. OBJECTIVES To assess the effect of prophylactic oral/topical non-absorbed antifungal therapy on the incidence of invasive fungal infection, mortality and morbidity in very preterm or very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL: The Cochrane Library, 2015, Issue 7), MEDLINE, EMBASE, and CINAHL (to May 2015), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic oral/topical non-absorbed antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very preterm or very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS Four trials, in which a total of 1800 infants participated, compared oral/topical non-absorbed antifungal prophylaxis (nystatin or miconazole) with placebo or no drug. These trials had various methodological weaknesses including quasi-randomisation, lack of allocation concealment, and lack of blinding of intervention and outcomes assessment. The incidence of invasive fungal infection was very high in the control groups of three of these trials. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection (typical risk ratio 0.20, 95% confidence interval 0.14 to 0.27; risk difference -0.18, -0.21 to -0.15) but substantial statistical heterogeneity was present. We did not find a statistically significant effect on mortality (typical risk ratio 0.87, 0.72 to 1.05; risk difference -0.03, -0.06 to 0.01). None of the trials assessed posthospital discharge outcomes. Three trials (N = 326) assessed the effect of oral/topical non-absorbed versus systemic antifungal prophylaxis. Meta-analyses did not find any statistically significant differences in the incidences of invasive fungal infection or all-cause mortality. AUTHORS' CONCLUSIONS The finding of a reduction in risk of invasive fungal infection in very low birth weight infants treated with oral/topical non-absorbed antifungal prophylaxis should be interpreted cautiously because of methodological weaknesses in the included trials. Further large randomised controlled trials in current neonatal practice settings are needed to resolve this uncertainty. These trials might compare oral/topical non-absorbed antifungal agents with placebo, with each other, or with systemic antifungal agents and should include an assessment of effect on long-term neurodevelopmental outcomes.
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Affiliation(s)
- Nicola Austin
- Christchurch Womens HospitalNICUChristchurchNew Zealand
| | - Jemma Cleminson
- University of YorkAcademic Clinical Fellow in Child Health NIHR Centre for Reviews & DisseminationYorkUK
| | - Brian A Darlow
- Christchurch School of MedicineDepartment of PaediatricsPO Box 4345ChristchurchNew Zealand
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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Cleminson J, Austin N, McGuire W. Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants. Cochrane Database Syst Rev 2015; 2015:CD003850. [PMID: 26497056 PMCID: PMC7156892 DOI: 10.1002/14651858.cd003850.pub5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very preterm and very low birth weight infants. Early diagnosis is difficult and treatment is often delayed. Systemically absorbed antifungal agents (usually azoles) are increasingly used as prophylaxis against invasive fungal infection in this population. OBJECTIVES To assess the effect of prophylactic systemic antifungal therapy on mortality and morbidity in very preterm or very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 8), MEDLINE, EMBASE, and CINAHL (to May 2015), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic systemic antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS We identified 15 eligible trials enrolling a total of 1690 infants. Ten trials (1371 infants) compared systemic antifungal prophylaxis versus placebo or no drug. These trials were generally of good methodological quality. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection (typical risk ratio (RR) 0.43, 95% confidence interval (CI) 0.31 to 0.59; risk difference (RD) -0.09, 95% CI -0.12 to -0.06). The average incidence of invasive fungal infection in the control groups of the trials (16%) was much higher than that generally reported from large cohort studies. Meta-analysis did not find a statistically significant difference in the risk of death prior to hospital discharge (typical RR 0.79, 95% CI 0.61 to 1.02; typical RD -0.04, 95% CI -0.07 to 0.00). Very limited data on long-term neurodevelopmental outcomes were available. Three trials that compared systemic versus oral or topical non-absorbed antifungal prophylaxis did not detect any statistically significant effects on invasive fungal infection or mortality. Two trials that compared different dose regimens of prophylactic intravenous fluconazole did not detect any significant differences in infection rates or mortality. AUTHORS' CONCLUSIONS Prophylactic systemic antifungal therapy reduces the incidence of invasive fungal infection in very preterm or very low birth weight infants. This finding should be interpreted and applied cautiously since the incidence of invasive fungal infection was very high in the control groups of many of the included trials. Meta-analysis does not demonstrate a statistically significant effect on mortality. There are currently only limited data on the long-term neurodevelopmental consequences for infants exposed to this intervention. In addition, there is a need for further data on the effect of the intervention on the emergence of organisms with antifungal resistance.
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Affiliation(s)
- Jemma Cleminson
- University of YorkAcademic Clinical Fellow in Child Health NIHR Centre for Reviews & DisseminationYorkUK
| | - Nicola Austin
- Christchurch Womens HospitalNICUChristchurchNew Zealand
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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Off-label and unlicensed drug treatments in Neonatal Intensive Care Units: an Italian multicentre study. Eur J Clin Pharmacol 2015; 72:117-23. [DOI: 10.1007/s00228-015-1962-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/02/2015] [Indexed: 01/20/2023]
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17
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Metsvaht T, Nellis G, Varendi H, Nunn AJ, Graham S, Rieutord A, Storme T, McElnay J, Mulla H, Turner MA, Lutsar I. High variability in the dosing of commonly used antibiotics revealed by a Europe-wide point prevalence study: implications for research and dissemination. BMC Pediatr 2015; 15:41. [PMID: 25880733 PMCID: PMC4407781 DOI: 10.1186/s12887-015-0359-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic dosing in neonates varies between countries and centres, suggesting suboptimal exposures for some neonates. We aimed to describe variations and factors influencing the variability in the dosing of frequently used antibiotics in European NICUs to help define strategies for improvement. METHODS A sub-analysis of the European Study of Neonatal Exposure to Excipients point prevalence study was undertaken. Demographic data of neonates receiving any antibiotic on the study day within one of three two-week periods from January to June 2012, the dose, dosing interval and route of administration of each prescription were recorded. The British National Formulary for Children (BNFC) and Neofax were used as reference sources. Risk factors for deviations exceeding ±25% of the relevant BNFC dosage recommendation were identified by multivariate logistic regression analysis. RESULTS In 89 NICUs from 21 countries, 586 antibiotic prescriptions for 342 infants were reported. The twelve most frequently used antibiotics - gentamicin, penicillin G, ampicillin, vancomycin, amikacin, cefotaxime, ceftazidime, meropenem, amoxicillin, metronidazole, teicoplanin and flucloxacillin - covered 92% of systemic prescriptions. Glycopeptide class, GA <32 weeks, 5(th) minute Apgar score <5 and geographical region were associated with deviation from the BNFC dosage recommendation. While the doses of penicillins exceeded recommendations, antibiotics with safety concerns followed (gentamicin) or were dosed below (vancomycin) recommendations. CONCLUSIONS The current lack of compliance with existing dosing recommendations for neonates needs to be overcome through the conduct of well-designed clinical trials with a limited number of antibiotics to define pharmacokinetics/pharmacodynamics, efficacy and safety in this population and by efficient dissemination of the results.
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Affiliation(s)
- Tuuli Metsvaht
- Institute of Microbiology, Tartu University, Tartu, Estonia. .,Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
| | - Georgi Nellis
- Institute of Microbiology, Tartu University, Tartu, Estonia. .,Children's Clinic, Tartu University Hospital, Tartu, Estonia.
| | - Heili Varendi
- Children's Clinic, Tartu University Hospital, Tartu, Estonia.
| | - Anthony J Nunn
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - Susan Graham
- Research and Development, Liverpool women's NHS Foundation Trust, Liverpool, UK.
| | - Andre Rieutord
- Pharmacy Department, Hospital Antoine Beclère, Paris, France.
| | - Thomas Storme
- Pharmacy Department, APHP, Hospital Robert Debré, Paris, France.
| | - James McElnay
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK.
| | - Hussain Mulla
- Department of Pharmacy, University Hospitals of Leicester, Leicester, UK.
| | - Mark A Turner
- Department of Women's and Children's Health, Institute of Translational Medicine, Liverpool Women's NHS Foundation Trust, University of Liverpool, Liverpool, UK.
| | - Irja Lutsar
- Institute of Microbiology, Tartu University, Tartu, Estonia.
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Affiliation(s)
- Claudia Pansieri
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - Chiara Pandolfini
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - Evelyne Jacqz-Aigrain
- Service de Pharmacologie Pédiatrique, AP-HP, Hôpital Robert Debré, Paris, France Université Paris Diderot, Sorbonne Paris Cité, France INSERM, CIC1426, Hôpital Robert Debré, Paris, France
| | - John van den Anker
- Division of Pediatric Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA Department of Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, IRCCS-Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
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Swanson JR, Gurka MJ, Kaufman DA. Risk Factors for Invasive Fungal Infection in Premature Infants: Enhancing a Targeted Prevention Approach. J Pediatric Infect Dis Soc 2014; 3:49-56. [PMID: 26624907 DOI: 10.1093/jpids/pit068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 07/27/2013] [Indexed: 11/13/2022]
Abstract
BACKGROUND Premature infants are at high risk of developing invasive candidal infections (ICI). We investigated maternal and perinatal risk factors for ICI that may help in defining at-risk infants, allowing more targeted antifungal prophylaxis to prevent morbidity and mortality. METHODS Maternal and neonatal data from infants with a birthweight between 500 and 1250 g admitted across 95 neonatal intenisve care units were analyzed for risk factors for ICI. RESULTS Data from 1890 infants were analyzed, 78 of whom had ICI. Overall mortality was 20.5% for all cases of ICI, 18.8% with candidemia, 17.2% with candiduria, and 75% when Candida was isolated in both the blood and urine. Birthweight, gestational age, male sex, and vaginal delivery were predictors of infection on univariate analysis. After logistic regression, gestational age (P < .01) and male sex (P < .01) remained significant. Vaginal birth and receiving antibiotics during the first week of life increased the risk for ICI in the 22-25 weeks' and 26-28 weeks' gestation subgroups. CONCLUSIONS Gestational age and male gender are risk factors for the development of ICI, whereas vaginal delivery and antibiotics during the first week further increase the incidence in the more premature infants. Knowing maternal and perinatal risk factors for ICI allows more targeted antifungal prophylaxis in at-risk infants.
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Affiliation(s)
| | - Matthew J Gurka
- Department of Biostatistics, West Virginia University, Morgantown
| | - David A Kaufman
- Department of Pediatrics, University of Virginia, Charlottesville
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Ureaplasma, bronchopulmonary dysplasia, and azithromycin in European neonatal intensive care units: a survey. Sci Rep 2014; 4:4076. [PMID: 24518104 PMCID: PMC5379254 DOI: 10.1038/srep04076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 01/27/2014] [Indexed: 11/08/2022] Open
Abstract
A survey was set up to gauge the opinions of neonatologists on the role of Ureaplasma in bronchopulmonary dysplasia (BPD) development, the use of azithromycin for BPD prevention, and the factors influencing azithromycin use in European neonatal intensive care units (NICUs). 167 NICUs participated in the survey, representing 28 European countries. For respondents, the two major perceived risk factors for BPD were prematurity of <28 weeks and high oxygen requirements. Only 38% of NICUs had a protocol for BPD prevention and 47% routinely tested for Ureaplasma. In cases of infection, macrolides were the first choice. Most (78%) NICUs were interested in participating in a trial evaluating azithromycin safety and efficacy in reducing BPD rates. Opinions and clinical practice varied between European neonatal units, and differences in Ureaplasma treatment and prevention of BPD highlight the need for further azithromycin evaluation and for improved therapeutic knowledge in preterms.
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Austin N, McGuire W. Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants. Cochrane Database Syst Rev 2013:CD003850. [PMID: 23633315 DOI: 10.1002/14651858.cd003850.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very low birth weight infants. Early diagnosis is difficult and treatment is often delayed. Systemic antifungal agents (usually azoles) are increasingly used as prophylaxis against invasive fungal infection. OBJECTIVES To assess the effect of prophylactic systemic antifungal therapy on mortality and morbidity in very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 3), MEDLINE, EMBASE, and CINAHL (to August 2012), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic systemic antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS We identified 11 eligible trials enrolling a total of 1136 infants. Seven trials (involving 880 infants) compared systemic antifungal prophylaxis versus placebo or no drug. These trials were generally small but of good methodological quality. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection in infants who received systemic antifungal prophylaxis (typical risk ratio (RR) 0.41, 95% confidence interval (CI) 0.27 to 0.61; risk difference (RD) -0.09, 95% CI -0.14 to -0.05). The average incidence of invasive fungal infection in the control groups of the trials (16%) was much higher than that generally reported from large cohort studies (< 5%). Meta-analysis did not find a statistically significant difference in the risk of death prior to hospital discharge (typical RR 0.74, 95% CI 0.52 to 1.05; RD -0.04, 95% CI -0.08 to 0.01). Very limited data on long-term neurodevelopmental outcomes were available. Two trials that compared systemic versus oral or topical non-absorbed antifungal prophylaxis did not detect any statistically significant effects on invasive fungal infection or mortality. Two trials that compared different dose regimens of prophylactic intravenous fluconazole did not detect any significant differences in infection rates or mortality. AUTHORS' CONCLUSIONS Prophylactic systemic antifungal therapy reduces the incidence of invasive fungal infection in very low birth weight infants. This finding should be interpreted and applied cautiously since the incidence of invasive fungal infection was very high in the control groups of most of the included trials. Meta-analysis does not demonstrate a statistically significant effect on mortality. There are currently only limited data on the long-term neurodevelopmental consequences for infants exposed to this intervention. In addition, there is a need for further data on the effect of the intervention on the emergence of organisms with antifungal resistance.
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Affiliation(s)
- Nicola Austin
- NICU, Christchurch Womens Hospital, Christchurch, New Zealand
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Austin N, Darlow BA, McGuire W. Prophylactic oral/topical non-absorbed antifungal agents to prevent invasive fungal infection in very low birth weight infants. Cochrane Database Syst Rev 2013:CD003478. [PMID: 23543519 DOI: 10.1002/14651858.cd003478.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very preterm or very low birth weight infants. Uncertainty exists about the effect of prophylactic oral/topical non-absorbed antifungals to reduce mucocutaneous colonisation and so limit the risk of invasive fungal infection in this population. OBJECTIVES To assess the effect of prophylactic oral/topical non-absorbed antifungal therapy on the incidence of invasive fungal infection, mortality and morbidity in very preterm or very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL: The Cochrane Library, 2012, Issue 3), MEDLINE, EMBASE, and CINAHL (to August 2012), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic oral/topical non-absorbed antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very preterm or very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS Four trials, in which a total of 1800 infants participated, compared oral/topical non-absorbed antifungal prophylaxis (nystatin or miconazole) with placebo or no drug. These trials had various methodological weaknesses including quasi-randomisation, lack of allocation concealment, and lack of blinding of intervention and outcomes assessment. The incidence of invasive fungal infection was very high in the control groups of three of these trials. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection [typical risk ratio 0.20 (95% confidence interval 0.14 to 0.27); risk difference -0.18 (-0.21 to -0.16)] but substantial statistical heterogeneity was present. We did not find a statistically significant effect on mortality [typical risk ratio 0.87 (0.72 to 1.05); risk difference -0.03 (-0.06 to 0.01)]. None of the trials assessed posthospital discharge outcomes.Two trials (N = 265) assessed the effect of oral/topical non-absorbed versus systemic antifungal prophylaxis. Meta-analyses did not find any statistically significant differences in the incidences of invasive fungal infection or all-cause mortality. AUTHORS' CONCLUSIONS The finding of a reduction in risk of invasive fungal infection in very low birth weight infants treated with oral/topical non-absorbed antifungal prophylaxis should be interpreted cautiously because of methodological weaknesses in the included trials. Further large randomised controlled trials in current neonatal practice settings are needed to resolve this uncertainty. These trials might compare oral/topical non-absorbed antifungal agents with placebo, with each other, or with systemic antifungal agents and should include an assessment of effect on long-term neurodevelopmental outcomes.
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Affiliation(s)
- Nicola Austin
- NICU, Christchurch Womens Hospital, Christchurch, New Zealand.
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Pandolfini C, Marco S, Paolo M, Maurizio B. The use of ciprofloxacin and fluconazole in Italian neonatal intensive care units: a nationwide survey. BMC Pediatr 2013; 13:5. [PMID: 23294560 PMCID: PMC3546886 DOI: 10.1186/1471-2431-13-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 12/28/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment and prophylaxis of sepsis in very low birth weight neonates is a matter of concern and research is being undertaken with the aim to give rise to shared approaches based on solid evidence. As part of a European initiative, a survey was set up to describe the use of two drugs in this area. The Italian national practices concerning neonatal sepsis, as well as calls for related guidance, are described. METHODS A standardized and previously tested questionnaire was submitted online to all Italian level III NICUs. A 5-point Likert scale was used to analyze attitudinal replies. Categorical variables were compared by χ2 analysis and 2-tailed P-values are reported. RESULTS Data was provided by 38 Italian NICUs (36% of the country's level III centers), 53% of which have 1-10 cases of bacterial sepsis monthly and 90% a prevalence of <1% fungal infections. Ciprofloxacin and fluconazole treatment for neonatal sepsis are scantly used in Italian NICUs (13% and 45%, respectively). Major concerns are related to the safety of ciprofloxacin and the efficacy of fluconazole. On the contrary, prophylaxis of fungal infections is a routine approach in many Italian NICUs. The use of both ciprofloxacin and fluconazole is characterized by a large inter-NICU variability in dose and scheme of use. The lack of adequate, shared evidence is a common consideration made by the survey participants. CONCLUSIONS Common approaches are needed to standardize and update a national drug strategy for the prevention and treatment of sepsis in very low birth weight newborns. This can be achieved through collaborative initiatives aimed at setting up guidelines, based on available data, and multicenter trials to produce new evidence that will address the knowledge gaps.
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Affiliation(s)
- Chiara Pandolfini
- Laboratory for Mother and Child Health, Department of Public Health “Mario Negri” Pharmacological Research Institute, Milan, Italy
| | - Sequi Marco
- Laboratory for Mother and Child Health, Department of Public Health “Mario Negri” Pharmacological Research Institute, Milan, Italy
| | - Manzoni Paolo
- Neonatology and Hospital Neonatal Intensive Care Unit, Azienda Ospedaliera Regina Margherita – Sant’Anna, Turin, Italy
| | - Bonati Maurizio
- Laboratory for Mother and Child Health, Department of Public Health “Mario Negri” Pharmacological Research Institute, Milan, Italy
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Pandolfini C, Kaguelidou F, Sequi M, Jacqz-Aigrain E, Choonara I, Turner MA, Manzoni P, Bonati M. Wide intra- and inter-country variability in drug use and dosage in very-low-birth-weight newborns with severe infections. Eur J Clin Pharmacol 2012; 69:1031-6. [PMID: 23052414 PMCID: PMC3621995 DOI: 10.1007/s00228-012-1415-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 09/18/2012] [Indexed: 11/01/2022]
Abstract
PURPOSE To describe the use of ciprofloxacin and fluconazole for the treatment of sepsis in European neonatal intensive care units (NICUs) in order to better orient research aimed at acquiring essential knowledge in this critical area. METHODS The survey consisted of an online questionnaire for all participating NICUs on treatment schemes employed, rationales behind drug choices and interest in participation in research involving the two drugs. RESULTS A total of 189 level II and III NICUs participated in the survey, representing 25 countries, with Italy, UK and France providing the greatest number of centres (54 % of total). Ciprofloxacin is used in 25 % of NICUs that responded, although the indications for administering it vary between centres and the dosage ranges vary considerably, with 25 % of NICUs giving ≤10 mg/kg/day and another 25 % giving ≥21 mg/kg/day. Factors given as affecting the decision to use ciprofloxacin are uncertainty about its safety and pharmacokinetics and level of penetration in the cerebrospinal fluid. Among the 70 % of responding units that use fluconazole to treat fungal infection, 45 % administer 6 mg/kg unit doses while 33 % administer 12 mg/kg; 41 % of NICUs use a 24-h interval between administrations while 20 % wait 72 h. Among the responding NICUs, 57 % were willing to participate in a project on ciprofloxacin and 59 % would consider participating in a randomized controlled trial evaluating fluconazole versus micafungin. CONCLUSIONS Great variability in therapies exists within and between countries. Numerous centres are interested in participating in research on these drugs, highlighting the need for further knowledge on sepsis treatment and European centres' interest in off-patent medicine research.
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Affiliation(s)
- Chiara Pandolfini
- Laboratory for Mother and Child Health, Department of Public Health "Mario Negri" Pharmacological Research Institute, Via Giuseppe la Masa 19, 20156 Milan, Italy.
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Castagnola E, Jacqz-Aigrain E, Kaguelidou F, Maragliano R, Stronati M, Rizzollo S, Farina D, Manzoni P. Fluconazole use and safety in the nursery. Early Hum Dev 2012; 88 Suppl 2:S11-5. [PMID: 22633503 DOI: 10.1016/s0378-3782(12)70005-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Fluconazole is a triazole antifungal agent that is widely used in the nursery. It is available in both intravenous and oral formulation, and is active against most of the fungal pathogens that require treatment when retrieved from culture samples in neonatal intensive care units. Although clinical use has been wide for over 15 years, there have been small safety and efficacy studies completed in young infants. Randomised clinical trials assessing effectiveness of this agent in prevention of systemic fungal infections in neonates have been published in the last decade, and one large additional randomised study has been recently completed. Nevertheless, a certain degree of uncertainty still exists regarding the kinetics and appropriate dosing of this agent in premature and term infants, as well as regarding safety. Areas of poignant debate include the feasibility of loading dose strategies, appropriate dosages in the early days of life in the different subgroups of preterm infants, and long-term safety of fluconazole administered in prophylaxis during the first weeks of life in extremely premature infants. This paper reviews the most recent evidence on fluconazole and its role in the NICU settings.
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MESH Headings
- Antifungal Agents/administration & dosage
- Antifungal Agents/adverse effects
- Antifungal Agents/therapeutic use
- Candida/drug effects
- Candidiasis, Invasive/drug therapy
- Candidiasis, Invasive/prevention & control
- Fluconazole/administration & dosage
- Fluconazole/adverse effects
- Fluconazole/therapeutic use
- Humans
- Infant
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/microbiology
- Intensive Care Units, Neonatal
- Nurseries, Infant
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Affiliation(s)
- E Castagnola
- Infectious Disease Unit, Gaslini Institute, Genova, Italy
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Manzoni P, Stronati M, Jacqz-Aigrain E, Maragliano R, Ruffinazzi G, Rizzollo S, Castagnola E, Farina D. Correct choices for correct treatments: key issues in the management of Candida infections in preterm neonates. Early Hum Dev 2012; 88 Suppl 2:S98-S100. [PMID: 22633526 DOI: 10.1016/s0378-3782(12)70026-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Invasive Candida infections (ICI) have a high burden of morbidity and mortality in the neonatal setting. Although the identification of effective prophylactic strategies has recently led to the prevention of many episodes of systemic fungal disease, the identification of effective treatment strategies is still a priority. The correct choice of the most appropriate antifungal drug for treatment of such infections requires specific expertise, as well as careful consideration of a number of variables related both to the characteristics of the patient and to the peculiarities of these infections in neonates. The ideal antifungal drug for preterm neonates should have a good ability to target fungal biofilms, in order to prevent or improve the course of end-organ localisations. It should also be active against fluconazole-resistant species, as well as safe enough to be used with no or limited interference with other neonatal drugs. In this view, the echinocandin class of antifungal agents has recently proven to be a suitable option for treatment. However, further studies are warranted to better establish kinetics and appropriate dosing of these agents in premature and term infants, as well as their ability to improve late outcomes of ICI.
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Affiliation(s)
- P Manzoni
- Neonatology and NICU, S Anna Hospital, Torino, Italy.
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Leibovitz E. Strategies for the prevention of neonatal candidiasis. Pediatr Neonatol 2012; 53:83-9. [PMID: 22503254 DOI: 10.1016/j.pedneo.2012.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Revised: 11/19/2011] [Accepted: 11/29/2011] [Indexed: 11/17/2022] Open
Abstract
Invasive fungal infections represent the third-leading cause of late-onset sepsis in very-low-birth-weight infants (VLBWI) and have a high rate of infection-associated mortality. The infants at high risk for fungal sepsis are VLBWI with presence of additional risk factors that contribute to increased colonization and concentration of fungal organisms. Colonization with Candida spp. in neonates is secondary to either maternal vertical transmission or nosocomial acquisition in the nursery. Multiple sites may become colonized and a direct correlation between fungal colonization and subsequent progression to invasive candidemia was determined. Randomized, single and multiple-center, placebo-controlled trials found intravenous fluconazole prophylaxis to be effective in decreasing fungal colonization and sepsis for at-risk preterm infants <1500 g birth weight. The prophylactic use of fluconazole was found to be safe with no significant development of fungal resistance. Fluconazole prophylaxis administered to preterm neonates with birth weight <1000 g and/or 27 weeks' gestation or less has the potential of reducing and potentially eliminating invasive fungal infections and Candida-related mortality.
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Affiliation(s)
- Eugene Leibovitz
- Pediatric Emergency Medicine Department, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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