Chemoprophylaxis of neonatal fungal infections in very low birthweight infants: efficacy and safety of fluconazole and nystatin

Oral Nystatin Prophylaxis for the Prevention of Fungal Colonization in Very Low Birth Weight Infants: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

We conducted this systematic review and meta-analysis of randomized controlled trials (RCTs) to investigate the prophylactic role of oral nystatin in the prevention of fungal colonization in very low birth weight (VLBW) infants compared with placebo or no treatment intervention. From inception until June 2022, we screened four major databases for pertinent RCTs and examined their risk of bias. The main outcomes were the rate of fungal colonization, rate of invasive fungal infection, rate of mortality, mean length of stay in the neonatal intensive care unit (NICU), and mean duration of antibiotic treatment. We summarized data as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI), using the fixed-effects model. Five RCTs met our inclusion criteria. One RCT was evaluated as having "high risk," one RCT was evaluated as having "some concerns," and three RCTs were evaluated as having "low risk" of bias. Compared with the control group, oral nystatin prophylaxis was correlated with substantial decrease in the frequency of fungal colonization (n=4 RCTs, RR=0.34, 95% CI {0.24, 0.48}, p<0.0001), the rate of invasive fungal infection (n=4 RCTs, RR=0.15, 95% CI {0.12, 0.19}, p<0.0001), and the mean duration of antibiotic treatment (n=3 RCTs, MD=-2.79 days, 95% CI {-5.01, -0.56}, p=0.01). However, there was no significant difference between both groups regarding the rate of mortality (n=4 RCTs, RR=0.87, 95% CI {0.64, 1.18}, p=0.37) and mean length of stay in NICU (n=3 RCTs, MD=-2.85 days, 95% CI {-6.52, 0.82}, p=0.13). In conclusion, among VLBW infants, the prophylactic use of oral nystatin was correlated with favorable antifungal benefits compared with placebo or no treatment intervention.

Antifungal prescribing in neonates: using national point prevalence survey data from Australia

We describe contemporary antifungal use in neonates, with point-prevalence survey data from the National Antimicrobial Prescribing Survey across Australian hospitals from 2014-2018. There were 247 antifungal prescriptions in 243 neonates in 20 hospitals, median age six days (range 0-27 days). In 219/247 prescriptions (89%) antifungals were prescribed as prophylaxis. Topical (oral) nystatin was the most frequently prescribed in 233/247 prescriptions (94%), followed by fluconazole 11/247 (4%), with substantial variation in dosing for both. Two of 243 neonates (0.8%) had invasive fungal infection. Nystatin use dominates current antifungal prescribing for Australian neonates, in contrast to other countries, and invasive fungal infection is rare.

LAY ABSTRACT

Novel nationwide surveillance found newborn infants in Australian hospitals commonly receive antifungal medications, mostly oral nystatin. This is given to prevent rather than treat infection, which is rare. There is substantial unexplained variation in dosing of antifungal drugs nationally.

Polyhydroxyalkanoate/Antifungal Polyene Formulations with Monomeric Hydroxyalkanoic Acids for Improved Antifungal Efficiency

Novel biodegradable and biocompatible formulations of "old" but "gold" drugs such as nystatin (Nys) and amphotericin B (AmB) were made using a biopolymer as a matrix. Medium chain length polyhydroxyalkanoates (mcl-PHA) were used to formulate both polyenes (Nys and AmB) in the form of films (~50 µm). Thermal properties and stability of the materials were not significantly altered by the incorporation of polyenes in mcl-PHA, but polyene containing materials were more hydrophobic. These formulations were tested in vitro against a panel of pathogenic fungi and for antibiofilm properties. The films containing 0.1 to 2 weight % polyenes showed good activity and sustained polyene release for up to 4 days. A PHA monomer, namely 3-hydroxydecanoic acid (C10-OH), was added to the films to achieve an enhanced synergistic effect with polyenes against fungal growth. Mcl-PHA based polyene formulations showed excellent growth inhibitory activity against both Candida yeasts (C. albicans ATCC 1023, C. albicans SC5314 (ATCC MYA-2876), C. parapsilosis ATCC 22019) and filamentous fungi (Aspergillus fumigatus ATCC 13073; Trichophyton mentagrophytes ATCC 9533, Microsporum gypseum ATCC 24102). All antifungal PHA film preparations prevented the formation of a C. albicans biofilm, while they were not efficient in eradication of mature biofilms, rendering them suitable for the transdermal application or as coatings of implants.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Efficacy and safety of fluconazole in prophylaxis of invasive fungal infections in very low birth weight infants: a Meta analysis]

OBJECTIVE

To assess the efficacy and safety of fluconazole in the prophylaxis of invasive fungal infection in very low birth weight (VLBW) infants.

METHODS

Databases including PubMed, Embase, the Cochrane Library, Wanfang Data, Weipu, and CNKI were searched for randomized controlled trials (RCTs) of prophylactic fluconazole in VLBW infants. Review Manager 5.3 software was used to perform a Meta analysis of the included studies.

RESULTS

A total of 12 RCTs were included, involving 1 679 VLBW infants. The Meta analysis showed that prophylactic fluconazole significantly reduced the incidence of invasive fungal infection (RR=0.44, 95%CI: 0.27-0.71, P<0.001), the incidence of fungal colonization (RR=0.31, 95%CI: 0.24-0.40, P<0.001), and the mortality during hospitalization (RR=0.74, 95%CI: 0.58-0.94, P=0.01) compared with the control group. There were no significant differences between VLBW infants using different doses of fluconazole in the incidence of invasive fungal infection and fungal colonization (P>0.05). No significant differences were found in the incidence of fluconazole resistance and complications between the fluconazole and control groups (P>0.05).

CONCLUSIONS

Prophylactic fluconazole can effectively and safely prevent invasive fungal infection in VLBW infants, even at a small dose.

Oral nystatin prophylaxis to prevent systemic fungal infection in very low birth weight preterm infants: a randomized controlled trial

Background

Systemic fungal infection (SFI) is one of leading causes of morbidity and mortality in very low birth weight (VLBW) preterm infants. Because early diagnosis of SFI is challenging due to nonspecific manifestations, prophylaxis becomes crucial. This study aimed to assess effectiveness of oral nystatin as an antifungal prophylaxis to prevent SFI in VLBW preterm infants.

Methods

A prospective, open-labelled, randomized controlled trial was performed in a neonatal intensive care unit (NICU) of an academic hospital in Indonesia. Infants with a gestational age ≤ 32 weeks and/or birth weight of ≤ 1500 g with risk factors for fungal infection were assessed for eligibility and randomized to either an intervention group (nystatin) or control group. The intervention group received 1 ml of oral nystatin three times a day, and the control group received a dose of 1 ml of sterile water three times a day. The incidence of fungal colonization and SFI were observed and evaluated during the six-week study period. Overall mortality rates and nystatin-related adverse drug reactions during the study period were also documented.

Results

A total of 95 patients were enrolled. The incidence of fungal colonization was lower among infants in nystatin group compared to those in control group (29.8 and 56.3%, respectively; relative risk 0.559; 95% confidence interval 0.357–0.899; p-value = 0.009). There were five cases of SFI, all of which were found in the control group (p-value = 0.056). There was no difference in overall mortality between the two groups. No adverse drug reactions were noted during the study period.

Conclusions

Nystatin is effective and safe as an antifungal prophylactic medication in reducing colonization rates in the study population. Whilst the use of nystatin showed a potential protective effect against SFI among VLBW preterm infants, there was no statistical significant difference in SFI rates between groups.

Trial registration

NCT03390374. Registered 4 January 2018 - Retrospectively registered.

Nationwide survey of neonatal invasive fungal infection in Japan

Invasive fungal infection (IFI) is a life-threating infectious disease in high-risk neonates. Strategies for the treatment and prevention of IFI in neonates in Japan remain unclear. We conducted a nationwide retrospective survey to determine IFI incidence between January 2014 and October 2015. Primary survey questionnaires were submitted to 309 medical facilities that regularly treat high-risk neonates. The questionnaire assessed IFI incidence during the study period, methods for preventing fungal infection in early delivery neonates, and methods for preventing mother-to-child fungal transmission. The secondary questionnaire was for facilities that had IFI cases and replied to the primary questionnaire. In total, 128 medical facilities (41.4%) completed the primary questionnaire, 17/128 facilities recorded 23 proven or probable IFI cases. Estimated annual IFI incidence was 0.33/1000 live births of hospitalized neonates. Patient data at IFI onset were available for all 23 patients. Birth weight was < 1000 g in 18 patients. Causative microorganisms were identified in 22 patients. Candida species (n = 21) were the most common pathogens, and one patient had mucormycosis. The mortality rate was 17.4%. Regarding neonatal fungal prophylaxis, 55/128 facilities (43.0%) reported administering therapy. The most frequently used prophylactic drugs were fluconazole, then micafungin. Fungal prophylaxis for mothers who showed fungal colonization was performed in 30/128 facilities (23.4%). Oxiconazole vaginal tablets were most commonly used as prophylaxis for high-risk mothers. In Japan, the diagnosis, treatment, and prevention of neonatal IFI varied. Continuous surveillance and treatment regimen for neonatal IFI are required to improve outcomes in high-risk neonates.

Fluconazole administration leading to anaphylactic shock in a preterm newborn

Preterm infants, born with immature innate immunity, are less likely to develop anaphylaxis. Fluconazole prophylaxis during the first six weeks of life decreases invasive candidiasis in very low birth weight infants. Adverse effects of fluconazole are very rare. In this study, we report a newborn (a male, 26 weeks gestation and 900 g birth weight) who developed anaphylaxis after fluconazole administration. Hypotension and erythematous rash were present. We believe this to be the first anaphylaxis case in newborns caused by fluconazole in literature. Clinicians should be aware of the possibility of this potentially fatal adverse effect occurring with intravenous fluconazole.

Fluconazole Doses Used for Prophylaxis of Invasive Fungal Infection in Neonatal Intensive Care Units: A Network Meta-Analysis

OBJECTIVES

To evaluate the safety and efficacy of different doses of fluconazole used for invasive prophylaxis of fungal infection in neonates.

STUDY DESIGN

A systematic search was conducted with PubMed, Scopus, and Web of Science. A manual search was performed as well. Only randomized controlled trials of neonates in a neonatal intensive care unit (NICU) who received fluconazole prophylaxis for invasive fungal infection, regardless of the dose or therapeutic regimen, were included in this review. Data on baseline characteristics, outcomes incidence of proven invasive Candida infection, overall mortality, and invasive Candida infection-related mortality were extracted.

RESULTS

Eleven studies were included in the review, with fluconazole doses of 3, 4, or 6?mg/kg. When the incidence of invasive Candida and invasive Candida-related mortality were considered as outcomes, the 3 and 6?mg/kg fluconazole doses were found to be statistically superior to placebo (OR, 5.48 [95% credible interval, 1.81-18.94] and 2.63 [1.18-7.02], respectively, and 15.32 [1.54-54.31] and 9.14 [1.26-142.7], respectively), but data for the 3 doses were not statistically significantly different.

CONCLUSIONS

Use of the lowest fluconazole dose (3?mg/kg) should be recommended for Candida prophylaxis in neonates, given that increasing the fluconazole dose is not associated with higher efficacy and has greater potential for toxicity and increased cost.

Australia-wide Point Prevalence Survey of Antimicrobial Prescribing in Neonatal Units: How Much and How Good?

BACKGROUND

There is increasing recognition of the threat to neonatal patients from antibiotic resistance. There are limited data on antimicrobial prescribing practices for hospitalized neonates. We aimed to describe antimicrobial use in hospitalized Australian neonatal patients, and to determine its appropriateness.

METHODS

Multicentre single-day hospital-wide point prevalence survey in 2012, in conjunction with the Antimicrobial Resistance and Prescribing in European Children study. The appropriateness of antimicrobial prescriptions was also assessed. All patients admitted at 8 am on the survey day, in 6 neonatal units in tertiary children's hospitals across 5 states, were included in an analysis of the quantity and quality of all antimicrobial prescriptions.

RESULTS

The point prevalence survey included 6 neonatal units and 236 patients. Of 109 patients (46%) receiving at least 1 antimicrobial, 66 (61%) were being treated for infection, with sepsis the most common indication. There were 216 antimicrobial prescriptions, 134 (62%) for treatment of infection and 82 (38%) for prophylaxis, mostly oral nystatin. Only 15 prescriptions were for targeted as opposed to empirical treatment. Penicillin and gentamicin were the most commonly prescribed antibiotics, with vancomycin third most common. Half of all treated patients were receiving combination antimicrobial therapy. There was marked variation in vancomycin and gentamicin dosing. Overall, few prescriptions (4%) were deemed inappropriate.

CONCLUSION

This is the first Australia-wide point prevalence survey of neonatal antimicrobial prescribing in tertiary children's hospitals. The findings highlight positive practices and potential targets for quality improvement.

A multispecies probiotic reduces oral Candida colonization in denture wearers

PURPOSE

The prevalence of Candida infections has been rising with an increasingly aging population and a larger population of immunocompromised individuals. The use of probiotics may be an alternative approach to antifungal agents in the prevention and treatment of oral candidiasis. This study aimed to evaluate the short-term effect of probiotics in reducing the infection level of oral Candida in candidiasis-asymptomatic elderly denture wearers.

MATERIALS AND METHODS

In a double-blind randomized study, 59 denture wearers harboring Candida spp. in the oral cavity with no clinical symptoms were allocated into two groups: probiotic and placebo. All patients were instructed to clean the denture daily. The probiotic group poured a capsule containing lyophilized Lactobacillus rhamnosus HS111, Lactobacillus acidophillus HS101, and Bifidobacterium bifidum daily on the palatal surface of the maxillary denture, whereas the placebo group was submitted to the same regimen using placebo capsules. Candida spp. infection levels were evaluated in palate mucosa samples obtained before and after a 5-week experimental period.

RESULTS

All patients harbored Candida in the palate mucosa at baseline. Fifty-five individuals completed the experimental period. The detection rate of Candida spp. was 92.0% in the placebo group after the experimental period, whereas it was reduced to 16.7% in the probiotic group. The reduction promoted by the probiotic regimen was independent of baseline characteristics such as Candida infection level and colonizing species, age of denture, and other variables.

CONCLUSION

The probiotic product was effective in reducing the colonization of the oral cavity with Candida in candidiasis-asymptomatic elderly denture wearers, suggesting that this multispecies probiotic could be used to prevent oral candidiasis.

CLINICAL IMPLICATIONS

Colonization of oral surfaces by Candida is considered a risk factor for invasive fungal infections. The use of a product with L. rhamnosus, L. acidophilus, and B. bifidum may represent an alternative treatment for reduction of Candida infections in elderly denture wearers.

Stimulation of erythrocyte cell membrane scrambling by nystatin

The antifungal ionophore nystatin dissipates the Na(+) and K(+) gradients across the cell membrane, leading to cellular gain of Na(+) and cellular loss of K(+) . The increase of cellular Na(+) concentration may result in Ca(2+) accumulation in exchange for Na(+) . Increase of cytosolic Ca(2+) activity ([Ca(2+) ]i ) and loss of cellular K(+) foster apoptosis-like suicidal erythrocyte death or eryptosis, which is characterised by cell shrinkage and cell membrane scrambling leading to phosphatidylserine exposure at the erythrocyte surface. The present study explored whether nystatin stimulates eryptosis. Cell volume was estimated from forward scatter (FSC), phosphatidylserine exposure from annexin V binding and [Ca(2+) ]i from Fluo3-fluorescence in flow cytometry. A 48-hr exposure to nystatin (15 μg/ml) was followed by a significant increase of [Ca(2+) ]i , a significant increase of annexin V binding and a significant decrease of FSC. The annexin V binding after nystatin treatment was significantly blunted in the nominal absence of extracellular Ca(2+) . Partial replacement of extracellular Na(+) with extracellular K(+) blunted the nystatin-induced erythrocyte shrinkage but increased [Ca(2+) ]i and annexin V binding. Nystatin triggers cell membrane scrambling, an effect at least partially due to entry of extracellular Ca(2+) .

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.