Neonatal candidiasis: ophthalmologic infection

Invasive candidiasis in children

The prevalence of invasive candidiasis (IC) in pediatric hospitals is from 4,3 to 15,2 per 10,000 hospitalized, in ICU – from 3,5 to 7 cases per 1,000, with HSCT – 2,9%. The average length of stay of a patient in the hospital before the development of IC varies from 21 to 56 days, in the ICU – more than 15 days. Knowledge of risk factors (ICU stay for ≥15 days, use of antibacterial drugs and parenteral nutrition, active malignant neoplasm, etc.) makes it possible to identify patients with a high (10-46%) risk of developing IC. Candida albicans remains the leading causative agent of IC in children, but infections with non-albicans Candida spp. have increased and an increase in the resistance of IC pathogens to azole antimycotics was noted. The main clinical variant of IC in children is candidemia, other forms include the central nervous system, abdominal organs, eyes, heart, bones and joints, kidneys, skin and subcutaneous tissue involvement, as well as chronic disseminated (hepatolienal) candidiasis. Blood culture, the main method of laboratory diagnostics of IC, is characterized by low sensitivity and requires a long time. Methods of noncultural diagnostics of IC (1,3-β-D-glucan, mannan and antimannan antibodies, T2 Candida etc) in children have not been sufficiently studied. The main drugs for the treatment of IC in children are echinocandins (anidulafungin, etc.), and CVC removal/replacement is necessary. The overall mortality rate in pediatric patients within 30 days after the diagnosis of IC is 37% to 44%.

Trends in Infantile Endogenous Endophthalmitis Hospitalizations in the United States: An Analysis from 2007 through 2014 Using the National Inpatient Sample

PURPOSE

To determine the annual change in incidence of neonatal and infantile endogenous endophthalmitis in the United States between 2007 and 2014 and identify associated risk factors for development of endophthalmitis and mortality.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Neonates (<28 days; n = 1650) hospitalized for endogenous endophthalmitis between 2003 and 2014 and infants (age range, 28 days-1 year; n = 1850) hospitalized between 2007 and 2014 across United States community hospitals were analyzed.

METHODS

The Nationwide Inpatient Sample database was queried to identify neonates hospitalized for endogenous endophthalmitis between 2003 and 2014 and infants hospitalized between 2007 and 2014 across the United States. National and regional incidence of neonatal and infantile endogenous endophthalmitis and comorbidities as well as risk factors in the development of the disease and predictive factors for mortality from the years 2007 through 2014 were calculated.

MAIN OUTCOMES AND MEASURES

National incidence, regional incidence, and risk factors for development of neonatal and infantile endogenous endophthalmitis.

RESULTS

The rate of decline in incidence of neonatal endogenous endophthalmitis was 4% from 2003 through 2014. The rate of decline in the infantile population was 7% from 2007 through 2014. In 2007, an estimated 291 total cases of infantile endophthalmitis were identified, in comparison with 140 cases in 2014. Comorbidities prevalent in the endophthalmitis population included prematurity, respiratory disorders, perinatal infections, and retinopathy of prematurity (ROP). Significant positive predictors for the development of endogenous endophthalmitis based on multivariate logistic regression were perinatal infections, candidemia, bacteremia, very low birth weight, prematurity, respiratory disorders, and ROP. Descriptive analyses showed that the in-hospital mortality rate for patients identified with endophthalmitis was 1.55% in comparison with infants without endophthalmitis.

CONCLUSIONS

The incidence of endogenous endophthalmitis declined in both the neonatal and infantile population from 2007 through 2014. Odds of endogenous endophthalmitis were higher for premature and low-birthweight infants and those identified with perinatal infections, candidemia, bacteremia, respiratory disorders, or ROP. These findings are consistent with the decline observed in pediatric infectious disease-related hospitalizations in general.

CANDIDA ENDOPHTHALMITIS FROM THE REACTIVATION OF A DORMANT LENTICULAR FUNGAL ABSCESS IN A PREMATURE INFANT

BACKGROUND/PURPOSE

To report a case of fungal endophthalmitis from reactivation of a dormant lenticular fungal abscess in a severely premature infant.

METHODS

Single retrospective case report.

RESULTS

A female born at 23 and 6/7 weeks and weighing 620 g was diagnosed at age 29 weeks post menstrual age with persistent tunica vasculosa lentis, lenticular opacity, and aggressive posterior retinopathy of prematurity, and received bilateral intravitreal injection of bevacizumab. At the time of injection she was receiving systemic antibiotics for sepsis and fungemia. The retinopathy of prematurity regressed, as did the tunica vasculosa lentis, but a small plaque remained on the lens. At 5.5 months of age, patient presented with hypopyon and elevated intraocular pressure. Culture of intraocular fluid demonstrated Candida albicans.

CONCLUSION

Candida lenticular abscess is a rare complication of systemic fungemia in premature infants. Bevacizumab-induced regression of tunica vasculosa lentis may have decreased the ability of systemically administered antifungal medications to reach the colonized lens.

Recognition and Clinical Presentation of Invasive Fungal Disease in Neonates and Children

Invasive fungal diseases (IFDs) are devastating opportunistic infections that result in significant morbidity and death in a broad range of pediatric patients, particularly those with a compromised immune system. Recognizing them can be difficult, because nonspecific clinical signs and symptoms or isolated fever are frequently the only presenting features. Therefore, a high index of clinical suspicion is necessary in patients at increased risk of IFD, which requires knowledge of the pediatric patient population at risk, additional predisposing factors within this population, and the clinical signs and symptoms of IFD. With this review, we aim to summarize current knowledge regarding the recognition and clinical presentation of IFD in neonates and children.

Etiological agents of fungal endophthalmitis: diagnosis and management

Endophthalmitis caused by fungi is commonly diagnosed around the world in apparently healthy and immunocompromised individuals. An accurate clinical diagnosis for endophthalmitis confirmed by laboratory techniques is essential for early treatment with antifungal drugs, such as amphotericin B, imidazoles, and other antifungals. Here, we review endophthalmitis caused by fungi according to its classification into endogenous fungal endophthalmitis (EFE) and exogenous fungal endophthalmitis (EXFE). EFE is caused by endogenously acquired fungi, whereas the traumatic implantation of opportunistic fungal pathogens is the main feature of EXFE. We highlight the most important etiologies causing endophthalmitis and the steps required for a rapid diagnosis and management.

Recommendations for the management of candidemia in neonates in Latin America. Latin America Invasive Mycosis Network

Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. 'Recommendations for the diagnosis and management of candidemia' are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, 'Recommendations for the management of candidemia in neonates in Latin America', was written to provide guidance to healthcare professionals on the management of neonates who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. 'Recommendations for the management of candidemia in neonates in Latin America' includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, central venous catheter management, and management of complications. This manuscript is the fourth of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: 'Recommendations for the diagnosis of candidemia in Latin America', 'Recommendations for the management of candidemia in adults in Latin America', and 'Recommendations for the management of candidemia in children in Latin America'.

[Recommendations for the management of candidemia in neonates in Latin America. Grupo Proyecto Épico]

Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. 'Recommendations for the diagnosis and management of candidemia' are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, 'Recommendations for the management of candidemia in neonates in Latin America', was written to provide guidance to healthcare professionals on the management of neonates who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. 'Recommendations for the management of candidemia in neonates in Latin America' includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, central venous catheter management, and management of complications. This manuscript is the fourth of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: 'Recommendations for the diagnosis of candidemia in Latin America', 'Recommendations for the management of candidemia in adults in Latin America', and 'Recommendations for the management of candidemia in children in Latin America'.

Bilateral Candida endophthalmitis in a premature infant

Endogenous infantile Candida endophthalmitis is a rare but potentially devastating condition resulting from sequestration of the fungus within the lens after systemic infection. We report the case of a 20-week-old girl with a history of Candida sepsis who presented with bilateral Candida albicans endophthalmitis 15 weeks after completing a 6-week course of intravenous antifungal therapy. Prompt vitrectomy resulted in salvage of the right eye, although a total retinal detachment occurred. Cataract extraction and administration of intravenous and intravitreal amphotericin B preserved vision in the left eye.

Scrotal abscess owing to Candida albicans in a newborn

Acute scrotal abscess in neonates is rare and may mimic testicular torsion. An unusual case of unilateral scrotal abscess caused by Candida albicans in a preterm infant is presented. As far as we are aware, this complication has not been reported before.

Retinal vasculitis as an early indicator of systemic candidal abscesses in a premature infant

We report a case of fungal retinal vasculitis in a 32 week gestational age, 1200 g premature infant detected during routine screening for retinopathy of prematurity at 78 days of age. The patient subsequently developed sepsis with perinephric abscess but responded rapidly to systemic therapy. Fortuitous detection of retinal vasculitis as the first evidence of a systemic fungal infection in an immunocompetent and asymptomatic infant has not, to our knowledge, been previously reported.

Declining incidence of neonatal endophthalmitis in the United States

PURPOSE

To determine the incidence of neonatal endogenous endophthalmitis in the United States between 1998 and 2006 and to identify associated risk factors.

DESIGN

Retrospective cohort study.

METHODS

We used the Nationwide Inpatient Sample database, a 20% representative sample of all hospital discharges in the United States, to help refine our understanding of this condition. International Classification of Diseases, ninth edition, codes for endophthalmitis, sepsis, and suspected endophthalmitis risk factors in hospitalized infants and neonates were searched in the database and were tracked over time. The main outcome measure was incidence of neonatal endophthalmitis over the study period.

RESULTS

Of 3.64 million live births in 1998, 317 newborns were identified with endophthalmitis (8.71 cases per 100 000 live births). Of 4.14 million live births in 2006, only 183 newborns were identified with endophthalmitis (4.42 cases per 100 000 live births) by comparison. The incidence of endophthalmitis decreased at a rate of 6% per year (P = .01130) between 1998 and 2006. Neonates with endophthalmitis were more likely to have systemic bacteremia (odds ratio, 21.114; P < .0001), Candidemia (odds ratio, 2.356; P < .0001), a birth weight of less than 1500 g (odds ratio, 1.215; P < .0001), and retinopathy of prematurity (odds ratio, 2.052; P < .0001).

CONCLUSIONS

We objectively validated the commonly held belief that Candidemia, bacteremia, retinopathy of prematurity, and low birth weight are significant risk factors for endophthalmitis development in infants, which seems to have had a decreasing incidence in recent years.

Neonatal Candidemia Exacerbated the Progression of Retinopathy of Prematurity in an Extremely-Low-Birth-Weight Infant with Persistent Tunica Vasculosa Lentis

Eyes with threshold retinopathy of prematurity (ROP) often show dilation of the existing tunica vasculosa lentis (TVL), which is a prognostic factor in ROP screening and treatment, but can be frequently misdiagnosed as true iris neovascularization (NV). Besides, candidemia in preterm infants can aggravate the severity of ROP, possibly to the threshold stage requiring laser treatment. A case of prolonged candidemia without ophthalmic infection in an extremely-low-birth-weight (ELBW) (birth weight: 800 g), pre-term (gestation: 26 weeks) infant with persistent TVL and severe ROP are reported. The threshold ROP was successfully treated with argon laser therapy. Candidemia without eye infection in this case was associated with early use of a systemic antifungal drug. To our knowledge, no similar cases have been reported in the literature.

Intravitreal injection of therapeutic agents

BACKGROUND

Intravitreal injection (IVI) with administration of various pharmacological agents is a mainstay of treatment in ophthalmology for endopthalmitis, viral retinitis, age-related macular degeneration, cystoid macular edema, diabetic retinopathy, uveitis, vascular occlusions, and retinal detachment. The indications and therapeutic agents are reviewed in this study.

METHODS

A search of the English, German, and Spanish language MEDLINE database was conducted. A total of 654 references spanning the period through early 2008 were individually evaluated.

RESULTS

The advantage of the IVI technique is the ability to maximize intraocular levels of medications and to avoid the toxicities associated with systemic treatment. Intravitreal injection has been used to deliver several types of pharmacological agents into the vitreous cavity: antiinfective and antiinflammatory medications, immunomodulators, anticancer agents, gas, antivascular endothelial growth factor, and several others. The goal of this review is to provide a detailed description of the properties of numerous therapeutic agents that can be delivered through IVI, potential complications of the technique, and recommendations to avoid side effects.

CONCLUSION

The IVI technique is a valuable tool that can be tailored to the disease process of interest based on the pharmacological agent selected. This review provides the reader with a comprehensive summary of the IVI technique and its multitude of uses.

Invasive Candida infections in the neonate

Advances in medical therapy have increased premature infant survival. A rise in Candida infections in neonatal intensive care units (NICUs) has followed. Once considered a contaminant, Candida is now recognized as a major cause of mortality and morbidity within these units. We will examine what is known about the epidemiology, risk factors and end-organ involvement of Candida infections with a focus on invasive disease. In addition, diagnostic alternatives to traditional blood culture, experience with antifungal agents for prophylaxis and therapeutic options, including newer antifungal agents, will be presented.

Very low prevalence of endophthalmitis in very low birthweight infants who survive candidemia

OBJECTIVE

Candida species often cause sepsis in very low birthweight (VLBW) infants, leading to formal ophthalmologic evaluation for endophthalmitis. Our experience suggests that endophthalmitis is rare in this setting, and retinal vascular compromise in extreme prematurity may decrease the risk. We studied the prevalence of endophthalmitis in surviving VLBW infants with candidemia.

STUDY DESIGN

Epidemiologic data and presence of ROP and endophthalmitis were ascertained for all VLBW infants with candidemia at our institution from 1994 to 2001.

RESULTS

A total of 123 infants were included. Median EGA was 25 weeks (range, 23 to 32) and median birthweight was 735 g (range, 426 to 1460). Of these 123, only one had transient retinal findings (prevalence 0.8%; 95% confidence interval 0 to 4%), which resolved during therapy. In no case was either the duration of therapy or the outcome of candidemia altered by retinal examination.

CONCLUSIONS

Aggressive treatment of candidemia has made endogenous endophthalmitis rare in candidemic VLBW infants.

Fungal infection in the very low birthweight infant

PURPOSE OF REVIEW

Fungal infections are prevalent in very low birthweight (<1500 g) infants and are associated with significant morbidity and mortality. A better understanding of the adherence factors, molecular diagnostics and risk factors for invasive fungal infection are important in treatment and prevention.

RECENT FINDINGS

Animal studies have demonstrated that Candida readily adheres to apical microvilli and the junctions between enterocytes. Although antibiotics facilitate colonization, dissemination occurs with immunosuppression. The INT1 gene is associated with enhanced colonization and dissemination in these animal models. Dissemination is probably caused by yeast cell adherence and invasion, whereas tissue injury may be related to filamentous formation. Polymerase chain reaction techniques have demonstrated promise in neonatal patients and may not only detect bloodstream infection, but fungal infection at other sites. At the time of fungal sepsis, less than 28 weeks' gestation, thrombocytopenia, and previous exposure to broad-spectrum antibiotics continue to be risk factors for infection. Empiric therapy is still being defined and investigated. Fluconazole prophylaxis should be strongly considered in the most immature infants.

SUMMARY

Preventative strategies against fungal colonization and infection are critical in high-risk very low birthweight infants. Also promising is the ability of molecular diagnostics to detect infection earlier, allowing for prompt treatment, including central venous catheter removal. Identifying the highest risk very low birthweight infants for prophylaxis and empiric therapy may lead to better outcomes. Multicenter clinical trials of fluconazole prophylaxis to confirm its safety and efficacy, and of empiric treatment to test safety and outcomes are urgently needed.

Clinical microbiology of bacterial and fungal sepsis in very-low-birth-weight infants

Twenty percent of very-low-birth-weight (<1500 g) preterm infants experience a serious systemic infection, and despite advances in neonatal intensive care and antimicrobials, mortality is as much as threefold higher for these infants who develop sepsis than their counterparts without sepsis during their hospitalization. Outcomes may be improved by preventative strategies, earlier and accurate diagnosis, and adjunct therapies to combat infection and protect the vulnerable preterm infant during an infection. Earlier diagnosis on the basis of factors such as abnormal heart rate characteristics may offer the ability to initiate treatment prior to the onset of clinical symptoms. Molecular and adjunctive diagnostics may also aid in diagnosing invasive infection when clinical symptoms indicate infection but no organisms are isolated in culture. Due to the high morbidity and mortality, preventative and adjunctive therapies are needed. Prophylaxis has been effective in preventing early-onset group B streptococcal sepsis and late-onset Candida sepsis. Future research in prophylaxis using active and passive immunization strategies offers prevention without the risk of resistance to antimicrobials. Identification of the differences in neonatal intensive care units with low and high infection rates and implementation of infection control measures remain paramount in each neonatal intensive care unit caring for preterm infants.