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Flores-Maldonado O, González GM, Enríquez-Bañuelos JF, Andrade Á, Treviño-Rangel R, Becerril-García MA. Candida albicans causes brain regional invasion and necrosis, and activation of microglia during lethal neonatal neurocandidiasis. Microbes Infect 2023; 25:105119. [PMID: 36758890 DOI: 10.1016/j.micinf.2023.105119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/10/2023]
Abstract
Neurocandidiasis is a fungal infection that primarily affects neonates, which is associated with 70% case fatality rates, while pediatric patients who survive infection often have long-term neurological sequelae, making it a clinical requirement to understand the pathogenesis of neonatal neurocandidiasis. Currently, the brain regions to Candida albicans invasion during the neonatal period are not characterized. In this study, 0-day-old mice were infected with C. albicans intravenously to determine dissemination and invasion into the brain at different times post-infection by fungal burden assay and histopathological analysis, additionally cellular death and microglial activation were evaluated by flow cytometry. The results evidenced the dissemination of C. albicans within the first hour of infection in the brain. The meninges were the initial site of invasion during the first 6 hours post infection and then filamentous structures into the brain parenchyma increases during infection, the anatomic regions most susceptible to invasion being the cerebral cortex, thalamus, hypothalamus, midbrain, pons, and medulla oblongata. Furthermore, C. albicans invasion of brain tissue results in cell necrosis and activation of microglia as a consequence of fungal invasion.
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Affiliation(s)
- Orlando Flores-Maldonado
- Departamento de Microbiología, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Av. Francisco I. Madero, Mitras Centro, 64460, Monterrey, Mexico
| | - Gloria M González
- Departamento de Microbiología, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Av. Francisco I. Madero, Mitras Centro, 64460, Monterrey, Mexico
| | - Juan F Enríquez-Bañuelos
- Departamento de Microbiología, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Av. Francisco I. Madero, Mitras Centro, 64460, Monterrey, Mexico
| | - Ángel Andrade
- Departamento de Microbiología, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Av. Francisco I. Madero, Mitras Centro, 64460, Monterrey, Mexico
| | - Rogelio Treviño-Rangel
- Departamento de Microbiología, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Av. Francisco I. Madero, Mitras Centro, 64460, Monterrey, Mexico
| | - Miguel A Becerril-García
- Departamento de Microbiología, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Av. Francisco I. Madero, Mitras Centro, 64460, Monterrey, Mexico.
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Andes D. Regulatory Level of Evidence and Practicality in Antifungal Use Decisions for Less Common Fungal Diseases. Clin Infect Dis 2021; 73:2341-2343. [PMID: 34459896 DOI: 10.1093/cid/ciab015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- David Andes
- Departments of Medicine and Medical Microbiology & Immunology, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Robati Anaraki M, Nouri-Vaskeh M, Abdoli Oskoei S. Fluconazole prophylaxis against invasive candidiasis in very low and extremely low birth weight preterm neonates: a systematic review and meta-analysis. Clin Exp Pediatr 2021; 64:172-179. [PMID: 32683818 PMCID: PMC8024115 DOI: 10.3345/cep.2019.01431] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/29/2020] [Indexed: 01/15/2023] Open
Abstract
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.
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Affiliation(s)
- Mahmoud Robati Anaraki
- Dental and Periodontal Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Prosthodontics, Dental School, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Nouri-Vaskeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahram Abdoli Oskoei
- Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Raj S, Vinod V, Jayakumar J, Suresh P, Kumar A, Biswas R. Antifungal activity of Syzygium samarangense leaf extracts against Candida. Lett Appl Microbiol 2021; 73:31-38. [PMID: 33735468 DOI: 10.1111/lam.13471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 11/26/2022]
Abstract
Candida species are opportunistic human fungal pathogens that cause acute and chronic infections against which only few antifungal agents are available. Here we have elucidated the antifungal effect of Syzygium samarangense leaf extracts (SSLE). Antifungal activity of SSLE was studied against Candida albicans, C. krusei, C. parapsilosis, C. glabrata, C. auris and C. tropicalis. Following experiments were performed: minimum fungicidal concentration (MFC) determination, agar well disc diffusion assays, fungal morphology analysis using scanning electron microscope (SEM), ex vivo fungal survival assays on porcine tongue and skin and in vivo fungal survival assays using Drosophila melanogaster fly model. Results demonstrated MFC of SSLE ranges between 100 and 125 mg ml-1 . SEM images showed cell wall degradation of C. albicans when treated with SSLE. Around 75% decrease in C. albicans viability was observed when infected porcine tongue and skin were treated using SSLE. The C. albicans infected D. melanogaster when fed with SSLE showed significant decrease (around 80%) of fungal count than the infected control. Furthermore, agar plate disc diffusion assays demonstrated that the antifungal activity of SSLE could be due to chalcone, which is one of the active constituents in SSLE. Our study demonstrated that SSLE could be used for the topical treatment of Candida infections.
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Affiliation(s)
- S Raj
- Centre for Nanosciences and Molecular Medicine, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - V Vinod
- Centre for Nanosciences and Molecular Medicine, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - J Jayakumar
- Centre for Nanosciences and Molecular Medicine, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - P Suresh
- Centre for Nanosciences and Molecular Medicine, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - A Kumar
- Department of Microbiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - R Biswas
- Centre for Nanosciences and Molecular Medicine, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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High-Dose Micafungin in Neonates and Young Infants with Invasive Candidiasis: Results of a Phase 2 Study. Antimicrob Agents Chemother 2021; 65:AAC.02494-20. [PMID: 33558294 DOI: 10.1128/aac.02494-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 01/31/2021] [Indexed: 12/20/2022] Open
Abstract
Limited data are available on the most appropriate dosing, efficacy, and safety of micafungin in neonates and young infants with invasive candidiasis (IC). This study evaluated plasma levels, efficacy, and safety of micafungin at a dose of 8 mg/kg daily for a mean of 13.3 days (±5.2 days) in 35 neonates and young infants with IC. Micafungin plasma concentrations were 5.70 mg/liter preadministration and 17.23, 15.59, and 10.27 mg/liter after 1, 2, and 8 h, respectively. The resolution of the infection was achieved in 86.7% of patients treated for ≥14 days. In 20.0% of patients, we observed a transient hypertransaminasemia. Micafungin at a dose of 8 mg/kg daily is effective and well tolerated in neonates and young infants with IC. (This study has been registered at ClinicalTrials.gov under identifier NCT03421002 and in the EU Clinical Trials Register under number 2014-003087-20.).
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Efficacy and Pharmacokinetics of Fosmanogepix (APX001) in the Treatment of Candida Endophthalmitis and Hematogenous Meningoencephalitis in Nonneutropenic Rabbits. Antimicrob Agents Chemother 2021; 65:AAC.01795-20. [PMID: 33361304 DOI: 10.1128/aac.01795-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/12/2020] [Indexed: 12/22/2022] Open
Abstract
Candida endophthalmitis is a serious sight-threatening complication of candidemia that may occur before or during antifungal therapy. Hematogenous Candida meningoencephalitis (HCME) is also a serious manifestation of disseminated candidiasis in premature infants, immunosuppressed children, and immunocompromised adults. We evaluated the antifungal efficacy and pharmacokinetics of the prodrug fosmanogepix (APX001) in a rabbit model of endophthalmitis/HCME. Manogepix (APX001A), the active moiety of prodrug fosmanogepix, inhibits the fungal enzyme Gwt1 and is highly active in vitro and in vivo against Candida spp., Aspergillus spp., and other fungal pathogens. Plasma pharmacokinetics of manogepix after oral administration of fosmanogepix on day 6 at 25, 50, and 100 mg/kg resulted in maximum concentration of drug in plasma (C max) of 3.96 ± 0.41, 4.14 ± 1.1, and 11.5 ± 1.1 μg/ml, respectively, and area under the concentration-time curve from 0 to 12 h (AUC0-12) of 15.8 ± 3.1, 30.8 ± 5.0, 95.9 ± 14 μg·h/ml, respectively. Manogepix penetrated the aqueous humor, vitreous, and choroid with liquid-to-plasma ratios ranging from 0.19 to 0.52, 0.09 to 0.12, and 0.02 to 0.04, respectively. These concentrations correlated with a significant decrease in Candida albicans burden in vitreous (>101 to 103 log CFU/g) and choroid (>101 to 103 log CFU/g) (P ≤ 0.05 and P ≤ 0.001, respectively). The aqueous humor had no detectable C. albicans in treatment and control groups. The tissue/plasma concentration ratios of manogepix in meninges, cerebrum, cerebellum, and spinal cord were approximately 1:1, which correlated with a >102 to 104 decline of C. albicans in tissue versus control (P ≤ 0.05). Serum and cerebrospinal fluid (CSF) (1→3)-β-d-glucan levels demonstrated significant declines in response to fosmanogepix treatment. These findings provide an experimental foundation for fosmanogepix in treatment of Candida endophthalmitis and HCME and derisk the clinical trials of candidemia and invasive candidiasis.
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Hornik CD, Bondi DS, Greene NM, Cober MP, John B. Review of Fluconazole Treatment and Prophylaxis for Invasive Candidiasis in Neonates. J Pediatr Pharmacol Ther 2021; 26:115-122. [PMID: 33603574 PMCID: PMC7887891 DOI: 10.5863/1551-6776-26.2.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/17/2020] [Indexed: 01/29/2023]
Abstract
Invasive candidiasis accounts for approximately 10% of nosocomial infections in preterm infants, with an incidence of 1% to 4% among neonatal intensive care unit (NICU) admissions and a mortality as high as 20% to 30%. These outcomes warrant improved treatment and prevention strategies for infants at highest risk. The Infectious Diseases Society of America provides guidelines on antifungal medications for the prophylaxis and treatment of candidiasis in NICUs; however, there are still variations in practice on the use of fluconazole for prophylaxis and treatment of invasive candidiasis. This review provides specific information regarding fluconazole activity, pharmacokinetics, and a literature evaluation of dosing strategies and comparisons to other treatments in the neonatal population.
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Cai S, Thompson DK, Anderson PJ, Yang JYM. Short- and Long-Term Neurodevelopmental Outcomes of Very Preterm Infants with Neonatal Sepsis: A Systematic Review and Meta-Analysis. CHILDREN-BASEL 2019; 6:children6120131. [PMID: 31805647 PMCID: PMC6956113 DOI: 10.3390/children6120131] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 01/23/2023]
Abstract
Sepsis is commonly experienced by infants born very preterm (<32 weeks gestational age and/or <1500 g birthweight), but the long-term functional outcomes are unclear. The objective of this systematic review was to identify observational studies comparing neurodevelopmental outcomes in very preterm infants who had blood culture-proven neonatal sepsis with those without sepsis. Twenty-four studies were identified, of which 19 used prespecified definitions of neurodevelopmental impairment and five reported neurodevelopmental outcomes as continuous variables. Meta-analysis was conducted using 14 studies with defined neurodevelopmental impairment and demonstrated that very preterm infants with neonatal sepsis were at higher risk of impairments, such as cerebral palsy and neurosensory deficits, compared with infants without sepsis (OR 3.18; 95% CI 2.29–4.41). Substantial heterogeneity existed across the studies (I2 = 83.1, 95% CI 73–89). The five studies that reported outcomes as continuous variables showed no significant difference in cognitive performance between sepsis and non-sepsis groups. Neonatal sepsis in very preterm infants is associated with increased risk of neurodevelopmental disability. Due to the paucity of longitudinal follow-up data beyond 36 months, the long-term cognitive effect of neonatal sepsis in very preterm infants could not be conclusively determined. Effects on the development of minor impairment could not be assessed, due to the small numbers of infants included in the studies.
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Affiliation(s)
- Shirley Cai
- Victorian Infant Brain Study, Murdoch Children’s Research Institute, Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052, Australia; (S.C.); (P.J.A.)
- Developmental Imaging, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia;
- Melbourne Medicine School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Deanne K. Thompson
- Victorian Infant Brain Study, Murdoch Children’s Research Institute, Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052, Australia; (S.C.); (P.J.A.)
- Developmental Imaging, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia;
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
- Florey Institute of Neuroscience and Mental Health, Parkville, VIC 3052, Australia
- Correspondence:
| | - Peter J. Anderson
- Victorian Infant Brain Study, Murdoch Children’s Research Institute, Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052, Australia; (S.C.); (P.J.A.)
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, VIC 3800, Australia
| | - Joseph Yuan-Mou Yang
- Developmental Imaging, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia;
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
- Neuroscience Research, Murdoch Children’s Research Institute, Parkville, VIC 3052, Australia
- Department of Neurosurgery, Royal Children’s Hospital, Parkville, VIC 3052, Australia
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Lamba M, Sharma D, Sharma R, Vyas A, Mamoria V. To study the profile of Candida isolates and antifungal susceptibility pattern of neonatal sepsis in a tertiary care hospital of North India. J Matern Fetal Neonatal Med 2019; 34:2655-2659. [PMID: 31581861 DOI: 10.1080/14767058.2019.1670799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIMS AND OBJECTIVE To study the profile of Candida infection and antifungal susceptibility (AFS) pattern in neonatal sepsis. MATERIALS AND METHODS In this prospective observational study, 850 blood samples were collected and processed from neonates who were suspected clinically to have sepsis. The blood culture that showed growth of Candida was further processed for species identification. Antifungal susceptibility was done as per the National Committee for Clinical Laboratory Standards (NCCLS)/Clinical Laboratory Standards Institute (CLSI) M44-A-2 guidelines by disc diffusion method and automated vitek-2 compact system. Candidemia was diagnosed by isolation of Candida species from at least one positive blood culture containing pure growth of Candida species with supportive clinical features. RESULTS Candida species were isolated in 32 specimens of the total 322 culture-positive cases. The most common isolate was Candida tropicalis (14/32; 43.75%) followed by Candida albicans (7/32; 21.87%) and Candida glabrata (6/32; 18.75%). The three most common neonatal risk factors for candidemia were low birth weight, prolonged use of intravenous antibiotics and presence of central venous line. Non-albicans Candida (NAC) showed good sensitivity to fluconazole as compared to Candida albicans. The fluconazole sensitivity of Candida tropicalis, Candida glabrata, and Candida parapsilosis was 93, 67, and 100%, respectively, whereas it was 57% in Candida albicans. The sensitivity to amphotericin B was 95% among all Candida isolates. All NAC were sensitive to amphotericin B, while only 72% Candida albicans were sensitive to amphotericin B. CONCLUSIONS The incidence of neonatal sepsis secondary to NAC is increasing and has replaced Candida albicans as a major cause of neonatal fungal sepsis. Low birth weight is the most important risk factor for Candida sepsis. The resistance of Candida albicans is increasing for both fluconazole and amphotericin B when compared to NAC. Increasing antifungal resistance warrants its judicious use both for prophylaxis and treatment.
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Affiliation(s)
- Mamta Lamba
- Mahatma Gandhi National Institute of Medical Sciences, Jaipur, India
| | - Deepak Sharma
- National Institute of Medical Science Medical College and Hospital, Jaipur, India
| | - Rajni Sharma
- Department of Microbiology, SMS Medical College, Jaipur, India
| | - Aruna Vyas
- Department of Microbiology, SMS Medical College, Jaipur, India
| | - Ved Mamoria
- Mahatma Gandhi National Institute of Medical Sciences, Jaipur, India
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Gerhart JG, Watt KM, Edginton A, Wade KC, Salerno SN, Benjamin DK, Smith PB, Hornik CP, Cohen-Wolkowiez M, Duara S, Ross A, Shattuck K, Stewart DL, Neu N, Gonzalez D. Physiologically-Based Pharmacokinetic Modeling of Fluconazole Using Plasma and Cerebrospinal Fluid Samples From Preterm and Term Infants. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:500-510. [PMID: 31087536 PMCID: PMC6656941 DOI: 10.1002/psp4.12414] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 12/16/2022]
Abstract
Fluconazole is used to treat hematogenous Candida meningoencephalitis in preterm and term infants. To characterize plasma and central nervous system exposure, an adult fluconazole physiologically‐based pharmacokinetic (PBPK) model was scaled to infants, accounting for age dependencies in glomerular filtration and metabolism. The model was optimized using 760 plasma samples from 166 infants (median postmenstrual age (range) 28 weeks (24–50)) and 27 cerebrospinal fluid (CSF) samples from 22 infants (postmenstrual age 28 weeks (24–33)). Simulations evaluated achievement of the surrogate efficacy target of area under the unbound concentration‐time curve ≥ 400 mg • hour/L over the dosing interval in plasma and CSF using dosing guidelines. Average fold error of predicted concentrations was 0.73 and 1.14 for plasma and CSF, respectively. Target attainment in plasma and CSF was reached faster after incorporating a loading dose of 25 mg/kg. PBPK modeling can be useful in exploring CNS kinetics of drugs in children.
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Affiliation(s)
- Jacqueline G Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kevin M Watt
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Kelly C Wade
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sara N Salerno
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Shahnaz Duara
- Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Ashley Ross
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Karen Shattuck
- Department of Pediatrics, University of Texas Medical Branch, Galveston, Texas, USA
| | - Dan L Stewart
- Department of Pediatrics, University of Louisville, Louisville, Kentucky, USA
| | - Natalie Neu
- Department of Pediatrics, Columbia University Medical Center, New York, New York, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Chen SN, Wang PH, Hsieh MF, Tsai HW, Lin LT, Tsui KH. Maternal pregnancy-induced hypertension increases the subsequent risk of neonatal candidiasis: A nationwide population-based cohort study. Taiwan J Obstet Gynecol 2019; 58:261-265. [PMID: 30910150 DOI: 10.1016/j.tjog.2019.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Neonatal candidiasis is a leading infectious cause of significant morbidity and mortality in premature birth mainly due to impaired physical barriers and immature immune system of fetus. Maternal pregnancy-induced hypertension (PIH) has been reported to be able to disturb the neonatal immune system, which could cause the increased possibility of neonatal infection. Therefore, we hypothesized that maternal PIH may increase the risk of neonatal candidiasis. The aim of this study was to evaluate whether PIH increased the risk of neonatal candidiasis and identify the predictive risk factors. MATERIALS AND METHODS Patients with newly diagnosed PIH between January 1, 2000, and December 31, 2013 were selected from the Taiwan National Health Insurance Research Database (NHIRD). For each patient in the PIH cohort, 4 subjects without PIH, matched for age and year of delivery, were randomly selected as the comparison cohort. A Cox proportional regression model was used to estimate the risks of neonatal candidiasis in both cohorts. RESULTS Among the 23.3 million individuals registered in the NHIRD, 29,013 patients with PIH and 116,052 matched controls were identified. Patients with PIH had a higher incidence of neonatal candidiasis than did those without PIH. According to the multivariate analysis, PIH (odds ratio [OR] = 2.08, 95% confidence interval [CI] = 1.11-3.19, p < 0.0228), single parity (OR = 1.91, 95% CI = 1.00-3.65, p < 0.0499), and preterm birth (OR = 3.57, 95% CI = 1.84-6.93, p = 0.0002) were independent risk factors for the development of neonatal candidiasis. CONCLUSION Patients who had a history of PIH was associated with an increased risk of having infants who develop neonatal candidiasis compared with those without PIH. Additionally, preterm birth was an independent risk factor for the development of neonatal candidiasis.
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Affiliation(s)
- San-Nung Chen
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Ming-Fang Hsieh
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hsiao-Wen Tsai
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Li-Te Lin
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan; Department of Nursing, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan.
| | - Kuan-Hao Tsui
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan; Department of Pharmacy and Graduate Institute of Pharmaceutical Technology, Tajen University, Pingtung County, Taiwan.
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12
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Pecoraro HL, Berg MR, Dozier BL, Martin LD, McEvoy CT, Davies MH, Ducore R. Candida albicans-associated sepsis in a pre-term neonatal rhesus macaque (Macaca mulatta). J Med Primatol 2019; 48:186-188. [PMID: 30734326 DOI: 10.1111/jmp.12401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 01/13/2019] [Indexed: 11/30/2022]
Abstract
Invasive Candida infections (ICI) have been associated with neurodevelopmental impairment or death in human pre-term neonates. Candidiasis in nonhuman primates is seen mostly in immunosuppressed animals, and ICI is not commonly reported. Here, we report a case of Candida albicans-associated ICI in a pre-term neonatal rhesus macaque.
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Affiliation(s)
- Heidi L Pecoraro
- Oregon National Primate Research Center, Division of Comparative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Melissa R Berg
- Oregon National Primate Research Center, Division of Comparative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Brandy L Dozier
- Oregon National Primate Research Center, Division of Comparative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Lauren Drew Martin
- Oregon National Primate Research Center, Division of Comparative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Cindy T McEvoy
- Department of Pediatrics, Division of Neonatology, Oregon Health & Science University, Portland, Oregon
| | - Michael H Davies
- Division of Neuroscience, Oregon Health & Science University, Portland, Oregon
| | - Rebecca Ducore
- Oregon National Primate Research Center, Division of Comparative Medicine, Oregon Health & Science University, Portland, Oregon
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Bersani I, Piersigilli F, Goffredo BM, Santisi A, Cairoli S, Ronchetti MP, Auriti C. Antifungal Drugs for Invasive Candida Infections (ICI) in Neonates: Future Perspectives. Front Pediatr 2019; 7:375. [PMID: 31616647 PMCID: PMC6764087 DOI: 10.3389/fped.2019.00375] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 09/02/2019] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Iliana Bersani
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Fiammetta Piersigilli
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Bianca Maria Goffredo
- Biochemistry Laboratory, Department of Specialist Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Alessandra Santisi
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sara Cairoli
- Biochemistry Laboratory, Department of Specialist Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Maria Paola Ronchetti
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Cinzia Auriti
- Neonatal Intensive Care Unit, Department of Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
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14
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Savioli K, Rouse C, Susi A, Gorman G, Hisle-Gorman E. Suspected or known neonatal sepsis and neurodevelopmental delay by 5 years. J Perinatol 2018; 38:1573-1580. [PMID: 30202045 DOI: 10.1038/s41372-018-0217-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 08/13/2018] [Accepted: 08/20/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Evaluate impact of known and suspected neonatal sepsis in the term and preterm infant on neurodevelopmental delay by 5 years. STUDY DESIGN Included infants were born in 2009-2010 and followed for 5 years. Diagnostic codes and at least 5 days of antibiotic use identified suspected sepsis. Laboratory results confirmed known sepsis. Diagnostic codes stratified developmental delay by sub-type. Logistic regression analysis determined odds of developmental delay for sepsis and suspected sepsis. RESULTS Of 65,938 included infants, 190 had sepsis and 3449 had suspected sepsis. After adjustment for known developmental risk factors, sepsis and suspected sepsis were associated with increased risk for any developmental delay, (1.48 (1.05-2.09) and 1.09 (1.01-1.18)), respectively, and multiple developmental delay sub-types. CONCLUSION Neonatal sepsis and suspected sepsis are associated with neurodevelopmental delay by 5 years of age.
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Affiliation(s)
- Katrina Savioli
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Christopher Rouse
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Apryl Susi
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Gregory Gorman
- Department of Pediatrics, Walter Reed National Military Medical Center, Bethesda, MD, USA.,Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Elizabeth Hisle-Gorman
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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15
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Esposito E, Campolo M, Casili G, Lanza M, Filippone A, Peritore AF, Cuzzocrea S. Effect of pea protein plus grape seed dry extract on a murine model of Candida albicans induced vaginitis. Future Microbiol 2018; 13:1375-1382. [DOI: 10.2217/fmb-2018-0102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Aim: The objective of this research was to evaluate the antifungal properties of the association between grape seed and pea by using a nonpharmacological medical device that contains them. Materials & methods: A murine model of vulvovaginal candidiasis, induced by Candida albicans infection, was used. Results: We showed that topical treatment with the device significantly reduced the fungal burden in vagina and preserved vagina tissue architecture from C. albicans infection. Conclusion: We can support the potential beneficial effect of the association between grape and pea extract present in the medical device. Together these results supported this device as a favorable antifungal agent and a promising synergist with fluconazole in the clinical management of vulvovaginal candidiasis caused by C. albicans biofilms.
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Affiliation(s)
- Emanuela Esposito
- Department of Chemical, Biological, Pharmacological & Environmental Sciences, University of Messina, Italy
| | - Michela Campolo
- Department of Chemical, Biological, Pharmacological & Environmental Sciences, University of Messina, Italy
| | - Giovanna Casili
- Department of Chemical, Biological, Pharmacological & Environmental Sciences, University of Messina, Italy
| | - Marika Lanza
- Department of Chemical, Biological, Pharmacological & Environmental Sciences, University of Messina, Italy
| | - Alessia Filippone
- Department of Chemical, Biological, Pharmacological & Environmental Sciences, University of Messina, Italy
| | - Alessio F Peritore
- Department of Chemical, Biological, Pharmacological & Environmental Sciences, University of Messina, Italy
| | - Salvatore Cuzzocrea
- Department of Chemical, Biological, Pharmacological & Environmental Sciences, University of Messina, Italy
- Department of Pharmacological & Physiological Science, Saint Louis University School of Medicine, USA
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16
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Autmizguine J, Tan S, Cohen-Wolkowiez M, Cotten CM, Wiederhold N, Goldberg RN, Adams-Chapman I, Stoll BJ, Smith PB, Benjamin DK. Antifungal Susceptibility and Clinical Outcome in Neonatal Candidiasis. Pediatr Infect Dis J 2018; 37:923-929. [PMID: 29369937 PMCID: PMC6057841 DOI: 10.1097/inf.0000000000001913] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Invasive candidiasis is an important cause of sepsis in extremely low birth weight infants (ELBW, < 1000 g), is often fatal, and frequently results in neurodevelopmental impairment (NDI) among survivors. We sought to assess the antifungal minimum inhibitory concentration (MIC) distribution for Candida in ELBW infants and evaluate the association between antifungal resistance and death or NDI. METHODS This was a secondary analysis of a National Institute of Child Health and Human Development Neonatal Research Network study. MIC values were determined for fluconazole, amphotericin B and micafungin. NDI was assessed at 18-22 months adjusted age using the Bayley Scales of Infant Development. An infant was defined as having a resistant Candida isolate if ≥ 1 positive cultures from normally sterile sites (blood, cerebrospinal fluid, or urine) were resistant to ≥ 1 antifungal agent. In addition to resistance status, we categorized fungal isolates according to MIC values (low and high). The association between death/NDI and MIC level was determined using logistic regression, controlling for gestational age and Bayley Scales of Infant Development (II or III). RESULTS Among 137 ELBW infants with IC, MICs were determined for 308 isolates from 110 (80%) infants. Three Candida isolates from 3 infants were resistant to fluconazole. None were resistant to amphotericin B or micafungin. No significant difference in death, NDI, or death/NDI between groups with low and high MICs was observed. CONCLUSIONS Antifungal resistance was rare among infecting Candida isolates, and MIC level was not associated with increased risk of death or NDI in this cohort of ELBW infants.
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MESH Headings
- Amphotericin B/pharmacology
- Antifungal Agents/pharmacology
- Antifungal Agents/therapeutic use
- Candida/drug effects
- Candida/isolation & purification
- Candidiasis, Invasive/complications
- Candidiasis, Invasive/drug therapy
- Candidiasis, Invasive/mortality
- Cohort Studies
- Drug Resistance, Fungal
- Female
- Fluconazole/pharmacology
- Gestational Age
- Humans
- Infant
- Infant, Extremely Low Birth Weight
- Infant, Newborn
- Infant, Newborn, Diseases/drug therapy
- Infant, Newborn, Diseases/microbiology
- Intensive Care Units, Neonatal/statistics & numerical data
- Male
- Micafungin/pharmacology
- Microbial Sensitivity Tests
- Neurodevelopmental Disorders/etiology
- Prospective Studies
- Sepsis/complications
- Sepsis/microbiology
- Sepsis/mortality
- Treatment Outcome
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Affiliation(s)
- Julie Autmizguine
- From the Department of Pharmacology and Physiology, Université de Montréal, Montréal, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Canada
- Department of Pediatrics, Duke University, Durham, NC
| | - Sylvia Tan
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
| | | | | | - Nathan Wiederhold
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | | | | | - Barbara J Stoll
- Department of Pediatrics, Emory University, Atlanta, GA
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
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17
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Abstract
Considerable progress has been made in the prevention, diagnosis, and management of pediatric patients with invasive fungal disease (IFD). The reported decreasing trend in the incidence of invasive candidiasis (IC) over the past 15 years in both neonates and children has been encouraging. Nevertheless, due to the growing number of immunocompromised children at risk for IFD, this disease continues to be associated with significant morbidity and death and with increased financial burden to the health care system. Therefore, it is important to understand the contemporary epidemiology of IFD. Incidence rates of IFD in children are affected by geographical, population, and time variability. There is an ongoing effort to constantly document and update the incidence of IFD and species distribution among different pediatric populations as a means to direct preventative, diagnostic, and therapeutic resources to the most appropriate subset of patients. Children with a hematologic malignancy or a primary or secondary immunodeficiency, those undergoing solid organ or hematopoietic stem cell transplantation, and premature neonates are the major subsets of pediatric patients at risk of developing IFD. In this review, we focus on fungal disease epidemiology with a specific emphasis on the 2 most common pediatric IFDs, IC and invasive aspergillosis (IA).
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Affiliation(s)
- Zoi Dorothea Pana
- Hospital Epidemiology and Infection Control Department (HEIC), Division of Infectious Diseases, Johns Hopkins Hospital, Baltimore, Maryland
- Third Department of Paediatrics, Infectious Diseases Unit, Aristotle University School of Medicine, Hippokration General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Third Department of Paediatrics, Infectious Diseases Unit, Aristotle University School of Medicine, Hippokration General Hospital, Thessaloniki, Greece
| | - Adilia Warris
- Aberdeen Fungal Group, MRC Centre for Medical Mycology, Institute of Medical Sciences and the Royal Aberdeen Children’s Hospital, University of Aberdeen, United Kingdom
| | - Andreas H Groll
- Center for Bone Marrow Transplantation and Department of Paediatric Hematology and Oncology, Infectious Disease Research Program, University Children’s Hospital, Muenster, Germany
| | - Theoklis Zaoutis
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness Research, Children’s Hospital of Philadelphia, Pennsylvania; and
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia
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18
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King J, Pana ZD, Lehrnbecher T, Steinbach WJ, Warris A. Recognition and Clinical Presentation of Invasive Fungal Disease in Neonates and Children. J Pediatric Infect Dis Soc 2017; 6:S12-S21. [PMID: 28927201 PMCID: PMC5907856 DOI: 10.1093/jpids/pix053] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Jill King
- Aberdeen Fungal Group, Medical Research Council Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, and the Royal Aberdeen Children’s Hospital, United Kingdom
| | - Zoi-Dorothea Pana
- Hospital Epidemiology and Infection Control, Division of Infectious Diseases, Johns Hopkins Hospital, Baltimore, Maryland
| | - Thomas Lehrnbecher
- Division of Paediatric Haematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe-University, Frankfurt, Germany; and
| | - William J Steinbach
- Division of Pediatric Infectious Diseases, Department of Pediatrics, and Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, North Carolina
| | - Adilia Warris
- Aberdeen Fungal Group, Medical Research Council Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, and the Royal Aberdeen Children’s Hospital, United Kingdom
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19
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McCarthy MW, Kalasauskas D, Petraitis V, Petraitiene R, Walsh TJ. Fungal Infections of the Central Nervous System in Children. J Pediatric Infect Dis Soc 2017; 6:e123-e133. [PMID: 28903523 DOI: 10.1093/jpids/pix059] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 07/04/2017] [Indexed: 01/03/2023]
Abstract
Although uncommon in children, fungal infections of the central nervous system can be devastating and difficult to treat. A better understanding of basic mycologic, immunologic, and pharmacologic processes has led to important advances in the diagnosis and management of these diseases, but their mortality rates remain unacceptably high. In this focused review, we examine the epidemiology and clinical features of the most common fungal pathogens of the central nervous system in children and explore recent advances in diagnosis and antifungal therapy.
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Affiliation(s)
- Matthew W McCarthy
- Division of General Internal Medicine, Weill Cornell Medicine of Cornell University, New York, New York
| | - Darius Kalasauskas
- Department of Neurosurgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany.,Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York
| | - Vidmantas Petraitis
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York.,Institute of Infectious Disease and Pathogenic Microbiology, Prienai, Lithuania
| | - Ruta Petraitiene
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York.,Institute of Infectious Disease and Pathogenic Microbiology, Prienai, Lithuania
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Division of Infectious Diseases, Department of Medicine, Weill Cornell Medicine of Cornell University, New York, New York.,Departments of Pediatrics, and Microbiology & Immunology, Weill Cornell Medicine of Cornell University, New York, New York
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20
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Katragkou A, Fisher BT, Groll AH, Roilides E, Walsh TJ. Diagnostic Imaging and Invasive Fungal Diseases in Children. J Pediatric Infect Dis Soc 2017; 6:S22-S31. [PMID: 28927203 DOI: 10.1093/jpids/pix055] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Invasive fungal disease (IFD) is a life-threatening condition, especially in immunocompromised children. The role of diagnostic imaging in children at risk for an IFD is multifactorial, including initially detecting it, evaluating for dissemination of infection beyond the primary site of disease, monitoring the response to antifungal therapy, and assessing for potential relapse. The objective of this review was to synthesize the published literature relevant to the use of various imaging modalities for the diagnosis and management of IFD in children.
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Affiliation(s)
- Aspasia Katragkou
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Nationwide Children's Hospital and Ohio State University, Columbus
| | - Brian T Fisher
- Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness Research, Children's Hospital of Philadelphia, Pennsylvania.,Departments of Pediatrics and Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Andreas H Groll
- Infectious Disease Research Program, Department of Pediatric Hematology and Oncology and Center for Bone Marrow Transplantation, University Children's Hospital Muenster, Germany
| | - Emmanuel Roilides
- Infectious Diseases Section, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Thessaloniki, Greece
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program and Departments of Medicine, Pediatrics, Microbiology and Immunology, Weill Cornell Medicine of Cornell University and New York Presbyterian Hospital
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21
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22
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Różańska A, Wójkowska-Mach J, Adamski P, Borszewska-Kornacka M, Gulczyńska E, Nowiczewski M, Helwich E, Kordek A, Pawlik D, Bulanda M. Antibiotic consumption in laboratory confirmed vs. non-confirmed bloodstream infections among very low birth weight neonates in Poland. Ann Clin Microbiol Antimicrob 2017; 16:20. [PMID: 28359268 PMCID: PMC5374675 DOI: 10.1186/s12941-017-0196-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 03/23/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Newborns are a population in which antibiotic consumption is extremely high. Targeted antibiotic therapy should help to reduce antibiotics consumption. The aim of this study was an assessment of antibiotic usage in bloodstream infections treatment in the Polish Neonatology Surveillance Network (PNSN) and determining the possibility of applying this kind of data in infection control, especially for the evaluation of standard methods of microbiological diagnostics. METHODS Data were collected between 01.01.2009 and 31.12.2013 in five teaching NICUs from the PNSN. The duration of treatment in days (DOT) and the defined daily doses (DDD) were used for the assessment of antibiotics consumption. RESULTS The median DOT for a single case of BSI amounted to 8.0 days; whereas the median consumption expressed in DDD was 0.130. In the case of laboratory confirmed BSI, median DOT was 8 days, and consumption-0.120 DDD. Median length of therapy was shorter for unconfirmed cases: 7 days, while the consumption of antibiotics was higher-0.140 DDD (p < 0.0001). High consumption of glycopeptides expressed in DOTs was observed in studied population, taking into account etiology of infection. CONCLUSIONS Even application of classical methods of microbiological diagnostics significantly reduces the consumption of antibiotics expressed by DDD. However, the high consumption of glycopeptides indicates the necessity of applying rapid diagnostic assays. Nevertheless, the assessment of antibiotic consumption in neonatal units represents a methodological challenge and requires the use of different measurement tools.
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Affiliation(s)
- A. Różańska
- Chair of Microbiology, Jagiellonian University Medical College, 18 Czysta Street, 31-121 Krakow, Poland
| | - J. Wójkowska-Mach
- Chair of Microbiology, Jagiellonian University Medical College, 18 Czysta Street, 31-121 Krakow, Poland
| | - P. Adamski
- Institute of Nature Conservation Polish Academy of Sciences, Krakow, Poland
| | - M. Borszewska-Kornacka
- Clinic of Neonatology and Intensive Neonatal Care, Warsaw Medical University, Warsaw, Poland
| | - E. Gulczyńska
- Clinic of Neonatology, Polish Mother’s Memorial Hospital-Research Institute, Lodz, Poland
| | - M. Nowiczewski
- Clinic of Neonatology, Polish Mother’s Memorial Hospital-Research Institute, Lodz, Poland
| | - E. Helwich
- Clinic of Neonatology and Intensive Neonatal Care, Institute of Mother and Child, Warsaw, Poland
| | - A. Kordek
- Department of Neonatal Diseases, Pomeranian Medical University, Szczecin, Poland
| | - D. Pawlik
- Clinic of Neonatology, Jagiellonian University Medical College, Krakow, Poland
| | - M. Bulanda
- Chair of Microbiology, Jagiellonian University Medical College, 18 Czysta Street, 31-121 Krakow, Poland
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23
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High-Dose Micafungin for Preterm Neonates and Infants with Invasive and Central Nervous System Candidiasis. Antimicrob Agents Chemother 2016; 60:7333-7339. [PMID: 27697761 DOI: 10.1128/aac.01172-16] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 09/23/2016] [Indexed: 11/20/2022] Open
Abstract
High doses of micafungin are advocated in neonates with systemic candidiasis, but limited pharmacokinetic (PK) and safety data are available to support their use. Eighteen preterm neonates and infants with systemic candidiasis, three of whom had meningitis, were treated for at least 14 days with 8 to 15 mg/kg of body weight/day of intravenous micafungin. Plasma micafungin concentrations (four measurements for each patient) were determined after the third dose, and the cerebrospinal fluid (CSF) micafungin concentrations in three patients were also obtained. Population PK analyses were used to identify the optimal model, and the model was further validated using external data (n = 5). The safety of micafungin was assessed by measurement of the levels of liver and kidney function biomarkers. The mean age and weight at the initiation of treatment were 2.33 months (standard deviation [SD], 1.98 months) and 3.24 kg (SD, 1.61 kg), respectively. The optimal PK model was one that scaled plasma clearance to weight and the transaminase concentration ratio. The CSF of three patients was sampled, and the observed concentrations were between 0.80 and 1.80 mg/liter. The model-predicted mean micafungin area under the concentration-time curve over 24 h was 336 mg · h/liter (SD, 165 mg · h/liter) with the 10-mg/kg/day dosage. Eighteen of the 23 subjects (78.2%) had clinical resolution of their infection, but 5 had neurologic impairments. Among the transaminases, alkaline phosphatase measurements were significantly higher posttreatment, with a geometric mean ratio of 1.17 (90% confidence interval, 1.01, 1.37). Furthermore, marked elevations in the gamma-glutamyltransferase (GGT) level were observed in three patients treated with 10- to 15-mg/kg/day doses, and improvement of the GGT level was noted after a dose reduction. Higher weight-based doses of micafungin were generally well tolerated in neonates and infants and achieved pharmacokinetic profiles predictive of an effect.
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24
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Aksoy GK, Koyun M, Kabaalioglu A, Dursun O, Akman S. Urinary system obstruction in a preterm infant: Answers. Pediatr Nephrol 2016; 31:2067-70. [PMID: 26556027 DOI: 10.1007/s00467-015-3243-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/02/2015] [Accepted: 10/02/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Gulsah Kaya Aksoy
- Department of Pediatric Nephrology, School of Medicine, Akdeniz University, Antalya, Turkey. .,Department of Pediatric Nephrology, Akdeniz University Medical Faculty, 07070, Antalya, Turkey.
| | - Mustafa Koyun
- Department of Pediatric Nephrology, School of Medicine, Akdeniz University, Antalya, Turkey
| | - Adnan Kabaalioglu
- Department of Radiology, School of Medicine, Akdeniz University, Antalya, Turkey
| | - Oguz Dursun
- Department of Pediatric Intensive Care, School of Medicine, Akdeniz University, Antalya, Turkey
| | - Sema Akman
- Department of Pediatric Nephrology, School of Medicine, Akdeniz University, Antalya, Turkey
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25
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Ericson JE, Kaufman DA, Kicklighter SD, Bhatia J, Testoni D, Gao J, Smith PB, Prather KO, Benjamin DK. Fluconazole Prophylaxis for the Prevention of Candidiasis in Premature Infants: A Meta-analysis Using Patient-level Data. Clin Infect Dis 2016; 63:604-10. [PMID: 27298330 PMCID: PMC4981761 DOI: 10.1093/cid/ciw363] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/14/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Invasive candidiasis (IC) is an important cause of sepsis in premature infants and is associated with a high risk of death and neurodevelopmental impairment. Prevention of IC has become a major focus in very low birth weight infants, with fluconazole increasingly used as prophylaxis. METHODS We identified all randomized, placebo-controlled trials evaluating fluconazole prophylaxis in premature infants conducted in the United States. We obtained patient-level data from the study investigators and performed an aggregated analysis. The occurrence of each endpoint in infants who received prophylaxis with fluconazole vs placebo was compared. Endpoints evaluated were IC or death, IC, death, Candida colonization, and fluconazole resistance among tested isolates. Safety endpoints evaluated included clinical and laboratory parameters. RESULTS Fluconazole prophylaxis reduced the odds of IC or death, IC, and Candida colonization during the drug exposure period compared with infants given placebo: odds ratios of 0.48 (95% confidence interval [CI], .30-.78), 0.20 (95% CI, .08-.51), and 0.28 (95% CI, .18-.41), respectively. The incidence of clinical and laboratory adverse events was similar for infants who received fluconazole compared with placebo. There was no statistically significant difference in the proportion of tested isolates that were resistant to fluconazole between the fluconazole and placebo groups. CONCLUSIONS Fluconazole prophylaxis is effective and safe in reducing IC and Candida colonization in premature infants, and has no impact on resistance.
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MESH Headings
- Antibiotic Prophylaxis/adverse effects
- Antibiotic Prophylaxis/methods
- Antibiotic Prophylaxis/statistics & numerical data
- Antifungal Agents/adverse effects
- Antifungal Agents/therapeutic use
- Candidiasis, Invasive/drug therapy
- Candidiasis, Invasive/epidemiology
- Candidiasis, Invasive/mortality
- Female
- Fluconazole/adverse effects
- Fluconazole/therapeutic use
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/drug therapy
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/mortality
- Infant, Premature
- Male
- Randomized Controlled Trials as Topic
- United States
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Affiliation(s)
- Jessica E Ericson
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - David A Kaufman
- Department of Pediatrics, University of Virginia, Charlottesville
| | | | - Jatinder Bhatia
- Department of Pediatrics, Georgia Regents University, Augusta
| | - Daniela Testoni
- Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
| | | | - P Brian Smith
- Duke Clinical Research Institute Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | | | - Daniel K Benjamin
- Duke Clinical Research Institute Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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26
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Haller S, Deindl P, Cassini A, Suetens C, Zingg W, Abu Sin M, Velasco E, Weiss B, Ducomble T, Sixtensson M, Eckmanns T, Harder T. Neurological sequelae of healthcare-associated sepsis in very-low-birthweight infants: Umbrella review and evidence-based outcome tree. ACTA ACUST UNITED AC 2016; 21:30143. [PMID: 26940884 DOI: 10.2807/1560-7917.es.2016.21.8.30143] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 09/30/2015] [Indexed: 01/08/2023]
Abstract
Sepsis is a frequent cause of death in very-low-birthweight infants and often results in neurological impairment. Its attributable risk of sequelae has not been systematically assessed. To establish an outcome tree for mapping the burden of neonatal sepsis, we performed systematic literature searches to identify systematic reviews addressing sequelae of neonatal sepsis. We included cohort studies and performed meta-analyses of attributable risks. Evidence quality was assessed using GRADE. Two systematic reviews met inclusion criteria. The first included nine cohort studies with 5,620 participants and five outcomes (neurodevelopmental impairment, cerebral palsy, vision impairment, hearing impairment, death). Pooled risk differences varied between 4% (95% confidence interval (CI):2-10) and 13% (95% CI:5-20). From the second review we analysed four studies with 472 infants. Positive predictive value of neurodevelopmental impairment for later cognitive impairment ranged between 67% (95% CI:22-96) and 83% (95% CI:36-100). Neonatal sepsis increases risk of permanent neurological impairment. Effect size varies by outcome, with evidence quality being low to very low. Data were used to construct an outcome tree for neonatal sepsis. Attributable risk estimates for sequelae following neonatal sepsis are suitable for burden estimation and may serve as outcome parameters in interventional studies.
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Affiliation(s)
- Sebastian Haller
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
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Austin N, Cleminson J, Darlow BA, McGuire W. Prophylactic oral/topical non-absorbed antifungal agents to prevent invasive fungal infection in very low birth weight infants. Cochrane Database Syst Rev 2015; 2015:CD003478. [PMID: 26497202 PMCID: PMC7154334 DOI: 10.1002/14651858.cd003478.pub5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very preterm or very low birth weight infants. Uncertainty exists about the effect of prophylactic oral/topical non-absorbed antifungals to reduce mucocutaneous colonisation and so limit the risk of invasive fungal infection in this population. OBJECTIVES To assess the effect of prophylactic oral/topical non-absorbed antifungal therapy on the incidence of invasive fungal infection, mortality and morbidity in very preterm or very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL: The Cochrane Library, 2015, Issue 7), MEDLINE, EMBASE, and CINAHL (to May 2015), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic oral/topical non-absorbed antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very preterm or very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS Four trials, in which a total of 1800 infants participated, compared oral/topical non-absorbed antifungal prophylaxis (nystatin or miconazole) with placebo or no drug. These trials had various methodological weaknesses including quasi-randomisation, lack of allocation concealment, and lack of blinding of intervention and outcomes assessment. The incidence of invasive fungal infection was very high in the control groups of three of these trials. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection (typical risk ratio 0.20, 95% confidence interval 0.14 to 0.27; risk difference -0.18, -0.21 to -0.15) but substantial statistical heterogeneity was present. We did not find a statistically significant effect on mortality (typical risk ratio 0.87, 0.72 to 1.05; risk difference -0.03, -0.06 to 0.01). None of the trials assessed posthospital discharge outcomes. Three trials (N = 326) assessed the effect of oral/topical non-absorbed versus systemic antifungal prophylaxis. Meta-analyses did not find any statistically significant differences in the incidences of invasive fungal infection or all-cause mortality. AUTHORS' CONCLUSIONS The finding of a reduction in risk of invasive fungal infection in very low birth weight infants treated with oral/topical non-absorbed antifungal prophylaxis should be interpreted cautiously because of methodological weaknesses in the included trials. Further large randomised controlled trials in current neonatal practice settings are needed to resolve this uncertainty. These trials might compare oral/topical non-absorbed antifungal agents with placebo, with each other, or with systemic antifungal agents and should include an assessment of effect on long-term neurodevelopmental outcomes.
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Affiliation(s)
- Nicola Austin
- Christchurch Womens HospitalNICUChristchurchNew Zealand
| | - Jemma Cleminson
- University of YorkAcademic Clinical Fellow in Child Health NIHR Centre for Reviews & DisseminationYorkUK
| | - Brian A Darlow
- Christchurch School of MedicineDepartment of PaediatricsPO Box 4345ChristchurchNew Zealand
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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Cleminson J, Austin N, McGuire W. Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants. Cochrane Database Syst Rev 2015; 2015:CD003850. [PMID: 26497056 PMCID: PMC7156892 DOI: 10.1002/14651858.cd003850.pub5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very preterm and very low birth weight infants. Early diagnosis is difficult and treatment is often delayed. Systemically absorbed antifungal agents (usually azoles) are increasingly used as prophylaxis against invasive fungal infection in this population. OBJECTIVES To assess the effect of prophylactic systemic antifungal therapy on mortality and morbidity in very preterm or very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 8), MEDLINE, EMBASE, and CINAHL (to May 2015), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic systemic antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS We identified 15 eligible trials enrolling a total of 1690 infants. Ten trials (1371 infants) compared systemic antifungal prophylaxis versus placebo or no drug. These trials were generally of good methodological quality. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection (typical risk ratio (RR) 0.43, 95% confidence interval (CI) 0.31 to 0.59; risk difference (RD) -0.09, 95% CI -0.12 to -0.06). The average incidence of invasive fungal infection in the control groups of the trials (16%) was much higher than that generally reported from large cohort studies. Meta-analysis did not find a statistically significant difference in the risk of death prior to hospital discharge (typical RR 0.79, 95% CI 0.61 to 1.02; typical RD -0.04, 95% CI -0.07 to 0.00). Very limited data on long-term neurodevelopmental outcomes were available. Three trials that compared systemic versus oral or topical non-absorbed antifungal prophylaxis did not detect any statistically significant effects on invasive fungal infection or mortality. Two trials that compared different dose regimens of prophylactic intravenous fluconazole did not detect any significant differences in infection rates or mortality. AUTHORS' CONCLUSIONS Prophylactic systemic antifungal therapy reduces the incidence of invasive fungal infection in very preterm or very low birth weight infants. This finding should be interpreted and applied cautiously since the incidence of invasive fungal infection was very high in the control groups of many of the included trials. Meta-analysis does not demonstrate a statistically significant effect on mortality. There are currently only limited data on the long-term neurodevelopmental consequences for infants exposed to this intervention. In addition, there is a need for further data on the effect of the intervention on the emergence of organisms with antifungal resistance.
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Affiliation(s)
- Jemma Cleminson
- University of YorkAcademic Clinical Fellow in Child Health NIHR Centre for Reviews & DisseminationYorkUK
| | - Nicola Austin
- Christchurch Womens HospitalNICUChristchurchNew Zealand
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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Candida Colonization in Low Birth Weight and Very Low Birth Weight Infants in a Neonatal Intensive Care Unit. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2015. [DOI: 10.5812/pedinfect.21234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Botero-Calderon L, Benjamin DK, Cohen-Wolkowiez M. Advances in the treatment of invasive neonatal candidiasis. Expert Opin Pharmacother 2015; 16:1035-48. [PMID: 25842986 PMCID: PMC4402277 DOI: 10.1517/14656566.2015.1031108] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Kelly MS, Benjamin DK, Smith PB. The epidemiology and diagnosis of invasive candidiasis among premature infants. Clin Perinatol 2015; 42:105-17, viii-ix. [PMID: 25677999 PMCID: PMC4328135 DOI: 10.1016/j.clp.2014.10.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Invasive candidiasis is a leading infectious cause of morbidity and mortality in premature infants. Improved recognition of modifiable risk factors and antifungal prophylaxis has contributed to the recent decline in the incidence of this infection among infants. Invasive candidiasis typically occurs in the first 6 weeks of life and presents with nonspecific signs of sepsis. Definitive diagnosis relies on the growth of Candida in blood culture or cultures from other normally sterile sites, but this may identify fewer than half of cases. Improved diagnostics are needed to guide the initiation of antifungal therapy in premature infants.
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Affiliation(s)
- Matthew S. Kelly
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, Duke University, Durham, North Carolina
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Bakhuizen SE, de Haan TR, Teune MJ, van Wassenaer-Leemhuis AG, van der Heyden JL, van der Ham DP, Mol BWJ. Meta-analysis shows that infants who have suffered neonatal sepsis face an increased risk of mortality and severe complications. Acta Paediatr 2014; 103:1211-8. [PMID: 25073543 DOI: 10.1111/apa.12764] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/06/2014] [Accepted: 07/28/2014] [Indexed: 11/28/2022]
Abstract
UNLABELLED Infants suffering from neonatal sepsis face an increased risk of early death and long-term neurodevelopmental delay. This paper analyses and summarises the existing data on short-term and long-term outcomes of neonatal sepsis, based on 12 studies published between January 2000 and 1 April 2012 and covering 3669 neonates with sepsis. CONCLUSION Infants who have suffered neonatal sepsis face an increased risk of mortality and severe complications such as brain damage and, or, neurodevelopmental delay.
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Affiliation(s)
- Sabine E. Bakhuizen
- Department of Obstetrics & Gynaecology; Academic Medical Centre; Amsterdam The Netherlands
| | - Timo R. de Haan
- Department of Neonatology; Emma Children's Hospital; Academic Medical Centre; Amsterdam The Netherlands
| | - Margreet J. Teune
- Department of Obstetrics & Gynaecology; Academic Medical Centre; Amsterdam The Netherlands
| | | | | | - David P. van der Ham
- Department of Obstetrics & Gynaecology; Martini Hospital Groningen; Groningen The Netherlands
| | - Ben Willem J. Mol
- School of Paediatrics and Reproductive Health; The Robinson Institute; University of Adelaide; Adelaide SA Australia
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Crystallinity, antimicrobial activity and dyeing properties of chitosan-g-poly(N-acryloyl morpholine) copolymer. Eur Polym J 2014. [DOI: 10.1016/j.eurpolymj.2014.06.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Wójkowska-Mach J, Gulczyńska E, Nowiczewski M, Borszewska-Kornacka M, Domańska J, Merritt TA, Helwich E, Kordek A, Pawlik D, Gadzinowski J, Szczapa J, Adamski P, Sulik M, Klamka J, Brzychczy-Włoch M, Heczko PB. Late-onset bloodstream infections of Very-Low-Birth-Weight infants: data from the Polish Neonatology Surveillance Network in 2009-2011. BMC Infect Dis 2014; 14:339. [PMID: 24939563 PMCID: PMC4074408 DOI: 10.1186/1471-2334-14-339] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 06/09/2014] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Jadwiga Wójkowska-Mach
- Microbiology, Jagiellonian University Medical College, 18 Czysta Street, Krakow 31-121, Poland.
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Barton M, O'Brien K, Robinson JL, Davies DH, Simpson K, Asztalos E, Langley JM, Le Saux N, Sauve R, Synnes A, Tan B, de Repentigny L, Rubin E, Hui C, Kovacs L, Richardson SE. 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. BMC Infect Dis 2014; 14:327. [PMID: 24924877 PMCID: PMC4063435 DOI: 10.1186/1471-2334-14-327] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 06/04/2014] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Susan E Richardson
- Division of Microbiology, Hospital for Sick Children, University of Toronto, Room 3654, Atrium, 555 University Ave, Toronto, ON M5G 1X8, Canada.
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Autmizguine J, Guptill JT, Cohen-Wolkowiez M, Benjamin DK, Capparelli EV. Pharmacokinetics and pharmacodynamics of antifungals in children: clinical implications. Drugs 2014; 74:891-909. [PMID: 24872147 PMCID: PMC4073603 DOI: 10.1007/s40265-014-0227-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Invasive fungal disease (IFD) remains life threatening in premature infants and immunocompromised children despite the recent development of new antifungal agents. Optimal dosing of antifungals is one of the few factors clinicians can control to improve outcomes of IFD. However, dosing in children cannot be extrapolated from adult data because IFD pathophysiology, immune response, and drug disposition differ from adults. We critically examined the literature on pharmacokinetics (PK) and pharmacodynamics (PD) of antifungal agents and highlight recent developments in treating pediatric IFD. To match adult exposure in pediatric patients, dosing adjustment is necessary for almost all antifungals. In young infants, the maturation of renal and metabolic functions occurs rapidly and can significantly influence drug exposure. Fluconazole clearance doubles from birth to 28 days of life and, beyond the neonatal period, agents such as fluconazole, voriconazole, and micafungin require higher dosing than in adults because of faster clearance in children. As a result, dosing recommendations are specific to bracketed ranges of age. PD principles of antifungals mostly rely on in vitro and in vivo models but very few PD studies specifically address IFD in children. The exposure-response relationship may differ in younger children compared with adults, especially in infants with invasive candidiasis who are at higher risk of disseminated disease and meningoencephalitis, and by extension severe neurodevelopmental impairment. Micafungin is the only antifungal agent for which a specific target of exposure was proposed based on a neonatal hematogenous Candida meningoencephalitis animal model. In this review, we found that pediatric data on drug disposition of newer triazoles and echinocandins are lacking, dosing of older antifungals such as fluconazole and amphotericin B products still need optimization in young infants, and that target PK/PD indices need to be clinically validated for almost all antifungals in children. A better understanding of age-specific PK and PD of new antifungals in infants and children will help improve clinical outcomes of IFD by informing dosing and identifying future research areas.
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Affiliation(s)
- Julie Autmizguine
- Duke Clinical Research Institute, 2400 Pratt St, Durham, NC 27705, USA
| | | | | | | | - Edmund V. Capparelli
- Department of Pediatric Pharmacology, University of California, 9500 Gilman Drive, La Jolla, CA 92093-0831, USA
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Roberts JK, Stockmann C, Constance JE, Stiers J, Spigarelli MG, Ward RM, Sherwin CMT. Pharmacokinetics and Pharmacodynamics of Antibacterials, Antifungals, and Antivirals Used Most Frequently in Neonates and Infants. Clin Pharmacokinet 2014; 53:581-610. [DOI: 10.1007/s40262-014-0147-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Abstract
PURPOSE OF REVIEW Invasive candidiasis is a serious infection in hospitalized infants that results in significant mortality and morbidity. Fluconazole is approved by the US Food and Drug Administration for prophylaxis of invasive candidiasis in patients undergoing bone marrow transplantation but is not approved for use in infants. This review will describe the history of fluconazole use for prophylaxis in infants. RECENT FINDINGS Limiting fluconazole prophylaxis to infants with risk factors, in addition to low birth weight and early gestational age, reduces the number of infants treated with fluconazole and the duration of fluconazole therapy for each infant. SUMMARY Fluconazole prophylaxis appears to be well tolerated for use in premature infants. Reduction in the incidence of invasive candidiasis is observed even when prophylaxis is limited to infants with multiple risk factors. Centers with a low incidence of invasive candidiasis may not benefit from fluconazole prophylaxis. Significant short-term and long-term toxicity and increases in fluconazole-resistant organisms have not been observed with fluconazole use in the intensive care nursery.
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Affiliation(s)
- Jessica E. Ericson
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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Hundalani S, Pammi M. Invasive fungal infections in newborns and current management strategies. Expert Rev Anti Infect Ther 2014; 11:709-21. [DOI: 10.1586/14787210.2013.811925] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Association of late‐onset neonatal sepsis with late neurodevelopment in the first two years of life of preterm infants with very low birth weight. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2014. [DOI: 10.1016/j.jpedp.2013.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Hentges CR, Silveira RC, Procianoy RS, Carvalho CG, Filipouski GR, Fuentefria RN, Marquezotti F, Terrazan AC. Association of late-onset neonatal sepsis with late neurodevelopment in the first two years of life of preterm infants with very low birth weight. J Pediatr (Rio J) 2014; 90:50-7. [PMID: 24148798 DOI: 10.1016/j.jped.2013.10.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 05/28/2013] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To establish the influence of late-onset sepsis on neurodevelopment of preterm infants with very low birth weight (VLBW), according to the etiologic agent. METHOD This was a cohort of newborns with birth weight<1,500 g and gestational age less than 32 weeks, admitted to the institutional intensive care unit (ICU) with up to 48 hours of life, and followed-up at the outpatient follow-up clinic for preterm infants with VLBW until 2 years of corrected age. EXCLUSION CRITERIA death within the first 72 hours of life, congenital malformations and genetic syndromes, children with congenital infection by the human immunodeficiency virus (HIV), congenital infection (STORCH), presence of early-onset sepsis and cases with more than one pathogen growth in blood cultures. Septic and non-septic infants were compared regarding neonatal outcomes and mortality. Neurodevelopment was assessed using the Bayley Scale (BSDI-II) at 18 to 24 months of corrected age. RESULTS 411 preterm infants with VLBW were eligible; the mean gestational age was 29 ± 2.2 weeks and mean birth weight was 1,041 ± 281 grams. Late-onset sepsis occurred in 94 preterm infants with VLBW (22.8%). VLBW infants with Gram-positive infection showed motor deficit when compared to the non-septic group, 68.8% vs. 29.3%, respectively (OR 6; 1.6-21.8, p=0.006); the cognitive development was similar between the groups. The overall mortality rate from infection was 26.7%; considering the pathogens, the rates were 18.7% for coagulase-negative Staphylococcus, 21.8% for Gram-positive bacteria, and 50% for Gram-negative bacteria and fungi. CONCLUSION Neonatal sepsis has a significant influence on late neurodevelopment at 2 years of corrected age in preterm infants with VLBW, and Gram-positive infections are associated with motor deficit.
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Affiliation(s)
- Cláudia Regina Hentges
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Neonatology Service, Hospital de Clinícas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Rita C Silveira
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Neonatology Service, Hospital de Clinícas de Porto Alegre, Porto Alegre, RS, Brazil.
| | - Renato Soibelmann Procianoy
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Neonatology Service, Hospital de Clinícas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Clarissa Gutierrez Carvalho
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil; Neonatology Service, Hospital de Clinícas de Porto Alegre, Porto Alegre, RS, Brazil
| | | | | | - Fernanda Marquezotti
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Ana Carolina Terrazan
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Adams-Chapman I, Bann CM, Das A, Goldberg RN, Stoll BJ, Walsh MC, Sanchez PJ, Higgins RD, Shankaran S, Watterberg KL, Duara S, Miller NA, Heyne RJ, Peralta-Carcelen M, Goldstein RF, Steichen JJ, Bauer CR, Hintz SR, Evans PW, Acarregui MJ, Myers GJ, Vohr BR, Wilson-Costello DE, Pappas A, Vaucher YE, Ehrenkranz RA, McGowan EC, Dillard RG, Fuller J, Benjamin DK. Neurodevelopmental outcome of extremely low birth weight infants with Candida infection. J Pediatr 2013; 163:961-7.e3. [PMID: 23726546 PMCID: PMC3786056 DOI: 10.1016/j.jpeds.2013.04.034] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 02/18/2013] [Accepted: 04/16/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Candida remains an important cause of late-onset infection in preterm infants. Mortality and neurodevelopmental outcome of extremely low birth weight (ELBW) infants enrolled in the Candida study were evaluated based on infection status. STUDY DESIGN ELBW infants born at Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) centers between March 2004 and July 2007 who were screened for suspected sepsis were eligible for inclusion in the Candida study. Primary outcome data for neurodevelopmental impairment (NDI) or death were available for 1317 of the 1515 infants (87%) enrolled in the Candida study. The Bayley Scales of Infant Development-II or -III was administered at 18 months' adjusted age. A secondary comparison was performed with 864 infants enrolled in the NRN Generic Database during the same cohort who were never screened for sepsis and therefore not eligible for the Candida study. RESULTS Among ELBW infants enrolled in the Candida study, 31% with Candida and 31% with late-onset non-Candida sepsis had NDI at 18 months. Infants with Candida sepsis and/or meningitis had an increased risk of death and were more likely to have the composite outcome of death and/or NDI compared with uninfected infants in adjusted analysis. Compared with infants in the NRN registry never screened for sepsis, overall risk for death were similar but those with Candida infection were more likely to have NDI (OR 1.83, 95% CI 1.01-3.33, P = .047). CONCLUSIONS In this cohort of ELBW infants, those with infection and/or meningitis were at increased risk for death and/or NDI. This risk was highest among those with Candida sepsis and/or meningitis.
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Affiliation(s)
| | - Carla M. Bann
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
| | - Abhik Das
- Statistics and Epidemiology Unit, RTI International, Rockville, MD
| | | | | | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Páblo J. Sanchez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | | | | | - Shahnaz Duara
- University of Miami Miller School of Medicine, Miami, FL
| | - Nancy A. Miller
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Roy J. Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Jean J. Steichen
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | | | - Susan R. Hintz
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Patricia W. Evans
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX
| | | | - Gary J. Myers
- University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Betty R. Vohr
- Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, RI
| | - Deanne E. Wilson-Costello
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Athina Pappas
- Department of Pediatrics, Wayne State University, Detroit, MI
| | | | | | - Elisabeth C. McGowan
- Department of Pediatrics, Division of Newborn Medicine, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | | | - Janell Fuller
- Department of Pediatrics, Wayne State University, Detroit, MI
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Hammoud MS, Al-Taiar A, Fouad M, Raina A, Khan Z. Persistent candidemia in neonatal care units: risk factors and clinical significance. Int J Infect Dis 2013; 17:e624-8. [DOI: 10.1016/j.ijid.2012.11.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 11/22/2012] [Accepted: 11/25/2012] [Indexed: 01/15/2023] Open
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Neurodevelopmental outcomes of very low birth weight infants with neonatal sepsis: systematic review and meta-analysis. J Perinatol 2013; 33:558-64. [PMID: 23328927 DOI: 10.1038/jp.2012.167] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To study the impact of neonatal sepsis on the long-term neurodevelopmental outcome in very low birth weight (VLBW) infants. STUDY DESIGN Systematic review and meta-analysis of observational studies comparing neurodevelopmental outcomes in VLBW infants exposed to culture-proven sepsis in the neonatal period with similar infants without sepsis. RESULT Seventeen studies involving 15,331 infants were included in the meta-analysis. Sepsis in VLBW infants was associated with an increased risk of one or more long-term neurodevelopmental impairments (odds ratio (OR) 2.09; 95% confidence interval (CI) 1.65 to 2.65) including cerebral palsy (CP; OR 2.09; 95% CI 1.78 to 2.45). Heterogeneity (I(2)=36.9%; P=0.06) between the studies was significant and related to variations in patient characteristics, causative pathogens and follow-up methods. Sensitivity analyses based on study design, follow-up rate and year of birth were not significantly different from the overall analysis. CONCLUSION The meta-analysis suggests that sepsis in VLBW infants is associated with a worse neurodevelopmental outcome including higher incidence of CP.
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Santolaya ME, Alvarado Matute T, de Queiroz Telles F, Colombo AL, Zurita J, Tiraboschi IN, Cortes JA, Thompson-Moya L, Guzman-Blanco M, Sifuentes J, Echevarría J, Nucci M. Recommendations for the management of candidemia in neonates in Latin America. Latin America Invasive Mycosis Network. Rev Iberoam Micol 2013; 30:158-70. [PMID: 23756219 DOI: 10.1016/j.riam.2013.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/30/2013] [Accepted: 05/31/2013] [Indexed: 11/28/2022] Open
Abstract
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'.
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Affiliation(s)
- María E Santolaya
- Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; Latin America Invasive Mycosis Network.
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46
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Santolaya ME, Alvarado Matute T, de Queiroz Telles F, Colombo AL, Zurita J, Tiraboschi IN, Cortes JA, Thompson-Moya L, Guzman-Blanco M, Sifuentes J, Echevarría J, Nucci M. [Recommendations for the management of candidemia in neonates in Latin America. Grupo Proyecto Épico]. Rev Iberoam Micol 2013; 30:158-70. [PMID: 23764559 DOI: 10.1016/j.riam.2013.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 05/31/2013] [Indexed: 10/26/2022] Open
Abstract
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'.
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Affiliation(s)
- María E Santolaya
- Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; Latin America Invasive Mycosis Network.
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Austin N, McGuire W. Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants. Cochrane Database Syst Rev 2013:CD003850. [PMID: 23633315 DOI: 10.1002/14651858.cd003850.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very low birth weight infants. Early diagnosis is difficult and treatment is often delayed. Systemic antifungal agents (usually azoles) are increasingly used as prophylaxis against invasive fungal infection. OBJECTIVES To assess the effect of prophylactic systemic antifungal therapy on mortality and morbidity in very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 3), MEDLINE, EMBASE, and CINAHL (to August 2012), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic systemic antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS We identified 11 eligible trials enrolling a total of 1136 infants. Seven trials (involving 880 infants) compared systemic antifungal prophylaxis versus placebo or no drug. These trials were generally small but of good methodological quality. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection in infants who received systemic antifungal prophylaxis (typical risk ratio (RR) 0.41, 95% confidence interval (CI) 0.27 to 0.61; risk difference (RD) -0.09, 95% CI -0.14 to -0.05). The average incidence of invasive fungal infection in the control groups of the trials (16%) was much higher than that generally reported from large cohort studies (< 5%). Meta-analysis did not find a statistically significant difference in the risk of death prior to hospital discharge (typical RR 0.74, 95% CI 0.52 to 1.05; RD -0.04, 95% CI -0.08 to 0.01). Very limited data on long-term neurodevelopmental outcomes were available. Two trials that compared systemic versus oral or topical non-absorbed antifungal prophylaxis did not detect any statistically significant effects on invasive fungal infection or mortality. Two trials that compared different dose regimens of prophylactic intravenous fluconazole did not detect any significant differences in infection rates or mortality. AUTHORS' CONCLUSIONS Prophylactic systemic antifungal therapy reduces the incidence of invasive fungal infection in very low birth weight infants. This finding should be interpreted and applied cautiously since the incidence of invasive fungal infection was very high in the control groups of most of the included trials. Meta-analysis does not demonstrate a statistically significant effect on mortality. There are currently only limited data on the long-term neurodevelopmental consequences for infants exposed to this intervention. In addition, there is a need for further data on the effect of the intervention on the emergence of organisms with antifungal resistance.
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Affiliation(s)
- Nicola Austin
- NICU, Christchurch Womens Hospital, Christchurch, New Zealand
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Austin N, Darlow BA, McGuire W. Prophylactic oral/topical non-absorbed antifungal agents to prevent invasive fungal infection in very low birth weight infants. Cochrane Database Syst Rev 2013:CD003478. [PMID: 23543519 DOI: 10.1002/14651858.cd003478.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very preterm or very low birth weight infants. Uncertainty exists about the effect of prophylactic oral/topical non-absorbed antifungals to reduce mucocutaneous colonisation and so limit the risk of invasive fungal infection in this population. OBJECTIVES To assess the effect of prophylactic oral/topical non-absorbed antifungal therapy on the incidence of invasive fungal infection, mortality and morbidity in very preterm or very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL: The Cochrane Library, 2012, Issue 3), MEDLINE, EMBASE, and CINAHL (to August 2012), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic oral/topical non-absorbed antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very preterm or very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS Four trials, in which a total of 1800 infants participated, compared oral/topical non-absorbed antifungal prophylaxis (nystatin or miconazole) with placebo or no drug. These trials had various methodological weaknesses including quasi-randomisation, lack of allocation concealment, and lack of blinding of intervention and outcomes assessment. The incidence of invasive fungal infection was very high in the control groups of three of these trials. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection [typical risk ratio 0.20 (95% confidence interval 0.14 to 0.27); risk difference -0.18 (-0.21 to -0.16)] but substantial statistical heterogeneity was present. We did not find a statistically significant effect on mortality [typical risk ratio 0.87 (0.72 to 1.05); risk difference -0.03 (-0.06 to 0.01)]. None of the trials assessed posthospital discharge outcomes.Two trials (N = 265) assessed the effect of oral/topical non-absorbed versus systemic antifungal prophylaxis. Meta-analyses did not find any statistically significant differences in the incidences of invasive fungal infection or all-cause mortality. AUTHORS' CONCLUSIONS The finding of a reduction in risk of invasive fungal infection in very low birth weight infants treated with oral/topical non-absorbed antifungal prophylaxis should be interpreted cautiously because of methodological weaknesses in the included trials. Further large randomised controlled trials in current neonatal practice settings are needed to resolve this uncertainty. These trials might compare oral/topical non-absorbed antifungal agents with placebo, with each other, or with systemic antifungal agents and should include an assessment of effect on long-term neurodevelopmental outcomes.
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Affiliation(s)
- Nicola Austin
- NICU, Christchurch Womens Hospital, Christchurch, New Zealand.
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Affiliation(s)
- Chun Soo Kim
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Sang Lak Lee
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
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50
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Abstract
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.
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MESH Headings
- Antibiotic Prophylaxis/methods
- Antibiotic Prophylaxis/statistics & numerical data
- Antifungal Agents/classification
- Antifungal Agents/therapeutic use
- Blood-Brain Barrier/drug effects
- Blood-Brain Barrier/physiopathology
- Candida/drug effects
- Candida/isolation & purification
- Candida/pathogenicity
- Candidiasis, Invasive/drug therapy
- Candidiasis, Invasive/microbiology
- Candidiasis, Invasive/mortality
- Candidiasis, Invasive/physiopathology
- Catheter-Related Infections/drug therapy
- Catheter-Related Infections/microbiology
- Catheter-Related Infections/mortality
- Catheter-Related Infections/physiopathology
- Central Nervous System/growth & development
- Child Development
- Cross Infection/drug therapy
- Cross Infection/microbiology
- Cross Infection/mortality
- Cross Infection/physiopathology
- Humans
- Incidence
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/microbiology
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/physiopathology
- Meningoencephalitis/drug therapy
- Meningoencephalitis/microbiology
- Meningoencephalitis/mortality
- Meningoencephalitis/physiopathology
- Randomized Controlled Trials as Topic
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Affiliation(s)
- Nidhi Tripathi
- Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kevin Watt
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
- Department of Pediatrics, Duke University Medical Center, Duke University, Durham, NC
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
- Department of Pediatrics, Duke University Medical Center, Duke University, Durham, NC
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