Fluconazole prophylaxis for prevention of invasive fungal infections in targeted highest risk preterm infants limits drug exposure

Updates in the Pharmacologic Prophylaxis and Treatment of Invasive Candidiasis in the Pediatric and Neonatal Intensive Care Units

Purpose of review

The goal of this review was to provide an update on the prevention and treatment options for invasive candidiasis (IC) in the neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU).

Recent findings

Studies have further validated the use of fluconazole for IC prophylaxis among high-risk patients in the NICU. It remains unclear if prophylaxis leads to resistance development and the ideal dosage regimen is still not clear. Recent studies have been published comparing caspofungin and micafungin to amphotericin B and illustrated similar efficacy outcomes in the NICU. Micafungin now has approval from the United States Food and Drug Administration (FDA) for use in infants < 4 months of age. Prophylactic strategies in the PICU could include zinc and vitamin D. Anidulafungin has recent non-comparative data supporting use in pediatric patients older than 1 month of age and also has a recent FDA approval for use in children 1 month of age and older.

Summary

Fluconazole prophylaxis remains a reasonable strategy in select NICU patients, although further analyses of resistance and the optimal dosage regimen are needed. Echinocandins are potential therapeutic options for non-meningitis or urinary tract infections in both the neonatal and pediatric population.

Fluconazole prophylaxis against invasive candidiasis in very low and extremely low birth weight preterm neonates: a systematic review and meta-analysis

BACKGROUND

Evidence shows that fluconazole prophylaxis is an effective treatment against invasive fungal infections in preterm neonates, however, the most efficient schedule of fluconazole prophylaxis for the colonization and mortality of invasive candidiasis (IC) is unknown.

PURPOSE

This systematic review and meta-analysis aimed to assess the efficiency of different prophylactic fluconazole schedules in controlling IC colonization, infection, and mortality in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants in neonatal intensive care units.

METHODS

We searched the PubMed, Scopus, Embase, and Cochrane databases using the keywords "candida," "invasive candidiasis," "IC," "fluconazole prophylaxis," "preterm infants," "very low birth weight infants," "VLBW," "extremely low birth weight," and "ELBW."

RESULTS

Mortality was significantly decreased in a metaanalysis of studies using different fluconazole prophylaxis regimens. The meta-analysis also indicated a significant decrease in the incidence of IC-associated mortality in ELBW infants using the same fluconazole prophylaxis schedules.

CONCLUSION

Future studies should explore the effectiveness of other different fluconazole prophylaxis schedules on IC colonization, infection, and mortality.

Urinary tract infections in very low birthweight infants: A two-center analysis of microbiology, imaging and heart rate characteristics

BACKGROUND

Increased understanding of characteristics of urinary tract infection (UTI) among very low birthweight infants (VLBW) might lead to improvement in detection and treatment. Continuous monitoring for abnormal heart rate characteristics (HRC) could provide early warning of UTIs.

OBJECTIVE

Describe the characteristics of UTI, including HRC, in VLBW infants.

METHODS

We reviewed records of VLBW infants admitted from 2005-2010 at two academic centers participating in a randomized clinical trial of HRC monitoring. Results of all urine cultures, renal ultrasounds (RUS), and voiding cystourethrograms (VCUG) were assessed. Change in the HRC index was analyzed before and after UTI.

RESULTS

Of 823 VLBW infants (27.7±2.9 weeks GA, 53% male), 378 had > / = 1 urine culture obtained. A UTI (≥10,000 CFU and >five days of antibiotics) was diagnosed in 80 infants, (10% prevalence, mean GA 25.8±2.0 weeks, 76% male). Prophylactic antibiotics were administered to 29 (36%) infants after UTI, of whom four (14%) had another UTI. Recurrent UTI also occurred in 7/51 (14%) of infants not on uroprophylaxis after their first UTI. RUS was performed after UTI in 78%, and hydronephrosis and other major anomalies were found in 19%. A VCUG was performed in 48% of infants and 18% demonstrated vesicoureteral reflux (VUR). The mean HRC rose and fell significantly in the two days before and after diagnosis of UTI.

CONCLUSIONS

UTI was diagnosed in 10% of VLBW infants, and the HRC index increased prior to diagnosis, suggesting that continuous HRC monitoring in the NICU might allow earlier diagnosis and treatment of UTI.

Meningitis, urinary tract, and bloodstream infections in very low birth weight infants enrolled in a heart rate characteristics monitoring trial

BACKGROUND

Displaying heart rate characteristic (HRC) scores was associated with lower sepsis-associated mortality in very low birth weight (VLBW) infants in a multicenter randomized controlled trial (HeRO trial). The aim of this study was to test whether HRC indices rise before diagnosis of urinary tract infection (UTI) or meningitis, with and without concomitant BSI.

METHODS

Blood, urine, and cerebrospinal fluid (CSF) culture data after 3 days of age and within 120 days of study enrollment were analyzed from 2989 VLBW infants. The HRC index was analyzed 12 h prior to positive cultures compared to 36 h prior, using paired signed-rank tests.

RESULTS

UTI, meningitis, and BSI were diagnosed in 10%, 2%, and 24% of infants, respectively. The mean hourly HRC index was significantly higher 12 h prior to diagnosis of UTI and BSI compared to 36 h prior (UTI 2.07 versus 1.81; BSI 2.62 versus 2.25, both p < 0.0001). The baseline HRC index was higher for meningitis, compared to UTI or BSI, but without a statistically significant rise in the day prior to meningitis diagnosis.

CONCLUSIONS

In a large cohort of VLBW infants enrolled in the HeRO trial, the HRC index increased in the 24-h period prior to diagnosis of UTI and BSI but not meningitis.

Risk factors for fungal infection in extremely low birthweight infants registered in the Korean neonatal network from 2013 to 2015: Male sex and hypotension

BACKGROUND

In Korea, improvement in the survival rates of extremely low birthweight (<1,000 g) infants has led to neonatal infection, especially fungal infection (FI), in the neonatal intensive care unit. The purpose of this study was to determine the risk factors for FI by analyzing the incidence of FI in extremely low birthweight infants in Korea.

METHODS

Data from 5,320 very low birthweight (<1,500 g) infants registered from 2013 to 2015 in the Korean Neonatal Network were analyzed. The infants were divided into two groups based on the presence or absence of FI.

RESULTS

Among infants, 1,524 with gestational ages of <27 weeks and birthweights of <1,000 g were included. The incidence of FI was 7.3% (111/1,524) and mortality of the infants with FI was 40% (44/111). The mean gestational age of infants with FI was 24.8 ± 1.0 weeks, which was significantly lower than those without FI. After logistic regression, being male, and having hypotension within 7 days of birth were independent risk factors for FI. Moreover, hypotension was strongly associated with mortality in FI. Adverse outcomes such as severe bronchopulmonary dysplasia, bacteremia, and abnormal hearing test occurred more frequently in infants with FI than non-FI.

CONCLUSIONS

As male sex and hypotension within 7 days of birth increased the risk of developing FI in infants with gestational ages of <27 weeks and birthweights of <1,000 g, preventive strategies to reduce the incidence of FI are required for infants with risk factors for the development of FI.

Prophylactic regimens with fluconazole for candidiasis in neonates under 1.500g: A retrospective chart review of two cohorts

BACKGROUND

The incidence rate of invasive candidiasis in newborns with birth weight below 1,500 g ranges from 2% to 8%, and fluconazole prophylaxis in neonatal units is recommended when the incidence of invasive candidiasis is higher than 5%. This study aimed to compare the effectiveness of targeted prophylaxis and universal prophylaxis with fluconazole in the prevention of invasive candidiasis.

METHODS

This was a historical cohort comparing the targeted prophylaxis for newborns weighing less than 1,500 g and the universal prophylaxis for newborns weighing less than 1,000 g.

RESULTS

The overall incidence rate of invasive candidiasis was 5.25% and was reduced from 7.1% to 3.72% with universal prophylaxis (p = 0.04). In a multivariate analysis, the significant factors associated with the development of candidiasis were birth weight less than 1,000 g, prolonged hospitalization, previous surgery, prolonged use of mechanical ventilation, prior exposure to antimicrobial treatments, and use of targeted prophylaxis.

CONCLUSIONS

Universal prophylaxis had lower incidence of invasive candidiasis, and preventive measures considering the risk factors are mandatory to reduce the incidence of invasive candidiasis.

Fluconazole prophylaxis in preterm infants: a systematic review

OBJECTIVE

This article aims to review the use of antifungal prophylaxis with intravenous fluconazole in premature newborns and the occurrence of Invasive Candidiasis.

METHODS

This is a systematic review with search at databases: PubMed, Capes Portal, Virtual Health Library (BVS - Biblioteca Virtual em Saúde)/Lilacs, Scopus and Cochrane. The keywords used were: "Antifungal", "Candida" "Fluconazole prophylaxis" and "Preterm infants".

RESULTS

Invasive Candidiasis was evaluated in all the twelve items. In eleven of them, there was a statistically significant difference between the groups receiving prophylactic fluconazole, with lower frequency of Invasive Candidiasis, compared to placebo or no prophylaxis group. Colonization by Candida species was also evaluated in five studies; four of them presented statistically lower proportion of colonization in patients with Fluconazole prophylaxis, compared to placebo or no drugs. In one study, there was a significant difference, favoring the use of fluconazole, and reduction of death.

CONCLUSION

Studies indicate the effectiveness of prophylaxis with fluconazole, with reduction in the incidence of colonization and invasive fungal disease. The benefits of prophylaxis should be evaluated considering the incidence of candidiasis in the unit, the mortality associated with candidiasis, the safety and toxicity of short and long-term medication, and the potential for development of resistant pathogens.

Cost Analysis of Fluconazole Prophylaxis for Prevention of Neonatal Invasive Candidiasis

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.

Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Manipulation of Host Diet To Reduce Gastrointestinal Colonization by the Opportunistic Pathogen Candida albicans

Candida albicans, the most common human fungal pathogen, can cause infections with a mortality rate of ~40%. C. albicans is part of the normal gut flora, but when a patient’s immune system is compromised, it can leave the gut and cause infections. By reducing the amount of C. albicans in the gut of susceptible patients, infections (and the resulting fatalities) can be prevented. Currently, this is done using antimicrobial drugs; to “preserve” drugs for treating infections, we looked for a dietary change to reduce the amount of C. albicans in the gut. Using a mouse model, we showed that adding coconut oil to the diet could become the first drug-free way to reduce C. albicans in the gut. More broadly, this model lets us study the interactions between our diet and the microbes in our body and the reasons why some of those microbes, under certain conditions, cause disease.

Candida albicans, the most common human fungal pathogen, can cause systemic infections with a mortality rate of ~40%. Infections arise from colonization of the gastrointestinal (GI) tract, where C. albicans is part of the normal microflora. Reducing colonization in at-risk patients using antifungal drugs prevents C. albicans-associated mortalities. C. albicans provides a clinically relevant system for studying the relationship between diet and the microbiota as it relates to commensalism and pathogenicity. As a first step toward a dietary intervention to reduce C. albicans GI colonization, we investigated the impact of dietary lipids on murine colonization by C. albicans. Coconut oil and its constituent fatty acids have antifungal activity in vitro; we hypothesized that dietary coconut oil would reduce GI colonization by C. albicans. Colonization was lower in mice fed a coconut oil-rich diet than in mice fed diets rich in beef tallow or soybean oil. Switching beef tallow-fed mice to a coconut oil diet reduced preexisting colonization. Coconut oil reduced colonization even when the diet also contained beef tallow. Dietary coconut oil also altered the metabolic program of colonizing C. albicans cells. Long-chain fatty acids were less abundant in the cecal contents of coconut oil-fed mice than in the cecal contents of beef tallow-fed mice; the expression of genes involved in fatty acid utilization was lower in C. albicans from coconut oil-fed mice than in C. albicans from beef tallow-fed mice. Extrapolating to humans, these findings suggest that coconut oil could become the first dietary intervention to reduce C. albicans GI colonization.

IMPORTANCECandida albicans, the most common human fungal pathogen, can cause infections with a mortality rate of ~40%. C. albicans is part of the normal gut flora, but when a patient’s immune system is compromised, it can leave the gut and cause infections. By reducing the amount of C. albicans in the gut of susceptible patients, infections (and the resulting fatalities) can be prevented. Currently, this is done using antimicrobial drugs; to “preserve” drugs for treating infections, we looked for a dietary change to reduce the amount of C. albicans in the gut. Using a mouse model, we showed that adding coconut oil to the diet could become the first drug-free way to reduce C. albicans in the gut. More broadly, this model lets us study the interactions between our diet and the microbes in our body and the reasons why some of those microbes, under certain conditions, cause disease.

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Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants

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.

Advances in the treatment of invasive neonatal candidiasis

INTRODUCTION

Invasive candidiasis is responsible for ∼ 10% of nosocomial sepsis in very-low-birth-weight infants and is associated with substantial morbidity and mortality. Over the last two decades, the antifungal armamentarium against Candida spp. has increased; however, efficacy and safety studies in this population are lacking.

AREAS COVERED

We reviewed the medical literature and extracted information on clinical and observational studies evaluating the use of antifungal agents in neonates with invasive candidiasis.

EXPERT OPINION

Efficacy and safety data for antifungals in neonates are lacking, and the majority of studies conducted to date have concentrated on pharmacokinetic/pharmacodynamic evaluations. Unlike other anti-infective agents, efficacy data in the setting of neonatal candidiasis cannot be extrapolated from adult studies due to differences in the pathophysiology of the disease in this population relative to older children and adults. Data for amphotericin B deoxycholate, fluconazole, and micafungin suggest that these are the current agents of choice for this disease in neonates until data for newer antifungal agents become available. For prophylaxis, data from fluconazole randomized controlled trials will be submitted to the regulatory agencies for labeling. Ultimately, the field of therapeutics for neonatal candidiasis will require multidisciplinary collaboration given the numerous challenges associated with conducting clinical trials in neonates.

Fluconazole prophylaxis is associated with a decreased rate of coagulase-negative Staphylococcal infections in a subset of extremely low birth weight neonates

Fluconazole prophylaxis is being used efficaciously in the neonatal intensive care unit (NICU) for fungal prophylaxis in very low birth weight and extremely low birth weight (ELBW) neonates. Little is known about the effect of fluconazole prophylaxis on bacterial infections. The purpose of this study was to examine that issue in a subset of ELBW, those weighing ≤900 g at birth. This is a retrospective study conducted in a level III NICU at state-designated children hospital in New Jersey (USA). We examined the data from our records of neonates ≤ 900 g birth weight during the period March 1, 2007-February 28, 2011. Inclusion in the study was all infants ≤ 900 g before (n = 67) and after (n = 81) the institution of fluconazole prophylaxis. Fluconazole prophylaxis was accompanied by a significant decrease in both the rate and number of days of bacterial infections as well as co-infections. We found that the incidence of coagulase-negative Staphylococcus (CONS) decreased from 46.2 to 24.7 % (OR 2.63; 95 % CI 1.31-5.27). Similarly, days of infection also decreased significantly (p < 0.0001). These data suggest that fluconazole prophylaxis may be associated with a reduction in CONS infections in that subset of ELBW neonates.

Fluconazole prophylaxis in preterm infants: a multicenter case-controlled analysis of efficacy and safety

BACKGROUND

Fluconazole prophylaxis has demonstrated efficacy in single and multicenter randomized controlled trials without side effects or emergence of resistance. Additional evidence based on incidence of invasive Candida infections, multicenter data, resistance, and safety is desired.

METHODS

We conducted a case-control analysis of efficacy and safety of fluconazole prophylaxis from a multicenter database from a neonatal infection study that included 2017 infants <1250 grams from 95 NICUs. Infants receiving intravenous antifungal prophylaxis were pre-identified during enrollment in the parent study. For each infant receiving antifungal prophylaxis (case), three infants not receiving antifungal (controls) were matched by birth weight (± 50 g), by gestational age (± 1 week), gender, and study site.

RESULTS

Fluconazole prophylaxis was administered to 127 patients [754 ± 163 g birth weight (BW) and 25.4 ± 1.7 weeks gestational age (GA)] and were compared with 399 control patients (756 ± 163 g BW and 25.5 ± 1.8 weeks GA). Invasive Candida infection occurred in 0.8% (1 of 127) infants who received fluconazole prophylaxis compared with 7.3% (29 of 399) of matched controls (p = 0.006). Candida bloodstream infection occurred in 0.8% (1 of 127) fluconazole prophylaxis infants compared with 5.5% (22 of 399) of matched controls (p = 0.02). There were no differences in late-onset sepsis due to gram-positive or gram-negative organisms, focal bowel perforation, necrotizing enterocolitis, cholestasis, or overall mortality.

CONCLUSION

Fluconazole prophylaxis is safe and efficacious in preventing invasive Candida infections. Even in NICUs with a low incidence of invasive Candida infections, antifungal prophylaxis for high-risk infants is a proven and safe opportunity for infection prevention in these patients.

Risk Factors for Invasive Fungal Infection in Premature Infants: Enhancing a Targeted Prevention Approach

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.

Incidence of catheter-related bloodstream infections in neonates following removal of peripherally inserted central venous catheters

OBJECTIVES

Catheter-associated bloodstream infections are a significant source of morbidity and healthcare cost in the neonatal ICU. Previous studies examining the prevalence of bloodstream infections after removal of peripherally inserted central venous catheters in neonates are equivocal.

DESIGN

A retrospective cohort study.

PATIENTS

All infants with peripherally inserted central venous catheters treated at the Vanderbilt neonatal ICU between 2007 and 2009.

MEASUREMENTS AND MAIN RESULTS

We evaluated the following outcomes: 1) bloodstream infections, 2) culture-negative sepsis, 3) number of sepsis evaluations, and 4) number of significant apnea/bradycardia events comparing odds ratios between 72 hours before and 72 hours after peripherally inserted central venous catheter removal. We analyzed a total of 1,002 peripherally inserted central venous catheters in 856 individual infants with a median (interquartile range) gestational age of 31 weeks (28-37 wk) and a median birth weight of 1,469 g (960-2,690 g). Comparing 72 hours before with 72 hours after peripherally inserted central venous catheter removal did not show a difference in the prevalence of bloodstream infections (9 vs 3, p = 0.08), prevalence of culture-negative sepsis (37 vs 40, p = 0.73), number of sepsis evaluations (p = 0.42), or number of apnea/bradycardia events (p = 0.32). However, in peripherally inserted central venous catheter not used for delivery of antibiotics, there was a 3.83-fold increase in odds for culture-negative sepsis following peripherally inserted central venous catheter removal (95% confidence interval, 1.48-10.5; p = 0.001). For infants less than 1,500 g birth weight (very low birth weight), odds for culture-negative sepsis increased to 6.3-fold following removal of peripherally inserted central venous catheters not used for antibiotic delivery (95% confidence interval, 1.78-26.86; p < 0.01).

CONCLUSIONS

Although these data do not support the routine use of antibiotics for sepsis prophylaxis prior to peripherally inserted central venous catheter removal, they suggests that very low birth weight infants not recently exposed to antibiotics are at increased odds for associated adverse events following discontinuation of their peripherally inserted central venous catheter.

Use of a computerized C-reactive protein (CRP) based sepsis evaluation in very low birth weight (VLBW) infants: a five-year experience

BACKGROUND

Serial C-reactive protein (CRP) values may be useful for decision-making regarding duration of antibiotics in neonates. However, established standard of practice for its use in preterm very low birth weight (<1500 g, VLBW) infants are lacking.

OBJECTIVE

Evaluate compliance with a CRP-guided computerized decision support (CDS) algorithm and compare characteristics and outcomes of compliant versus non-compliant cases. Measure correlation between CRPs and white blood count (WBC) indices.

METHODS

We examined 3 populations: 1) all preterm VLBW infants born at Vanderbilt 2006-2011 - we assessed provider compliance with CDS algorithm and measured relevant outcomes; 2) all patients with positive blood culture results admitted to the Vanderbilt NICU 2006-2012 - we tested the correlation between CRP and WBC results within 7 days of blood culture phlebotomy; 3) 1,000 randomly selected patients out of the 7,062 patients admitted to the NICU 2006-2012 - we correlated time-associated CRP values and absolute neutrophil counts.

RESULTS

Of 636 VLBW infants in cohort 1), 569 (89%) received empiric antibiotics for suspected early-onset sepsis. In 409 infants (72%) the CDS algorithm was followed; antibiotics were discontinued ≤48 hours in 311 (55%) with normal serial CRPs and continued in 98 (17%) with positive CRPs, resulting in significant reduction in antibiotic exposure (p<0.001) without increase in complications or subsequent infections. One hundred sixty (28%) were considered non-compliant because antibiotics were continued beyond 48 hours despite negative serial CRPs and blood cultures. Serial CRPs remained negative in 38 (12%) of 308 blood culture-positive infants from cohort 2, but only 4 patients had clinically probable sepsis with single organisms and no immunodeficiency besides extreme prematurity. Leukopenia of any cell type was not linked with CRPs in cohorts 2 and 3.

CONCLUSIONS

CDS/CRP-guided antibiotic use is safe and effective in culture-negative VLBW infants. CRP results are not affected by low WBC indices.

A prospective study of the patterns and dynamics of colonization with Candida spp. in very low birth weight neonates

BACKGROUND

Knowledge of fungal colonization patterns in very low birth weight infants (VLBWI) admitted to the neonatal intensive care unit (NICU) is essential in understanding the process of fungal infections in neonates. We analyzed prospectively, during 2009-2010, the patterns and dynamics of fungal colonization in VLBWI, including timing, colonization sites, and species involved.

METHODS

Weekly skin, oropharynx, and rectum/stool surveillance fungal cultures were collected from admission until discharge in VLBWI in the NICU. None received antifungal prophylaxis.

RESULTS

Overall, 118 VLBWI provided 1723 samples; 34 (29%) had 104 positive samples at least once during the first 10 hospitalization weeks. Thirty-nine (33%) weighed < 1000 g; 68 were delivered by cesarean section. Candida albicans (57/104, 55%) and Candida parapsilosis (26/104, 25%) were the main fungi isolated. Eight (24%) VLBWI were colonized during the first week and 23 (68%) during the second week. No differences in colonization were recorded between cesarean section and vaginally delivered VLBWI. The colonization risk at least once during the first 10 weeks was 23% for skin, 14% for oropharynx, 27% for rectum/stool, and 38% for any anatomic site sampled. Persistent colonization was recorded in 5/34 (15%), while transient colonization was found in 14/34 (41%) VLBWI; 16/34 (47%) were discharged or died colonized with Candida spp. Candidemia was diagnosed in 4 (3%) VLBWI and previous/simultaneous colonization was found in 3/4.

CONCLUSIONS

The cumulative risk of colonization, at any sampled site and at least once during follow-up, was high. Initial colonization occurred most often during the first 2 weeks of life. Colonization dynamics were characterized by various persistence, disappearance, and recolonization patterns. Candidemia was rare.

Safety of fluconazole in paediatrics: a systematic review

PURPOSE

To determine the safety of fluconazole in neonates and other paediatric age groups by identifying adverse events (AEs) and drug interactions associated with treatment.

METHODS

A search of EMBASE (1950-January 2012), MEDLINE (1946-January 2012), the Cochrane database for systematic reviews and the Cumulative Index to Nursing and Allied Health Literature (1982-2012) for any clinical study about fluconazole use that involved at least one paediatric patient (≤17 years) was performed. Only articles with sufficient quality of safety reporting after patients' exposure to fluconazole were included.

RESULTS

We identified 90 articles, reporting on 4,209 patients, which met our inclusion criteria. In total, 794 AEs from 35 studies were recorded, with hepatotoxicity accounting for 378 (47.6 %) of all AEs. When fluconazole was compared with placebo and other antifungals, the relative risk (RR) of hepatotoxicity was not statistically different [RR 1.36, 95 % confidence interval (CI) 0.87-2.14, P = 0.175 and RR 1.43, 95 % CI 0.67-3.03, P = 0.352, respectively]. Complete resolution of hepatoxicity was achieved by 84 % of patients with follow-up available. There was no statistical difference in the risk of gastrointestinal events of fluconazole compared with placebo and other antifungals (RR 0.81, 95 % CI 0.12-5.60, P = 0.831 and RR 1.23, 95 %CI 0.87-1.71, P = 0.235, respectively). There were 41 drug withdrawals, 17 (42 %) of which were due to elevated liver enzymes. Five reports of drug interactions occurred in children.

CONCLUSION

Fluconazole is relatively safe for paediatric patients. Hepatotoxicity and gastrointestinal toxicity are the most common adverse events. It is important to be aware that drug interactions with fluconazole can result in significant toxicity.

Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants

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.

Treatment and prophylaxis of invasive candidiasis

Invasive candidiasis (IC) is a leading cause of morbidity and mortality in preterm infants. Even if successfully treated, IC can cause significant neurodevelopmental impairment. Preterm infants are at increased risk for hematogenous Candida meningoencephalitis owing to increased permeability of the blood-brain barrier, so antifungal treatment should have adequate central nervous system penetration. Amphotericin B deoxycholate, lipid preparations of amphotericin B, fluconazole, and micafungin are first-line treatments of IC. Fluconazole prophylaxis reduces the incidence of IC in extremely premature infants, but its safety has not been established for this indication, and as yet, the product has not been shown to reduce mortality in neonates. Targeted prophylaxis may have a role in reducing the burden of disease in this vulnerable population.

Targeted fluconazole prophylaxis for high-risk very low birth weight infants

Antifungal prophylaxis is increasingly used in very low birth weight (VLBW) infants who are at risk for severe fungal infections. Our objective was to assess the effectiveness of targeted fluconazole prophylaxis for high-risk VLBW infants. A retrospective cohort study with historical controls was performed. During the period 2007-2008, all high-risk VLBW infants (birth weight, ≤1,000 g; gestational age, ≤28 weeks; seven antimicrobial therapy or additional risk factors present) received fluconazole prophylaxis until risk factors were not present. Treated infants were compared to a gestational age- and birth weight-matched untreated cohort. Statistical analyses used univariate and multivariate analyses. The main outcome variable was a breakthrough fungal bloodstream infection (BSI). The prophylaxis cohort of 130 VLBW infants was compared to 319 control infants. The rate of fungal infections was significantly lower in the fluconazole prophylaxis group (1 of 130 vs. 19 of 319, p = 0.016); however, they did not differ in mortality (16.2 vs. 15 %, p = 0.77) or complications of prematurity. Fluconazole prophylaxis was associated with a significant decrease in candidal BSI (odds ratio, 0.05; 95 % confidence interval, 0.005-0.523). Selective vs. nonselective prophylaxis reduced the number of infants treated from 247 to 130. Conclusion Targeted fluconazole prophylaxis in VLBW infants is effective in preventing fungal infections without increasing the risk of BSI among low-risk infants.

A review of Candida prophylaxis in the neonatal intensive care population

OBJECTIVE

To review the efficacy and safety of antifungal prophylaxis in the neonatal intensive care setting.

DATA SOURCES

English-language literature was accessed using MEDLINE (January 1988- December 2010). The following Medical Subject Heading (MeSH) search terms were used: "amphotericin B," "fluconazole," "nystatin," "itraconazole," "caspofungin," "voriconazole," "Candida," "prevention and control," and "critically ill." Literature was further limited to studies focusing on patient birth to 6 months of age. Abstracts and original research articles were included. Preference was given to published controlled trials. Articles providing descriptions of the safety and effectiveness of antifungal prophylaxis in neonatal intensive care patients were also used in this review.

RESULTS

Twenty-two studies have evaluated the impact of antifungal prophylaxis on Candida colonization or invasive infections in the Neonatal Intensive Care Unit (NICU). The two antifungal agents most commonly studied were nystatin and fluconazole. All of the nystatin studies demonstrated that nystatin is effective at reducing fungal colonization and invasive fungal infections. All of the studies designed to evaluate the impact of fluconazole prophylaxis on fungal colonization demonstrated a reduction in the incidence of fungal colonization with fluconazole prophylaxis. A total of 12 of 16 studies that evaluated the impact of fluconazole prophylaxis on the incidence of invasive fungal infections demonstrated a reduction in invasive fungal infections with fluconazole prophylaxis. Two studies found no difference between fluconazole and nystatin when used for prophylaxis.

CONCLUSION

Antifungal prophylaxis appears to be effective in reducing the incidence of Candida colonization and invasive Candida infections in the NICU. Antifungal prophylaxis also appears to be safe in the NICU population. The impact of antifungal prophylaxis on resistance patterns could be significant and needs to be evaluated long term before widespread prophylaxis can be recommended.

Trends in Candida central line-associated bloodstream infections among NICUs, 1999-2009

OBJECTIVES

To assess trends in incidence of Candida spp. central line-associated bloodstream infections (CLABSIs) in US NICUs, 1999-2009.

METHODS

Data from NICUs participating in the National Nosocomial Infections Surveillance (1999-2004) and National Healthcare Safety Network (2006-2009) were analyzed. Overall and birth weight-specific incidence rates of Candida spp. CLABSIs per 1000 central line-days were calculated. Trends in incidence were assessed by using Poisson regression, and trends in proportion of CLABSIs identified as Candida albicans were assessed by using weighted-linear regression.

RESULTS

Overall, 398 NICUs reported 1407 Candida spp. CLABSIs (706 due to C albicans) among 1400 neonates. Of the 1400 neonates, 963 (69%) were ≤ 1000 g at the time of birth, and 182 (13%) died. From 1999 to 2009, the overall incidence decreased significantly for CLABSIs due to Candida spp. (0.92 vs 0.2), C albicans (0.53 vs 0.09), and non-albicans Candida spp. (0.39 vs 0.1). Birth weight-specific incidence significantly decreased across all birth weight categories for C albicans. For CLABSIs due to non-albicans Candida spp., significant decreases were detected among all birth weight categories, except among neonates 1501 to 2500 g. The proportion of Candida spp. CLABSIs due to C albicans did not significantly change over time, remaining at ~50%.

CONCLUSIONS

Incidence of Candida spp. CLABSIs decreased substantially among NICU patients, regardless of birth weight. Decreases in incidence across all birth weight categories, and not only among neonates ≤ 1000 g in whom antifungal prophylaxis may be more common, suggest that multiple factors contributed to the declining incidence.

"Getting to Zero": preventing invasive Candida infections and eliminating infection-related mortality and morbidity in extremely preterm infants

Prevention of invasive Candida infections (ICI) is an achievable goal for every NICU and supported by A-1 evidence. Due to the incidence of ICI, high infection-associated mortality and neurodevelopmental impairment, antifungal prophylaxis should be targeted to infants <1000 g or ≤ 27 weeks gestation. There is A-1 evidence for both fluconazole and nystatin prophylaxis for the prevention of ICI. Evidence currently would favour fluconazole prophylaxis in high-risk preterm infants since intravenous fluconazole prophylaxis has greater efficacy compared to enteral nystatin prophylaxis, efficacy in the most immature patients in whom mortality is the highest, requires less dosing, and can be given to infants with gastrointestinal disease or haemodynamic instability. All NICUs caring for extremely preterm infants should use antifungal prophylaxis. Even in NICUs with low rates of ICI, antifungal prophylaxis is crucial to improving survival and neurodevelopmental outcomes for this vulnerable population. For infants 1000-1500 g if there is concern for ICI in the NICU, either drug could be chosen for prophylaxis. Fluconazole prophylaxis administered at 3 mg/kg twice a week, while intravenous access is required, appears to be the safest and most effective schedule in preventing ICI while attenuating the emergence of fungal resistance. Invasive Candida infections are one group of infections we can prevent.

Strategies for the prevention of neonatal candidiasis

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.

The use of antifungal therapy in neonatal intensive care

Invasive fungal infections remain a significant cause of infection-related mortality and morbidity in preterm infants. Central nervous system involvement is the hallmark of neonatal candidiasis, differentiating the disease's impact on young infants from that among all other patient populations. Over the past decade, the number of antifungal agents in development has grown, but most are not labeled for use in newborns. We summarize the findings of several antifungal studies that have been completed to date, emphasizing those including infant populations. We conclude that more studies are required for antifungals to be used safely and effectively in infants.

Impact of 'targeted' fluconazole prophylaxis for preterm neonates: efficacy of a highly selective approach?

OBJECTIVE

The objective of this study was to evaluate the efficacy of targeted intermittent fluconazole prophylaxis (FP) to high-risk preterm (PT) infants.

STUDY DESIGN

Observational pre-post cohort study (n=524). Targeted FP (3  mg  kg(-1)) was administered to PT infants (birth weights <1500  g and <6 weeks of age) who received broad-spectrum antibiotics for more than 2 days and had at least one additional risk factor for invasive candidiasis during the antibiotic administration period.

RESULT

Invasive candidiasis decreased significantly from 15.3 to 6.2% during the FP period. Duration of parenteral nutrition (15.5 vs 19.2 days), central line (12.7 vs 15.8 days) and necrotizing enterocolitis rates (7 vs 9.5%) were significantly higher in the FP period. FP was administered to 89 (31.3%) infants; the median (range) number of doses was four (1 to 24) and duration was 7 (1 to 38) days.

CONCLUSION

In the current study, targeted intermittent FP to a selected population of PT infants was efficacious in reducing the rate of invasive candidiasis, compared with historical controls.

European survey on the use of prophylactic fluconazole in neonatal intensive care units

Neonatal fungal infections are associated with substantial mortality and morbidity. Although prophylactic use of several antifungals has been proposed, this practice remains controversial. In order to evaluate the use of fluconazole prophylaxis in European NICUs, we conducted a cross-sectional survey by means of a structured questionnaire that was sent to European level II and III neonatal intensive care units, over a 9-month period, as part of a neonatal research FP7 European project. A total of 193 questionnaires from 28 countries were analysed. Use of antifungal prophylaxis was reported by 55% of the responders, and the most frequently used antifungal agent was fluconazole (92%). Main indications for prophylaxis were low gestational age (<28 weeks) and birth weight (<1,000 g). A dose of 3 mg/kg was used in 66% of NICUs using fluconazole, with an administration interval of 72 h in 52% of them. All responders acknowledged the need for additional trials on the efficacy of prophylactic fluconazole. Non-users of fluconazole prophylaxis were more likely to be influenced by the local incidence of candidiasis, the risk of increasing antifungal resistance and the absence of specific recommendations by paediatric societies.

CONCLUSIONS

Major concerns about the use of fluconazole prophylaxis include its efficacy, the risk of emergence of resistant species and the absence of clear consensus to support routine use. Future studies that address these issues will contribute to a more rational use of fluconazole prophylaxis.

Fluconazole to prevent systemic fungal infections in infants: reviewing the evidence

IN NEONATOLOGY, EVIDENCE-BASED practice (EBP) relies on well-designed, adequately powered trials to guide practitioners. Several large randomized controlled trials (RCTs) have been conducted to explore the use of fluconazole for fungal prophylaxis in premature infants. Despite the findings of these studies, practice varies among units. In a recent survey of members of the American Academy of Pediatrics (AAP), 34 percent of clinicians indicated that they have used antifungal prophylaxis and only 11 percent of clinicians indicated that a written protocol was in place in their NICU. Intravenous (IV) fluconazole (66 percent), oral nystatin (59 percent), and IV amphotericin (21 percent) were the three most commonly used agents among the respondents.1.

Neonatal PICC: one unit's six-year experience with limiting catheter complications

Safe dressing techniques for neonatal peripherally inserted central catheters (PICCs) remain controversial in the literature. This article describes one unit's experience with the placement and management of 491 PICCs during a six-year period with more than 5,600 catheter days. The dressing technique described in this article differs from that seen in the literature with the addition of a protective base layer. Catheter complication rates are low, and catheter dressing changes are minimized with this dressing technique.

Strategies to prevent invasive candidal infection in extremely preterm infants

The highest incidence of invasive candidal infection (ICI) occurs in extremely preterm infants (<1000 g birth weight and <or=27 weeks' gestation). In this population, ICI has high mortality, leads to significant neurodevelopmental impairment, and results in increased length of hospital stay and costs. Randomized clinical trials in infants of less than 1000 g birth weight have demonstrated that ICI is decreased 88% by antifungal prophylaxis with fluconazole compared to 54% by nystatin prophylaxis from retrospective studies. Fluconazole is more efficacious than nystatin prophylaxis in infants weighing less than 1000 g, is less expense, requires less frequent dosing (twice weekly intravenous [IV] dosing), and can be given when infants are not feeding. While antifungal prophylaxis is inexpensive, cost-effective, and easy to administer, yet has not been instituted universally despite A-1 evidence from single and multicenter studies demonstrating efficacy and safety. Debate is ongoing over whether empiric therapy or improved infection control practices are superior to prophylaxis, whether prophylaxis should be instituted only in neonatal intensive care units (NICUs) with a relatively high ICI rate, and whether fluconazole prophylaxis is safe or risks emergence of resistance. To date, azole resistance has not emerged with targeted treatment of high-risk infants for the duration of IV catheter use. Empiric therapy for suspected ICI and standardized therapy for candidemia, including central venous catheter removal, may decrease mortality; however, these approaches still risk neurodevelopmental impairment in ICI survivors. Infection control practices have not been subjected to prospective or randomized trials to demonstrate efficacy in reducing fungal infections. Evidence is presented in this article from clinical trials demonstrating efficacy and safety of antifungal prophylaxis in preventing ICI in preterm infants. The greatest impact of antifungal prophylaxis preventing ICI and decreasing Candida-related mortality and neurodevelopmental impairment would be achieved with a universal approach in all NICUs.

Challenging issues in neonatal candidiasis

In an era of quality improvement and 'getting to zero (infections and/or related mortality),' neonatal candidiasis is ripe for evidence-based initiatives. Knowledge of each institution's invasive Candida infection (ICI) incidence and infection-related mortality is critical to evaluate disease burden and effective interventions. Evidenced-based interventions include: antifungal prophylaxis, starting with appropriate dosing, and prompt removal of central venous catheters (CVC). There is A-I evidence supporting antifungal prophylaxis with fluconazole, and it should be considered in every neonatal intensive care unit (NICU). The literature supports targeting infants <1000 g and/or <or=27 weeks, because this group has high infection-related mortality and neurodevelopmental impairment in 57% of survivors. Antifungal prophylaxis has been shown to nearly eliminate infection-related mortality. Interventions start with prenatal initiatives, with women being treated for vaginal candidiasis, especially with preterm labor or complications. Targeting modifiable risk factors, including restriction policies for use of third- and fourth-generation cephalosporins, carbapenems, H2-antagonists, proton pump inhibitors, and postnatal steroids; guidelines for CVC care and removal; and feeding practices, with promotion of early feedings and breast milk, may also reduce risk. A few studies have emerged on empiric antifungal therapy with sepsis evaluations for preterm infants <1500 g and other high-risk patients that have shown favorable effects of eliminating mortality, but these have not been compared to appropriate antifungal therapy and central line removal. Further study of empiric therapy, prospective treatment studies with higher targeted dosing of amphotericin B preparations, fluconazole, and new antifungals with prompt CVC removal may contribute to a 100% survival rate for those infants >1000 g and >or=28 weeks not receiving antifungal prophylaxis. Evaluation of ICI incidence and mortality by gestational age and birth week should be followed in each NICU, to evaluate infection control and prevention.

Recently tested strategies to reduce nosocomial infections in the neonatal intensive care unit

Recent years have witnessed a renewed interest in reducing hospital-acquired infections in critically ill patients. We review three recently tested strategies to decrease nosocomial infections specifically in the neonatal intensive care unit. These include improvement of hand hygiene, the incorporation of hand-hygiene practices into broader care bundles, and the prophylactic administration of antimicrobials, especially fluconazole, to infants at high risk prior to the onset of infection. The effectiveness of the first two interventions is well supported, particularly in older patient populations, while the effectiveness of the third is counterbalanced by the threat of the emergence of resistant-organism infections.

Fluconazole Prophylaxis in High-Risk Neonates

OBJECTIVE

To evaluate the literature regarding the use of fluconazole prophylaxis in high-risk neonates.

DATA SOURCES

Literature was accessed through MEDLINE (February 2001-August 2009) using the search terms fluconazole and prophylaxis, with limits for age group (ie, birth-18 y). Reference citations from identified articles were also reviewed.

DATA SELECTION AND DATA EXTRACTION

All prospective and retrospective studies in English identified from MEDLINE were evaluated.

DATA SYNTHESIS

Critically ill neonates possess a number of risk factors that predispose them to fungal colonization with Candida spp. In many cases, colonization may progress to invasive systemic infections despite efforts aimed at early diagnosis and treatment. Because of its success among immunocompromised patients, fluconazole prophylaxis has been suggested as a possible approach for reducing the rates of both colonization and invasive fungal infections among at-risk neonates. To date, 4 prospective randomized controlled trials and 8 retrospective cohort studies have examined fluconazole prophylaxis in neonates. Although fluconazole prophylaxis appears to reduce the rates of colonization and invasive fungal infections, no trial in this review was able to demonstrate a significant difference in long-term morbidity or mortality. Concerns also remain regarding the adverse effects associated with prolonged exposure to fluconazole therapy. Lack of standardized study designs and treatment regimens also limit widespread recommendation for the use of fluconazole prophylaxis in clinical practice.

CONCLUSIONS

While it may be beneficial for critically ill neonates with certain predisposing risk factors (eg, central venous access, sustained exposure to broad-spectrum antibiotics, or units with significantly high incidence of invasive fungal infections), existing research does not support the use of fluconazole prophylaxis based on birth weight or gestational age alone. Multifactor analysis evaluating the effect of fluconazole prophylaxis is necessary to establish which neonates would benefit from this practice.

Epidemiology of candidemia at a Children's hospital, 2002 to 2006

BACKGROUND

There are few recent studies evaluating trends in the epidemiology of candidemia including changes in species or utilization of antifungal agents in children.

METHODS

We performed a retrospective case series of candidemia at our children's hospital from 2002 to 2006. Our objectives were to study trends in the rates of candidemia, demographic characteristics, Candida species, antifungal susceptibility, and antifungal utilization. These data were obtained from the electronic medical records.

RESULTS

There were 203 episodes of candidemia in 154 subjects. During the study period, the average rate of candidemia was 5.52 per 1000 patient-discharges and did not change throughout the study. The mean and median ages of subjects were 3 years versus 9 months, respectively, and 38% were less than 3 months of age. Gastrointestinal disorders were a common comorbid condition (33%), especially for subjects with multiple episodes of candidemia. Overall, Candida parapsilosis and Candida albicans caused 43% and 26% of episodes, respectively, and candidemia caused by Candida glabrata (5.3%-23%) and Candida krusei (0%-8.5%) increased during the study. Ninety-eight percent of C. albicans and C. parapsilosis isolates remained susceptible to all antifungal drugs. From 2003-2006, the use of antifungal agents increased from 79 days to 150 days per 1000 hospital-days.

CONCLUSIONS

While antifungal use at our hospital increased, candidemia rates remained stable. C. parapsilosis was the most common species but other non-C. albicans species increased during the study period. Local epidemiology should be monitored in pediatric populations for potential impact on management strategies.