Empiric antifungal therapy and outcomes in extremely low birth weight infants with invasive candidiasis

Late-Onset Sepsis Evaluation and Empiric Therapy in Extremely Low Gestational Age Newborns

BACKGROUND

Little is known about late-onset sepsis (LOS) evaluations in extremely low gestational age newborns (ELGANs). We describe frequencies of LOS evaluation in ELGANs, infant characteristics, and empiric therapy choices during evaluations.

METHODS

Cohort study of infants 22-28 weeks gestational age (GA) discharged from 243 centers from 2009 to 2018, excluding infants with congenital anomalies, discharged or deceased prior to postnatal day (PND) 2, or admitted after PND 2. A new LOS evaluation was defined as the first blood culture obtained between PND 3 and 90, or one obtained ≥1 day following a negative culture and ≥10 days from prior positive cultures. We determined numbers of evaluations and percentage positive by GA, center, and over time. We described characteristics associated with positive evaluations, infants with LOS, and empiric antimicrobials. We calculated descriptive and comparative statistics using Wilcoxon rank sum, Fisher's exact, or Pearson chi-square tests, as appropriate.

RESULTS

Of 47,187 included infants, 67% had ≥1 LOS evaluation and 21% of evaluated infants had ≥1 LOS (culture positive) episode; 1.6 evaluations occurred per infant and 10% were positive. The percentage of infants evaluated and positive for LOS was higher at earlier GA. LOS was associated with inotrope support (15% vs. 9%; p < .001) and invasive mechanical ventilation (66% vs. 51%; p < .001). Infants with positive cultures were more likely than infants with negative cultures to receive empiric antimicrobials during the LOS evaluation (95% vs. 73%; p < .001).

CONCLUSIONS

Among ELGANs, earlier GA and postnatal age were associated with LOS evaluation and positive cultures. Most infants undergoing evaluation were started on empiric antimicrobials.

Neonatal infections: Insights from a multicenter longitudinal research collaborative

For more than 30 years, the Neonatal Research Network (NRN) has conducted studies addressing the epidemiology of neonatal infections, including incidence, microbiology, maternal and neonatal risk factors, associated clinical findings, and outcomes. These studies have provided clinicians and policymakers critical data needed to inform national guidance for infection risk assessment and support daily practice. Further, NRN studies have prompted research into optimal approaches to infection diagnosis, treatment, and antimicrobial stewardship. In this article, we summarize the key findings of NRN infection-related studies, with an emphasis on those published in 2000 or later.

Survival Outcome of Empirical Antifungal Therapy and the Value of Early Initiation: A Review of the Last Decade

AIM

This rapid systematic review aimed to collect the evidence published over the last decade on the effect of empirical antifungal therapy and its early initiation on survival rates.

METHODS

A systematic search was conducted in PubMed, Cochrane, Medline, Scopus, and Embase, in addition to a hand search and experts' suggestions.

RESULTS

Fourteen cohort studies and two randomized clinical trials reporting the survival outcome of empirical antifungal therapy were included in this review. Two studies reported the association between early empirical antifungal therapy (EAFT) and survival rates in a hematological cancer setting, and fourteen studies reported the outcome in patients in intensive care units (ICU). Six studies reported that appropriate EAFT decreases hospital mortality significantly; ten studies could not demonstrate a statistically significant association with mortality rates.

DISCUSSION

The inconsistency of the results in the literature can be attributed to the studies' small sample size and their heterogeneity. Many patients who may potentially benefit from such strategies were excluded from these studies.

CONCLUSION

While EAFT is practiced in many settings, current evidence is conflicting, and high-quality studies are needed to demonstrate the true value of this approach. Meanwhile, insights from experts in the field can help guide clinicians to initiate EAFT when indicated.

Invasive fungal infections in neonates: a review

Invasive fungal infections remain the leading causes of morbidity and mortality in neonates, especially preterm and very low birth weight infants. Most invasive fungal infections are due to Candida or Aspergillus species, and other fungi are increasingly reported and described. Appropriate identification and treatment are required to augment activity and reduce the toxicity of antifungal drugs. Successful use of antifungals in the vulnerable neonatal population is important for both prevention and treatment of infection. Strategies for prevention, including prophylactic antifungal therapy as well as reducing exposure to modifiable risk factors, like limiting antibiotic exposure, discontinuation of central catheters, and hand hygiene are key techniques to prevent and decrease rates of invasive fungal infections. In conclusion, this is a review of the most common causes, prevention strategies, prophylaxis, and treatment of invasive fungal infections in neonates.

Neonatal invasive candidiasis: updates on clinical management and prevention

Neonatal invasive candidiasis is an important cause of morbidity and mortality in preterm infants. The incidence of invasive candidiasis in this population has been declining in high-income settings, largely due to preventive measures, although there are still considerable variations in incidence between health-care centres. Surveillance data and large, multicentre studies in lower-income settings are not available, although preventive measures in these settings have been shown to decrease the incidence of neonatal invasive candidiasis. Understanding risk factors and pathogenesis are key to the prevention of invasive candidiasis. The difficulty of a definitive diagnosis of invasive candidiasis and the high risk for death or substantial neurodevelopmental impairment, even with appropriate treatment, further increase the need for effective preventive measures. In this Review, we examine the pathogenesis, clinical presentation, and diagnosis of invasive candidiasis. We highlight commonly used and emerging preventive and prophylactic measures, including standardised central line care, antibiotic stewardship, antifungal prophylaxis, and probiotics. Finally, we provide updates on empirical treatment, clinical management in confirmed cases of invasive candidiasis, and antifungal pharmacotherapy.

Treatment with Micafungin in a Preterm Neonate with an Invasive Candida parapsilosis Infection after a Severe Terlipressin-Induced Skin Necrosis

Candida parapsilosis infections are increasingly reported in preterm neonates, but the optimal treatment remains uncertain. We report the clinical history of an extremely preterm neonate, who developed a devastating skin necrosis due to terlipressin administration, with subsequent superinfection by Candida parapsilosis. The infant underwent multiple curettages and skin grafts to resolve skin lesions and was treated with systemic micafungin administration at a high dose (8 mg/kg/day), with resolution of the fungal infection.

Congenital Cutaneous Candidiasis With Systemic Dissemination in a Preterm Infant

Congenital cutaneous candidiasis is an infrequent invasive fungal infection that usually appears in the first days of life. Extremely low birth weight infants are the most frequently affected. Classic presentation includes diffuse extensive erythematous rash with papules, plaques, pustules and vesicles, which later undergoes desquamation. Systemic dissemination is common in extremely low birth weight infants. Blood, urine and cerebrospinal fluid evaluation should be included in the initial assessment. Early and prolonged treatment has been associated with decreased mortality. We report the case of congenital cutaneous candidiasis in a preterm infant. Early skin lesion recognition allowed establishing adequate treatment in the first hours of life.

Invasive candidiasis in a Brazilian neonatal intensive care unit

Abstract Objectives: to describe the epidemiology of invasive candidiasis in a neonatal intensive care unit. Methods: cross-sectional study that included all neonates with invasive candidiasis confirmed by blood culture from April 2015 to June 2018. Demographic, clinical and microbiological data were analyzed, comparing neonates with extreme low birth weight (ELBW) with neonates ≥ 1000g birth weight, considering a p <0.05 as statistically significant. Results: there were 38 cases of invasive candidiasis, resulting in an overall incidence of 2.5%. Twelve (32%) were ELBW neonates and 26 (68%) neonates ≥ 1000g birth weight, an incidence of 4.4% and 2.0%, respectively. Abdominal surgery was more frequent among neonates with birth weight ≥ 1000g compared to ELBW neonates (85% vs. 17%; p <0.01), as well as the median in days of antibiotics use (18 vs. 10.5; p = 0.04). The median in days of mechanical ventilation was more frequent among ELBW neonates (10 vs. 5.5; p = 0.04). The majority of Candida species were non-albicans (64%). Fatality rate was 32%. Conclusions: the incidence of invasive candidiasis among neonates with birth weight ≥ 1000g was higher than that found in the literature. This group has a higher proportion of gastrointestinal malformations that require surgery. Thus, fluconazole prophylaxis may be necessary for a broader group of neonates.

Neonatal fluid and electrolytes profile effect on amphotericin B associated nephrotoxicity in neonatal tertiary care unit of Karachi-Pakistan

OBJECTIVES

Amphotericin-B (d-AmB) has a broader anti-fungal spectrum and is used for neonatal invasive-fungal-infections especially invasive-candidiasis (IC). To prevent d-AmB-induced nephrotoxicity, renal protective effect of fluid and electrolyte management has been established among adults; in this study, the authors determined this effect among neonates.

METHODS

In this retrospective cohort study, the authors reviewed neonatal medical records, admitted to neonatal intensive care unit and received d-AmB therapy. Patients were divided into, renal-insufficiency-group (RIG) and the non-renal-insufficiency-group (NIG).

RESULTS

A total of 90 cases were analyzed, 41 composed RIG and 49 NIG. Renal insufficiency (RI) was developed on 1.7 (0.84) and 7.8 (1.21) days of d-AmB therapy in 26 (63%) and 15 (37%) cases respectively. Bivariate and multivariate analysis demonstrate that >4 m Eq/kg/d sodium intake across all-time points was significantly (p < 0.0001) associated with reduced risk of RI [(phase-I: AOR: 0.96; 95% CI: 0.91-0.99), (phase-II: AOR: 0.84; 95% CI: 0.68-0.92) and (phase-III: AOR: 0.90; 95% CI: 0.86-0.95)]. While adequate fluid intake reduced the likelihood of RI if started before and initial 2 days of d-AmB therapy.

CONCLUSIONS

Adequate hydration before and 48 hours after d-AmB therapy and >4 mEq/kg/day sodium intake before and through d-AmB therapy may protect neonatal RI.

Diagnostic accuracy of serum (1,3)-beta-d-glucan for neonatal invasive candidiasis: systematic review and meta-analysis

OBJECTIVES

Neonatal invasive candidiasis (NIC) is a leading cause of infection-related morbidity and mortality in preterm neonates. Several studies have shown that (1,3)-Beta-d-glucan (BDG) was accurate in detecting invasive fungal infection in adults, but studies in neonates are scarce. The aim was to obtain summary estimates of the accuracy of BDG detection in serum for the diagnosis of NIC.

METHODS

We searched Medline, Embase, Clinicaltrials.gov, and Google Scholar (inception to July 2019). We checked the reference lists of included studies, clinical guidelines, and review articles. We included studies that assessed the accuracy of BDG against a reference standard that defined groups of patients with ordinal levels of NIC probability (e.g. proven, probable, possible) and included fungal blood culture. Participants were neonates suspected of having NIC. The intervention was BDG measurement in serum (Fungitell® assay). We assessed risk of bias and applicability using QUADAS-2. We used bivariate meta-analysis to produce summary estimates of diagnostic accuracy at prespecified positivity thresholds of 80 and 120 pg/mL. This study was registered with PROSPERO (CRD42018089545).

RESULTS

We included eight studies (465 participants). Of these, two were judged at low overall risk of bias. There was substantial variability across studies in the reference standards used. At a positivity threshold of 80 pg/mL, summary estimates of sensitivity and specificity of BDG were 89% (95% CI: 80-94%) and 60% (53-66%), respectively; summary sensitivity for detecting proven cases of NIC was 99% (93-100%). At a positivity threshold of 120 pg/mL, summary estimates of sensitivity and specificity were 81% (71-88%) and 80% (67-88%), respectively.

CONCLUSIONS

Because of high sensitivity, BDG seems promising to rule-out NIC. It might be too early to recommend its use because of the scarcity of reliable clinical data, heterogeneity in case definitions, and unstable accuracy estimates.

Antifungal Drugs for Invasive Candida Infections (ICI) in Neonates: Future Perspectives

Fungal infections may complicate the neonatal clinical course, and the spectrum of therapies for their treatment in the perinatal period is limited. Polyenes, Azoles and Echinocandins represent the three classes of antifungal drugs commonly used in the neonatal period. The present review provides an overview about the most recent therapeutic strategies for the treatment of fungal infections in neonates.

Antifungal Treatment and Outcome in Very Low Birth Weight Infants: A Population-based Observational Study of the German Neonatal Network

BACKGROUND

The diagnostic proof of fungal infection in preterm infants is difficult. Antifungal treatment (AFT) is often initiated empirically when infants with suspected infection do not improve despite broad-spectrum antibiotic therapy. It was the aim of our study to determine the rate of exposure to empirical AFT in a large cohort of very low birth weight infants (VLBWI) of the German Neonatal Network and to address associated risks and outcomes.

METHODS

The epidemiologic database consisted of n = 13,343 VLBWI born in 54 German Neonatal Network centers between 2009 and 2015. AFT was defined as number of neonates who got any dose of at least one of the following antifungal drugs: fluconazole, amphotericin B, voriconazole and caspofungin (denominator: number of infants enrolled in German Neonatal Network) for treatment (not prophylaxis) of (suspected) fungal infection. Univariate and logistic regression analyses were used to identify risk factors for exposure to AFT and associated short-term morbidities and long-term outcomes at 5-year follow-up.

RESULTS

In our cohort, 724 out of 13,343 (5.4%) VLBWI were exposed to empiric AFT and had a mean gestational age of 25.7 (±2.1) weeks. Forty-four out of 13,343 (0.3%) had proven bloodstream infection with Candida spp. The main risk factors for exposure to AFT were gestational age, postnatal steroid treatment, need for abdominal surgery and use of carbapenems. Notably, AFT was associated with adverse outcomes such as bronchopulmonary dysplasia [adjusted odds ratio (OR): 1.9; 95% confidence interval (CI): 1.6-2.3; P < 0.001) and retinopathy of prematurity requiring intervention (adjusted OR: 1.69; 95% CI: 1.3-2.3; P <0.001) but not mortality. In the subgroup of infants available for 5-year follow-up (n = 895), exposure to AFT was associated with a risk for cerebral palsy (adjusted OR: 2.79; 95% CI: 1.11-7.04; P = 0.04) and intelligence quotient < 85 (adjusted OR: 2.07; 95% CI: 1.01-4.28; P = 0.049).

CONCLUSIONS

A significant proportion of VLBWI is exposed to AFT, specifically those born <26 weeks. Exposed infants were found to have a higher risk for adverse outcomes, which may reflect their significant vulnerability in general. Given the observational design of our study, it remains unclear whether potential side effects of empirical or target AFT itself contribute to adverse outcome. Future studies need to include risk-based strategies and stewardship programs to restrict the use of antifungal management in VLBWI.

Advances in the Treatment of Mycoses in Pediatric Patients

The main indications for antifungal drug administration in pediatrics are reviewed as well as an update of the data of antifungal agents and antifungal policies performed. Specifically, antifungal therapy in three main areas is updated as follows: a) Prophylaxis of premature neonates against invasive candidiasis; b) management of candidemia and meningoencephalitis in neonates; and c) prophylaxis, empiric therapy, and targeted antifungal therapy in children with primary or secondary immunodeficiencies. Fluconazole remains the most frequent antifungal prophylactic agent given to high-risk neonates and children. However, the emergence of fluconazole resistance, particularly in non-albicans Candida species, should be considered during preventive or empiric therapy. In very-low birth-weight neonates, although fluconazole is used as antifungal prophylaxis in neonatal intensive care units (NICU's) with relatively high incidence of invasive candidiasis (IC), its role is under continuous debate. Amphotericin B, primarily in its liposomal formulation, remains the mainstay of therapy for treating neonatal and pediatric yeast and mold infections. Voriconazole is indicated for mold infections except for mucormycosis in children >2 years. Newer triazoles-such as posaconazole and isavuconazole-as well as echinocandins, are either licensed or under study for first-line or salvage therapy, whereas combination therapy is kept for refractory cases.

Invasive fungal infection in neonatal intensive care units: a multicenter survey

This study assesses the epidemiology of invasive fungal infection (IFI) in Portuguese Neonatal Intensive Care Units (NICUs) and compares the effectiveness and safety of antifungal therapies. A survey concerning the period 2005-2010 was carried out in NICUs of Greater Lisbon. Among 10 473 admitted neonates, 44 cases were identified, 29 among extreme low birth weight neonates (65.9%). Cumulative incidence rate was 0.42% (95%CI 0.309-0.559). A central vascular catheter was present before IFI in all cases. Candida albicans and Candida parapsilosis were the most frequent isolates. The initial antifungic was fluconazole in 22 cases and liposomal amphotericin B (L-AmB) in 18. Therapy was switched in 10 patients on fluconazole and 3 on L-AmB. Case fatality rate was 11.4% (95%CI 4.39-23.91). No serious adverse drugs reactions (SADRs) or clinical side effects were observed. The knowledge of the local epidemiology helps to identify adequate prophylactic and treatment strategies.

Update on the management of Candida infections in preterm neonates

Invasive fungal infections in preterm neonates in the neonatal intensive care unit are predominantly caused by Candida spp, and have a high burden of morbidity and mortality. Effective prophylactic strategies have recently become available, but the identification of the best possible strategies to manage high-risk infants is still a priority. Choice and use of appropriate antifungal drugs needs careful assessment of neonatal characteristics, the epidemiology and drug pharmacokinetics. Ideally, antifungal drugs for preterm neonates should target fungal bio-films, prevent or effectively treat end-organ localisations, be active against fluconazole-resistant Candida species, and have reliable safety and tolerability profiles. The paper reviews the state-of-the-art in the area of neonatal fungal infections, and addresses some open questions related to the best possible prophylactic and therapeutic strategies to be implemented in such unique patients.

Platelet parameters and (1, 3)-β-D-glucan as a diagnostic and prognostic marker of invasive fungal disease in preterm infants

The diagnosis of neonatal invasive fungal disease (IFD) is difficult and often delayed. The platelet parameters and (1, 3)-β-D-Glucan (BG) may be useful for diagnosing IFD, but their diagnostic performance are not well characterized in neonates. We studied 63 preterm infants with IFD, 160 preterm infants without sepsis (preterm control), and 41 preterm infants with bacterial sepsis. Platelet parameters at the first day of onset of IFD and at the fourteenth day after antifungal treatment were evaluated. Serum BG was measured. Platelet count (PC), plateletcrit (PCT), and platelet distribution width (PDW) values were significantly lower, and mean platelet volume (MPV) values significantly higher in the IFD versus preterm control infants. PC and PCT values were much lower in infants with IFD versus bacterial sepsis, and there were significant differences in BG value between the two groups. After 14 days of antifungal treatment, significant elevations in PC, PCT, PDW and reductions in MPV levels in IFD group were observed. Receiver operating characteristic (ROC) curves showed that PC and PCT were strong predictors of IFD. The PC and PCT cut-offs for predicting IFD were 119.5 (sensitivity 78%, specificity 95%) and 0.21 (sensitivity 83%, specificity 85%), respectively. There were significant differences in PC and PCT levels between deceased and survived patients. The PC and PCT cut-offs for predicting deceased IFD were 39 (sensitivity 62%, specificity 86%) and 0.04 (sensitivity 50%, specificity 95%), respectively. The sensitivity in diagnosing IFD by a BG cutoff of ≥10pg/ml was 68.3% and specificity was 75.6%. PC and PCT levels in the BG ≥400 pg/ml group were significantly lower compared to the BG<400 pg/ml group. Platelet parameters and BG could be useful biomarkers for the diagnosis and prognosis of neonatal IFD.

No survival benefit with empirical vancomycin therapy for coagulase-negative staphylococcal bloodstream infections in infants

BACKGROUND

Coagulase-negative Staphylococcus (CoNS) is the most common cause of bloodstream infections (BSI) in hospitalized infants. CoNS BSI is most reliably treated with vancomycin; however, concerns about side effects and promoting resistance often delay empirical vancomycin therapy until culture results become available.

METHODS

All infants with CoNS BSI discharged from 348 neonatal intensive care units managed by the Pediatrix Medical Group from 1997 to 2012 were identified. Empirical vancomycin therapy was defined as vancomycin exposure on the day of the first positive blood culture. Delayed vancomycin therapy was defined as vancomycin exposure 1-3 days after the first positive blood culture. We used multivariable logistic regression with random effects for site to evaluate the association between the use of empirical vancomycin therapy versus delayed vancomycin therapy and 30-day mortality, controlling for gestational age, small-for-gestational age status, postnatal age on the day of the first positive culture, oxygen requirement, ventilator support and inotropic support on the day the first positive culture was obtained.

RESULTS

A total of 4364 infants with CoNS BSI were identified; 2848 (65%) were treated with empirical vancomycin. The median postnatal age at first positive culture was 14 days (interquartile range: 9, 21). Unadjusted 30-day mortality was similar for infants treated with empirical vancomycin and infants treated with delayed vancomycin therapy [166/2848 (6%) vs. 69/1516 (4%); P = 0.08]. There was no significant difference in 30-day mortality on multivariable analysis [odds ratio: 1.14 (0.84, 1.56)]. The median duration of bacteremia was 1 day longer for infants with delayed vancomycin therapy [4 days (interquartile range: 2, 6) vs. 3 days (2, 5); P < 0.0001].

CONCLUSIONS

The median duration of bacteremia was 1 day longer in infants with CoNS BSI who received delayed vancomycin therapy. Despite this finding, empirical vancomycin therapy for CoNS BSI was not associated with improved mortality.

New antifungal and antiviral dosing

Neonatal fungal and viral infections are associated with mortality and neurologic impairment among survivors. Advances in pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobial medications have led to improved dosing guidance for neonates. This article discusses the basic PK/PD properties and dosing of the most common antifungal and antiviral medications used in neonates.

Therapeutic strategies for invasive fungal infections in neonatal and pediatric patients: an update

INTRODUCTION

Invasive fungal infections (IFIs) in neonatal and pediatric patients are still associated with high morbidity and mortality, increased length of hospital stay and high healthcare cost. Two key components are prerequisite to combat pediatric IFIs; first, definition of the 'at-risk' populations that could benefit the most from prophylactic treatment and second, prompt initiation of effective antifungal therapy.

AREAS COVERED

In this article, updated prevention and targeted therapeutic approaches for IFIs in neonates and immunocompromised children are reviewed. Furthermore, European and American guidelines concerning IFI treatment in neonates and children are compared.

EXPERT OPINION

IFIs in neonates and children present substantial differences from adults in respect to their epidemiology, pharmacokinetics of antifungal agents and dosing as well as absence of interventional Phase III and IV clinical trials for guidance of evidence-based decisions. In the therapeutic armamentarium of these age groups, although amphotericin B formulations remain widely indicated, azoles with broader spectrum activity as well as echinocandins have been added in the updated antifungal treatment algorithm. Recent European guidelines (ESCMID and ECIL) contain specific recommendations for pediatric patients with IFIs. In both age groups, definitive updated guidance for prophylaxis and more importantly targeted treatment need to be further evaluated by large, multicenter, randomized controlled trials.

Use of Raman spectroscopy to decrease time for identifying the species of Candida growth in cultures

BACKGROUND

The objective of this study is to establish Raman signatures from pure cultures of different Candida species using Raman Spectroscopy (RS) and use these signatures for rapid identification of unknown Candida species.

METHODS

Pure cultures of five Candida species were evaluated using RS to build a limited signature library. 'Raman Processing' (RP) software was used for Principal Component Analysis (PCA) and Differential Functional Analysis (DFA).

RESULTS

Eleven principal components described at least 95% variance in the spectra. Raman signatures from these known Candida species were able to identify the species of unknown Candida cultures with 100% accuracy.

CONCLUSION

Raman spectroscopy can improve early identification of Candida species and may facilitate early optimal antifungal therapy.

Comparative effectiveness and practice variation in neonatal care

Comparative effectiveness research (CER) is a relatively new term for clinical research that directly assists patients, clinicians, and policymakers in making informed decisions to improve health care. In neonatology, there are similarities and differences between CER and existing clinical research and quality improvement literature. This article uses existing examples in neonatal literature to describe CER methodology and list some future directions and challenges in neonatal CER.

Neonatal candidiasis: diagnosis, prevention, and treatment

Infection with Candida species is associated with significant morbidity and mortality in infants. The incidence of Candida infection varies widely across centers, likely due to differences in practice related to modifiable risk factors such as exposure to empiric antibiotics and length of parenteral nutrition. Early diagnosis of Candida and prompt treatment with appropriate antifungal agents, such as fluconazole, amphotericin B deoxycholate, and micafungin, are critical for improved outcomes. This paper reviews the current literature relating to the prevention, diagnosis, and treatment of Candida infections in the neonatal intensive care unit.

Timely empiric antimicrobials are associated with faster microbiologic clearance in preterm neonates with late-onset bloodstream infections

AIM

The impact of timely empiric antimicrobial therapy on neonates is unclear. Our aim was to examine rates of effective timely empiric antimicrobial therapy on preterm neonates, together with the associated outcomes.

METHODS

We performed a single-centre retrospective study of preterm infants (<32 weeks of gestational age) with a late-onset (>72 h of age) bloodstream infection (BSI). Empiric antimicrobial administration took place before the results of blood culture were available and its timing was determined by the electronic medical records.

RESULTS

Our cohort (n = 105) was predominantly female (59%) and black (83%) with a mean (SD) gestational age of 27.4 (2.3) weeks and birthweight of 948 (335) g. Effective empiric antimicrobials were initiated in 114 (69%) of 165 BSI episodes, and a third of the BSIs without empiric antimicrobials were found to be fungal. Both antimicrobial timing (r = 0.27, p = 0.002) and fungal organism (r = 0.35, p = 0.0001) showed significant correlations and were independently associated with time to clearance. Neither variable was associated with survival or length of stay.

CONCLUSION

Two-thirds of preterm infants with late-onset BSIs received effective empiric antimicrobials. Timely empiric antimicrobials were associated with shorter time to microbiologic clearance. These data suggest the need for standardised guidelines and quality improvement initiatives.

Late-onset bloodstream infections of Very-Low-Birth-Weight infants: data from the Polish Neonatology Surveillance Network in 2009-2011

Background

Late-Onset Bloodstream Infections (LO-BSI) continue to be one of the most important complications associated with hospitalization of infants born with very low birth weight (VLBW). The aims of this study were to assess the epidemiology of LO-BSI together with the risk factors and the distribution of causative pathogens at six Polish neonatal intensive care units that participated in the Polish Neonatology Surveillance Network from January 1, 2009 to December 31, 2011.

Methods

The surveillance covered 1,695 infants whose birth weights were <1501 grams (VLBW) in whom LO-BSI was diagnosed >72 hours after delivery. Case LO-BSI patients were defined according to NeoKISS.

Results

Four hundred twenty seven episodes of LO-BSI were diagnosed with a frequency of 25.3% and an incidence density of 6.7/1000 patient-days (pds). Results of our multivariate analysis demonstrated that surgical procedures and lower gestational age were significantly associated with the risk of LO-BSI. Intravascular catheters were used in infants with LO-BSI significantly more frequently and/or for longer duration: Central venous cathters (CVC) (OR 1.29) and Peripheral venous catheters (PVC) (OR 2.8), as well as, the total duration of total parenteral nutrition (13 vs. 29 days; OR 1.81). Occurrence of LO-BSI was significantly associated with increased the length of mechanical ventilation (MV) (OR 2.65) or the continuous positive airway pressure (CPAP) (OR 2.51), as well as, the duration of antibiotic use (OR 2.98). The occurrence of more than one infection was observed frequently (OR 9.2) with VLBW with LO-BSI. Microorganisms isolated in infants with LO-BSI were dominated by Gram-positive cocci, and predominantly by coagulase-negative staphylococci (62.5%).

Conclusions

Independent risk factor for LO-BSI in VLBV infants are: low gestational age and requirement for surgery. The incidence rates of LO-BSI especially CVC-BSI were higher in the Polish NICUs surveillance than those of other national networks, similar to the central- and peripheral utilization ratio.

Invasive candidiasis in low birth weight preterm infants: risk factors, clinical course and outcome in a prospective multicenter study of cases and their matched controls

Background

This multicenter prospective study of invasive candidiasis (IC) was carried out to determine the risk factors for, incidence of, clinical and laboratory features, treatment and outcome of IC in infants of birth weight <1250 g.

Methods

Neonates <1250 g with IC and their matched controls (2:1) were followed longitudinally and descriptive analysis was performed. Survivors underwent neurodevelopmental assessment at 18 to 24 months corrected age. Neurodevelopmental impairment (NDI) was defined as blindness, deafness, moderate to severe cerebral palsy, or a score <70 on the Bayley Scales of Infant Development 2nd edition. Multivariable analyses were performed to determine risk factors for IC and predictors of mortality and NDI.

Results

Cumulative incidence rates of IC were 4.2%, 2.2% and 1.5% for birth-weight categories <750 g, <1000 g, <1500 g, respectively. Forty nine infants with IC and 90 controls were enrolled. Necrotizing enterocolitis (NEC) was the only independent risk factor for IC (p = 0.03). CNS candidiasis occurred in 50% of evaluated infants, while congenital candidiasis occurred in 31%. Infants with CNS candidiasis had a higher mortality rate (57%) and incidence of deafness (50%) than the overall cohort of infants with IC. NDI (56% vs. 33%; p = 0.017) and death (45% vs. 7%; p = 0.0001) were more likely in cases than in controls, respectively. IC survivors were more likely to be deaf (28% vs. 7%; p = 0.01). IC independently predicted mortality (p = 0.0004) and NDI (p = 0.018).

Conclusion

IC occurred in 1.5% of VLBW infants. Preceding NEC increased the risk of developing IC. CNS candidiasis is under-investigated and difficult to diagnose, but portends a very poor outcome. Mortality, deafness and NDI were independently significantly increased in infants with IC compared to matched controls.

Invasive candidiasis and oral manifestations in premature newborns

Objective:

To investigate prevalence of invasive candidiasis in a Neonatal Intensive Care Unit and to evaluate oral diseases and Candida spp. colonization in low birth weight preterm newborns.

Methods:

A descriptive epidemiological study performed in two stages. First, prevalence of candidiasis was analyzed in a database of 295 preterm patients admitted to hospital for over 10 days and birth weight less than 2,000g. In the second stage, oral changes and Candida spp. colonization were assessed in 65 patients weighing less than 2,000g, up to 4 week-old, hospitalized for over 10 days and presenting oral abnormalities compatible with fungal lesions. Swab samples were collected in the mouth to identify fungi.

Results:

Prevalence of candidiasis was 5.4% in the database analyzed. It correlated with prolonged hospital length of stay (p<0.001), in average, 31 days, and 85% risk of developing infection in the first 25 days. It correlated with low birth weight (p<0.001), with mean of 1,140g. The most frequent alterations were white soft plaques, detachable, in oral mucosa and tongue. Intense oral colonization by Candida spp was observed (80%).

Conclusions:

The frequency of invasive candidiasis was low and correlated with low birth weight and prolonged hospital stay. The most common oral changes were white plaques compatible with pseudomembranous candidiasis and colonization by Candida spp. was above average.

Association of high levels of α-defensins and S100A proteins with Candida mannan detection in bronchoalveolar lavage fluid of preterm neonates

BACKGROUND

Candida mannan (Mn) detection in bronchoalveolar lavage fluid (BALF) was shown to be useful for earlier identification and preemptive therapy targeting in preterm infants at high risk of invasive Candida infection. We investigated whether early detection of Candida Mn in BALF is associated with the presence of some neutrophilic products, as markers of prenatal infection/inflammation.

METHODS

BALF specimens were collected during the first 48 h of life from mechanically ventilated preterm newborns. Samples were analyzed by high-performance liquid chromatography-electrospray ionization-mass spectrometry. The relative amounts of α-defensins 1-4 and S100A proteins were measured by extracted ion current peak area. Absolute and differential white cell counts in BALF were obtained. Mn antigen concentrations were determined by the Platelia Candida antigen kit.

RESULTS

Twenty-five studied neonates were divided into two groups: Mn-positive group and Mn-negative group. Levels of α-defensins 1-4 and S100A12 were significantly higher in the Mn-positive group than in the Mn-negative group. Moreover, positive significant correlations between the absolute number of neutrophils and the levels of α-defensins 1-4 and S100A8 were observed.

CONCLUSION

The detection of Mn antigen in BALF of preterm infants is consistent with evidence of an innate immune response in their lungs as demonstrated by higher levels of α-defensins and S100A proteins.

Time to initiation of antifungal therapy for neonatal candidiasis

The effect of delayed antifungal therapy in critically ill infants with invasive candidiasis has not been studied. Our objective was to evaluate the effect of time to initiation of antifungal therapy (TIA) on mortality, disseminated disease, and postinfection hospital stay. We conducted a cohort study of critically ill infants with cultures positive for Candida from 1990 to 2008. TIA was defined as the number of hours from the collection of the first positive culture until the start of antifungal therapy. Of 96 infants, 57% were male, the median gestational age was 27 weeks (range, 23 to 41 weeks), and the median birth weight was 956 g (range, 415 to 6,191 g). Most subjects received amphotericin B deoxycholate. TIA was ≤ 24 h for 35% of infants, between 25 and 48 h for 42%, and >48 h for 23%. Eleven subjects died during hospitalization, and 22% had disseminated candidiasis. The median duration of hospital stay postinfection was 53 days (range, 6 to 217 days). Both univariate and multivariate analyses demonstrated that TIA was not associated with mortality, disseminated disease, or hospital stay postinfection. However, ventilator use for >60 days significantly increased the risk of death (odds ratio [OR], 9.5; 95% confidence interval [CI], 2.2 to 66.7; P = 0.002). Prolonged candidemia increased the risk of disseminated disease by 10% per day of positive culture (OR, 1.1; 95% CI, 1.08 to 1.2; P = 0.007), and low gestational age was associated with increased neonatal intensive care unit (NICU) stay after the first positive Candida culture by 0.94 weeks (95% CI, 0.70 to 0.98; P < 0.001). The TIA was not associated with all-cause mortality, disseminated candidiasis, and postinfection length of hospital stay.

Risk factors for invasive candidiasis in infants >1500 g birth weight

BACKGROUND

We describe the incidence, risk factors and outcomes of invasive candidiasis in infants >1500 g birth weight.

METHODS

We conducted a retrospective cohort study of infants >1500 g birth weight discharged from 305 neonatal intensive care units in the Pediatrix Medical Group from 2001 to 2010. Using multivariable logistic regression, we identified risk factors for invasive candidiasis.

RESULTS

Invasive candidiasis occurred in 330 of the 530,162 (0.06%) infants. These were documented from positive cultures from ≥1 of these sources: blood (n = 323), cerebrospinal fluid (n = 6) or urine from catheterization (n = 19). Risk factors included day of life >7 (odds ratio [OR]: 25.2; 95% confidence interval: 14.6-43.3), vaginal birth (OR: 1.6 [1.2-2.3]), exposure to broad-spectrum antibiotics (OR: 1.6 [1.1-2.4]), central venous line (OR: 1.8 [1.3-2.6]) and platelet count <50,000/mm (OR: 3.7 [2.1-6.7]). All risk factors had poor sensitivities, low positive likelihood ratios and low positive predictive values. The combination of broad-spectrum antibiotics and low platelet count had the highest positive likelihood ratio (46.2), but the sensitivity of this combination was only 4%. Infants with invasive candidiasis had increased mortality (OR: 2.2 [1.3-3.6]).

CONCLUSIONS

Invasive candidiasis is uncommon in infants >1500 g birth weight. Infants at greatest risk are those exposed to broad-spectrum antibiotics and with platelet counts of <50,000/mm(3).