Fluconazole prophylaxis: can we eliminate invasive Candida infections in the neonatal ICU?

Invasive Candida Infections in Neonatal Intensive Care Units: Risk Factors and New Insights in Prevention

Invasive Candida infections represent a significant cause of morbidity and mortality in neonatal intensive care units (NICUs), with a particular impact on preterm and low-birth-weight neonates. In addition to prematurity, several predisposing factors for Candida colonization and dissemination during NICU hospitalization have been identified, including prolonged exposure to broad-spectrum antibiotics, central venous catheters, parenteral nutrition, corticosteroids, H2 antagonist administration, and poor adherence to infection control measures. According to the literature, the implementation of antifungal prophylaxis, mainly fluconazole, in high-risk populations has proven to be an effective strategy in reducing the incidence of fungal infections. This review aims to provide an overview of risk factors for invasive Candida infections and current perspectives regarding antifungal prophylaxis use. Recognizing and reducing people's exposure to these modifiable risk factors, in conjunction with the administration of antifungal prophylaxis, has been demonstrated to be an effective method for preventing invasive candidiasis in susceptible neonatal populations.

Candiduria: Evidence-based approach to management, are we there yet?

Candiduria is considered one of the most controversial issues in patient management. Neither the diagnosis nor the optimal treatment options are standardized. This is further complicated by lack of defined laboratory criteria for diagnosis as most of the studies were set for bacterial rather than fungal urinary tract infection (UTI). Furthermore, since Candida species is a known commensal of the genitourinary tract its presence in the urine sample adds ambiguity to making a definitive diagnosis of candidal UTI. Guidelines for diagnosis and management of candiduria have changed considerably over the past decades. In 1960s, the condition was believed to be benign with no intervention required. However, over the years new dimensions were added to address the issues associated with candiduria until the latest Infectious Diseases Association of America (IDSA) guidelines were published in 2009, which indicated that there was an increase in the incidence of candiduria caused by more resistant non-Candida albicans species. Further complicating the issue is the observation that candiduria may be the only indicator of a more serious invasive candidiasis, especially in immunocompromised patients. Long-term urinary catheterization is considered to be the most significant risk factor for candiduria followed by antibiotic use and diabetes. Strategies for management are based on the evaluation of candiduria in the context of the clinical setting to determine its relevance and make an appropriate decision about the need for antifungal therapy. Fluconazole is the main drug used for its efficacy and least complications. Other options include bladder irrigation with amphotericin B, flucytosine or parenteral amphotericin B. Since azoles other than fluconazole and all echinocandins are poorly excreted in urine they have been found to be less effective in candiduric patients.

Cost Analysis of Fluconazole Prophylaxis for Prevention of Neonatal Invasive Candidiasis

BACKGROUND

Fluconazole prophylaxis (FP) in premature infants is well studied and has been shown to decrease invasive candidiasis (ICs). IC in neonates has significant financial costs; determining the cost-benefit of FP may provide additional justification for targeting high-risk neonates. We aimed to determine the IC rate in premature infants at which FP is cost-beneficial.

METHODS

A decision tree cost-analysis model using cost of FP related to costs associated with IC was used. We searched PubMed for all papers that used intravenous FP and reported rates of IC in very low birth weight neonates. Average IC rates in those who received FP (2.0%; range, 0-6.1%) and in those who did not receive FP (9.2%; range, 0-20.5%) were used. Incremental hospital costs because of IC and for FP were retrieved from the literature. Sensitivity analysis was performed to determine the incremental cost of FP across the range of published IC rates.

RESULTS

The average cost per patient attributed to IC in patients receiving FP was $785 versus $2617 in those not receiving FP. Sensitivity analysis demonstrates the rate of IC would need to be <2.8% for FP to lose its cost-benefit. In Monte Carlo simulation, targeting infants <1000 g would lead to $50,304,333 in cost savings per year in the United States.

CONCLUSIONS

FP provides a cost-advantage across most IC rates seen in the youngest premature infants. Using a rate of 2.8% for their individual high-risk neonatal intensive care unit patients, providers can determine if FP is cost-beneficial in determining for whom to provide IC prophylaxis.

Integrated measures for prevention of invasive Candida infections in preterm infants in a Chinese neonatal intensive care unit

BACKGROUND

The increasing incidence of invasive Candida infections (ICIs) in preterm infants in the neonatal intensive care unit (NICU) of Xinhua Hospital aroused our concern. We undertook a retrospective study to evaluate the efficacy of different preventive measures for ICI in preterm infants.

METHODS

Preterm infants with gestational age (GA) <33 weeks admitted between 2010 and 2013 were divided into 3 groups according to the preventive measures applied in different periods: the control group (CG), fluconazole group (FG), and integrated measures group (IMG). We analyzed the incidence of ICI and distribution of fungal pathogens in these 3 groups, and also evaluated the efficiency of various measures in preventing ICIs in preterm infants.

RESULTS

The study sample comprised 261 preterm infants born at <33 weeks GA, including 94 in the CG, 99 in the FG, and 68 in the IMG. The differences among the groups were not significant at baseline. ICI developed in 41 of the 261 infants (15.7%). The incidence of ICI varied significantly among the groups: 22.3% in the CG (21/94), 18.2% in the FG (18/99), and only 2.9% in the IMG (2/68) (P = .003). ICI was less frequent in the IMG compared with the CG (P <.001) and the FG (P = .003).

CONCLUSIONS

The integrated measures approach is meaningful for the prevention of ICIs in preterm infants in NICUs with many patients but inadequate medical resources in some developing countries.

Challenges in the diagnosis and management of neonatal sepsis

Neonatal sepsis is the third leading cause of neonatal mortality and a major public health problem, especially in developing countries. Although recent medical advances have improved neonatal care, many challenges remain in the diagnosis and management of neonatal infections. The diagnosis of neonatal sepsis is complicated by the frequent presence of noninfectious conditions that resemble sepsis, especially in preterm infants, and by the absence of optimal diagnostic tests. Since neonatal sepsis is a high-risk disease, especially in preterm infants, clinicians are compelled to empirically administer antibiotics to infants with risk factors and/or signs of suspected sepsis. Unfortunately, both broad-spectrum antibiotics and prolonged treatment with empirical antibiotics are associated with adverse outcomes and increase antimicrobial resistance rates. Given the high incidence and mortality of sepsis in preterm infants and its long-term consequences on growth and development, efforts to reduce the rates of infection in this vulnerable population are one of the most important interventions in neonatal care. In this review, we discuss the most common questions and challenges in the diagnosis and management of neonatal sepsis, with a focus on developing countries.

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

BACKGROUND

Premature infants are at high risk of developing invasive candidal infections (ICI). We investigated maternal and perinatal risk factors for ICI that may help in defining at-risk infants, allowing more targeted antifungal prophylaxis to prevent morbidity and mortality.

METHODS

Maternal and neonatal data from infants with a birthweight between 500 and 1250 g admitted across 95 neonatal intenisve care units were analyzed for risk factors for ICI.

RESULTS

Data from 1890 infants were analyzed, 78 of whom had ICI. Overall mortality was 20.5% for all cases of ICI, 18.8% with candidemia, 17.2% with candiduria, and 75% when Candida was isolated in both the blood and urine. Birthweight, gestational age, male sex, and vaginal delivery were predictors of infection on univariate analysis. After logistic regression, gestational age (P < .01) and male sex (P < .01) remained significant. Vaginal birth and receiving antibiotics during the first week of life increased the risk for ICI in the 22-25 weeks' and 26-28 weeks' gestation subgroups.

CONCLUSIONS

Gestational age and male gender are risk factors for the development of ICI, whereas vaginal delivery and antibiotics during the first week further increase the incidence in the more premature infants. Knowing maternal and perinatal risk factors for ICI allows more targeted antifungal prophylaxis in at-risk infants.

Changes in the incidence of candidiasis in neonatal intensive care units

OBJECTIVE

Neonatal invasive candidiasis is associated with significant morbidity and mortality. We describe the association between invasive candidiasis and changes in use of antifungal prophylaxis, empirical antifungal therapy, and broad-spectrum antibacterial antibiotics over time.

METHODS

We examined data from 709,325 infants at 322 NICUs managed by the Pediatrix Medical Group from 1997 to 2010. We determined the cumulative incidence of invasive candidiasis and use of antifungal prophylaxis, broad-spectrum antibacterial antibiotics, and empirical antifungal therapy by year.

RESULTS

We identified 2063 (0.3%) infants with 2101 episodes of invasive candidiasis. Over the study period, the annual incidence of invasive candidiasis decreased from 3.6 episodes per 1000 patients to 1.4 episodes per 1000 patients among all infants, from 24.2 to 11.6 episodes per 1000 patients among infants with a birth weight of 750-999 g, and from 82.7 to 23.8 episodes per 1000 patients among infants with a birth weight <750 g. Fluconazole prophylaxis use increased among all infants with a birth weight <1000 g (or <1500 g), with the largest effect on birth weights <750 g, increasing from 3.8 per 1000 patients in 1997 to 110.6 per 1000 patients in 2010. The use of broad-spectrum antibacterial antibiotics decreased among all infants from 275.7 per 1000 patients in 1997 to 48.5 per 1000 patients in 2010. The use of empirical antifungal therapy increased over time from 4.0 per 1000 patients in 1997 to 11.5 per 1000 patients in 2010.

CONCLUSIONS

The incidence of invasive candidiasis in the NICU decreased over the 14-year study period. Increased use of fluconazole prophylaxis and empirical antifungal therapy, along with decreased use of broad-spectrum antibacterial antibiotics, may have contributed to this observation.

Neonatal severe bacterial infection impairment estimates in South Asia, sub-Saharan Africa, and Latin America for 2010

BACKGROUND

Survivors of neonatal infections are at risk of neurodevelopmental impairment (NDI), a burden not previously systematically quantified and yet important for program priority setting. Systematic reviews and meta-analyses were undertaken and applied in a three-step compartmental model to estimate NDI cases after severe neonatal bacterial infection in South Asia, sub-Saharan Africa, and Latin America in neonates of >32 wk gestation (or >1,500 g).

METHODS

We estimated cases of sepsis, meningitis, pneumonia, or no severe bacterial infection from among estimated cases of possible severe bacterial infection ((pSBI) step 1). We applied respective case fatality risks ((CFRs) step 2) and the NDI risk among survivors (step 3). For neonatal tetanus, incidence estimates were based on the estimated deaths, CFRs, and risk of subsequent NDI.

RESULTS

For 2010, we estimated 1.7 million (uncertainty range: 1.1-2.4 million) cases of neonatal sepsis, 200,000 (21,000-350,000) cases of meningitis, 510,000 cases (150,000-930,000) of pneumonia, and 79,000 cases (70,000-930,000) of tetanus in neonates >32 wk gestation (or >1,500 g). Among the survivors, we estimated moderate to severe NDI after neonatal meningitis in 23% (95% confidence interval: 19-26%) of survivors, 18,000 (2,700-35,000) cases, and after neonatal tetanus in 16% (6-27%), 4,700 cases (1,700-8,900).

CONCLUSION

Data are lacking for impairment after neonatal sepsis and pneumonia, especially among those of >32 wk gestation. Improved recognition and treatment of pSBI will reduce neonatal mortality. Lack of follow-up data for survivors of severe bacterial infections, particularly sepsis, was striking. Given the high incidence of sepsis, even minor NDI would be of major public health importance. Prevention of neonatal infection, improved case management, and support for children with NDI are all important strategies, currently receiving limited policy attention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Changes in incidence and antifungal drug resistance in candidemia: results from population-based laboratory surveillance in Atlanta and Baltimore, 2008-2011

BACKGROUND

Candidemia is common and associated with high morbidity and mortality; changes in population-based incidence rates have not been reported.

METHODS

We conducted active, population-based surveillance in metropolitan Atlanta, Georgia, and Baltimore City/County, Maryland (combined population 5.2 million), during 2008-2011. We calculated candidemia incidence and antifungal drug resistance compared with prior surveillance (Atlanta, 1992-1993; Baltimore, 1998-2000).

RESULTS

We identified 2675 cases of candidemia with 2329 isolates during 3 years of surveillance. Mean annual crude incidence per 100 000 person-years was 13.3 in Atlanta and 26.2 in Baltimore. Rates were highest among adults aged ≥65 years (Atlanta, 59.1; Baltimore, 72.4) and infants (aged <1 year; Atlanta, 34.3; Baltimore, 46.2). In both locations compared with prior surveillance, adjusted incidence significantly declined for infants of both black and white race (Atlanta: black risk ratio [RR], 0.26 [95% confidence interval {CI}, .17-.38]; white RR: 0.19 [95% CI, .12-.29]; Baltimore: black RR, 0.38 [95% CI, .22-.64]; white RR: 0.51 [95% CI: .29-.90]). Prevalence of fluconazole resistance (7%) was unchanged compared with prior surveillance; 32 (1%) isolates were echinocandin-resistant, and 9 (8 Candida glabrata) were multidrug resistant to both fluconazole and an echinocandin.

CONCLUSIONS

We describe marked shifts in candidemia epidemiology over the past 2 decades. Adults aged ≥65 years replaced infants as the highest incidence group; adjusted incidence has declined significantly in infants. Use of antifungal prophylaxis, improvements in infection control, or changes in catheter insertion practices may be contributing to these declines. Further surveillance for antifungal resistance and efforts to determine effective prevention strategies are needed.

Strategies for the prevention of neonatal candidiasis

Invasive fungal infections represent the third-leading cause of late-onset sepsis in very-low-birth-weight infants (VLBWI) and have a high rate of infection-associated mortality. The infants at high risk for fungal sepsis are VLBWI with presence of additional risk factors that contribute to increased colonization and concentration of fungal organisms. Colonization with Candida spp. in neonates is secondary to either maternal vertical transmission or nosocomial acquisition in the nursery. Multiple sites may become colonized and a direct correlation between fungal colonization and subsequent progression to invasive candidemia was determined. Randomized, single and multiple-center, placebo-controlled trials found intravenous fluconazole prophylaxis to be effective in decreasing fungal colonization and sepsis for at-risk preterm infants <1500 g birth weight. The prophylactic use of fluconazole was found to be safe with no significant development of fungal resistance. Fluconazole prophylaxis administered to preterm neonates with birth weight <1000 g and/or 27 weeks' gestation or less has the potential of reducing and potentially eliminating invasive fungal infections and Candida-related mortality.

Fluconazole prophylaxis in extremely low birth weight infants and neurodevelopmental outcomes and quality of life at 8 to 10 years of age

OBJECTIVE

To examine the long-term effects of fluconazole prophylaxis in extremely low birth weight infants.

STUDY DESIGN

Neurodevelopmental status and quality of life of survivors from a randomized, placebo-controlled trial of fluconazole prophylaxis were evaluated at 8 to 10 years of life using the Vineland Adaptive Behavior Scales-II (VABS-II) and the Child Health Questionnaire Parent-Completed Form 28 (CHQ-PF28), respectively.

RESULTS

VABS-II Domain Scores for the fluconazole-treated (n = 21; 9.1 ± 0.7 years) compared with the placebo group (n = 17; 9.3 ± 0.8 years) were similar for communication [94.6 (±14.8) versus 92.6 (±12.6), P = .65], daily living skills [87.9 (±10.6) versus 87.4 (±9.3), P = .89], socialization [97.2 (±9.2) versus 94.4 (±7.9), P = .31], and motor skills [92.1 (±17.8) versus 95.1 (±14.6), P = .57]. Internalizing and externalizing behaviors and maladaptive behavior index were also similar. The CHQ-PF28 revealed no differences between the two groups regarding quality of life. Survivors were also happy or satisfied with school (90% versus 100%, P = .49), friendships (90% versus 88%, P = 1.00), and life (95% versus 100%, P = 1.00). Self esteem scores were 87.3 ± 15.7 versus 89.7 ± 10.4 (P = .59). There were also no differences between groups regarding emotional difficulties or behavior problems.

CONCLUSIONS

Fluconazole prophylaxis for the prevention of invasive Candida infections is safe in extremely low birth weight infants and does not appear to be associated with any long-term adverse effects on neurodevelopment and quality of life at 8 to 10 years of life.

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

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

Strategies to prevent invasive candidal infection in extremely preterm infants

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

Early mannan detection in bronchoalveolar lavage fluid with preemptive treatment reduces the incidence of invasive Candida infections in preterm infants

BACKGROUND

Candida colonization is an important predictor for development of invasive fungal infection (IFI). We investigated whether early detection of Candida mannan (Mn) in bronchoalveolar lavage fluid (BALF) reduces IFI among preterm infants.

METHODS

We conducted an observational study of infants with gestational age of < or =28 weeks, where a group undergoing Candida surveillance cultures (pre-Mn detection group) was compared with a group defined after the initiation of routine use of Candida Mn detection in BALF (Mn detection group). Antifungal treatment was started based on positive microbiologic (surveillance culture or Mn-antigen assay) results.

RESULTS

No significant differences were detected when the groups were compared for several predictors of IFI. IFI was observed for 12 (23%) of 51 infants in the pre-Mn detection group, and for 0 (0%) of 29 infants in the Mn detection group (P = 0.003). Surveillance cultures in the pre-Mn detection group became positive at 15.0 +/- 7.2 days after birth, whereas the mean age at time of positive Mn antigen results in the Mn detection group was 4.3 +/- 3.1 days (P < 0.0001). Among 16 infants positive for surveillance cultures, 12 (75%) developed IFI (P < 0.0001).

CONCLUSIONS

This study suggests that Candida Mn detection in BALF may be useful for earlier identification and preemptive therapy targeting preterm infants at high risk of IFI.

Challenging issues in neonatal candidiasis

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

Candida infections of the genitourinary tract

All humans are colonized with Candida species, mostly Candida albicans, yet some develop diseases due to Candida, among which genitourinary manifestations are extremely common. The forms of genitourinary candidiasis are distinct from each other and affect different populations. While vulvovaginal candidiasis affects mostly healthy women, candiduria occurs typically in elderly, hospitalized, or immunocompromised patients and in neonates. Despite its high incidence and clinical relevance, genitourinary candidiasis is understudied, and therefore, important questions about pathogenesis and treatment guidelines remain to be resolved. In this review, we summarize the current knowledge about genitourinary candidiasis.

A rapid and sensitive LC-MS/MS method for determination of fluconazole in human plasma and its application in infants with Candida infections

A rapid and sensitive LC-MS/MS method was developed to quantify fluconazole in human plasma. Seventy microliters of plasma were treated with protein precipitation procedures. Chromatographic separation was achieved on a C18 column using a gradient mobile phase of acetonitrile and water in 0.1% formic acid. Fluconazole and its deuterium-labeled internal standard were monitored in positive mode using electrospray ionization source. The method was fully validated over the range of 0.01 to 10 microg/mL. Intraday and interday precision ranged from 2.84% to 10.8% and 5.27% to 11.5%, respectively. The process recovery efficiency for fluconazole ranged from 98.6% to 104.4%. No carryover and minimal matrix effects were observed. Acceptable stability of fluconazole in blood at room temperature for up to 72 hours guaranteed that fluconazole concentrations in scavenged blood specimens were usable for infant PK analysis and model development. This method has been utilized for a fluconazole pharmacokinetic trial with 55 preterm and term infants younger than 90 days of age. The fast sample preparation cycle and lower limit of quantitation make this method a potential tool for therapeutic drug monitoring of fluconazole to optimize pediatric antifungal therapy. Optimal dose regimen of fluconazole in neonates and young infants might be achieved with application of TDM and pharmacometric approach designed to achieve AUC/MIC >50 for most Candida species with a MIC90 less than 8 microg/mL.

Therapeutic strategies for invasive fungal infections in neonatal and pediatric patients

Invasive Candida and Aspergillus infections are the most commonly encountered fungal infections. They appear to be life threatening in the setting of profound immunosuppression, whereas cases that are resistant to antifungal therapy are occasionally encountered. Novel antifungal triazole and echinocandin agents appear to exhibit good activity as first-line or salvage therapy, whereas the use of amphotericin B formulations is particularly valuable in neonates. Significant differences in toxicity have been demonstrated among various antifungal agents with in vitro activity from available comparative data on fungal infections in children: however, no clear difference in treatment efficacy has been demonstrated. However, very little data are available about neonates. Host factors and responsible fungal species most frequently guide the choice of therapy.

Candida parapsilosis, an emerging fungal pathogen

SUMMARY

Candida parapsilosis is an emerging major human pathogen that has dramatically increased in significance and prevalence over the past 2 decades, such that C. parapsilosis is now one of the leading causes of invasive candidal disease. Individuals at the highest risk for severe infection include neonates and patients in intensive care units. C. parapsilosis infections are especially associated with hyperalimentation solutions, prosthetic devices, and indwelling catheters, as well as the nosocomial spread of disease through the hands of health care workers. Factors involved in disease pathogenesis include the secretion of hydrolytic enzymes, adhesion to prosthetics, and biofilm formation. New molecular genetic tools are providing additional and much-needed information regarding C. parapsilosis virulence. The emerging information will provide a deeper understanding of C. parapsilosis pathogenesis and facilitate the development of new therapeutic approaches for treating C. parapsilosis infections.