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Nguyen TQN, Nguyen TV, Pham TN, Ha TKO. Hepatic abscess due to Candida species in neonates: Case reports in Vietnam. IDCases 2023; 34:e01904. [PMID: 37822875 PMCID: PMC10563005 DOI: 10.1016/j.idcr.2023.e01904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023] Open
Abstract
Neonatal hepatic abscess (NHA) is a fatal condition in neonates. NHA can be caused by many organisms including bacteria, parasites, and fungi. Fungal NHA is a rare but troublesome cause in terms of diagnosis and treatment. We present three cases of fungal NHA caused by Candida. In these three cases, different underlying problems associated with NHA had been found.
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Affiliation(s)
- Thi Quynh Nga Nguyen
- Hanoi Medical University, Viet Nam
- Vietnam National Children’s Hospital, Viet Nam
| | | | - Thao Nguyen Pham
- Hanoi Medical University, Viet Nam
- Vietnam National Children’s Hospital, Viet Nam
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Risk Factors, Diagnosis, and Treatment of Neonatal Fungal Liver Abscess: A Systematic Review of the Literature. LIFE (BASEL, SWITZERLAND) 2023; 13:life13010167. [PMID: 36676116 PMCID: PMC9864123 DOI: 10.3390/life13010167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
(1) Background: Although invasive fungal infections are a major cause of neonatal morbidity and mortality, data on the incidence and outcomes of localized abscesses in solid organs due to fungal infections are scarce. The aim of this study was to consolidate evidence and enhance our understanding on neonatal liver abscesses due to invasive fungal infections. (2) Methods: An electronic search of the PubMed and Scopus databases was conducted, considering studies that evaluated fungal liver abscesses in the neonatal population. Data on the epidemiology, clinical course, treatment, and outcome of these infections were integrated in our study. (3) Results: Overall, 10 studies were included presenting data on 19 cases of neonatal fungal liver abscesses. Candida spp. were the most common causative pathogens (94.7%). Premature neonates constituted the majority of cases (93%), while umbilical venous catheter placement, broad spectrum antibiotics, and prolonged parenteral nutrition administration were identified as other common predisposing factors. Diagnosis was established primarily by abdominal ultrasonography. Medical therapy with antifungal agents was the mainstay of treatment, with Amphotericin B being the most common agent (47%). Abscess drainage was required in four cases (21%). Eradication of the infection was achieved in the majority of cases (80%). (4) Conclusions: Even though fungal liver abscess is a rare entity in the neonatal population, clinicians should keep it in mind in small, premature infants who fail to respond to conventional treatment for sepsis, particularly if an indwelling catheter is in situ. A high index of suspicion is necessary in order to achieve a timely diagnosis and the initiation of the appropriate treatment.
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Geetha O, Cherie C, Natalie TWH, Merchant K, Chien CM, Chandran S. Streptococcus gallolyticus subspecies pasteurianus causing early onset neonatal sepsis complicated by solitary liver abscess in a preterm infant. Access Microbiol 2021; 3:000200. [PMID: 34151155 PMCID: PMC8209707 DOI: 10.1099/acmi.0.000200] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 12/22/2020] [Indexed: 11/26/2022] Open
Abstract
Streptococcus gallolyticus ssp pasteurianus (SGp) is an uncommon but increasingly recognized cause of neonatal sepsis and meningitis. Liver abscess in neonates is extremely rare. But liver abscess due to SG has never been reported in the literature. We present the first case of liver abscess due to SGp in a late preterm infant. A female infant was born at 36 weeks via normal vaginal delivery to a mother with unremarkable antenatal history. She had progressively worsening respiratory distress since birth and was intubated at 13 h of life. One dose of surfactant was delivered and ventilation continued. Parenteral crystalline Penicillin and Gentamicin were initiated and her blood culture at birth grew SGp. She had a spike of fever on day 5 of life. An ultrasound (US) scan of the abdomen was included in the septic work up. A multi-septated cystic liver abscess was noted in the right lobe of the liver. As there was inadequate response to appropriate intravenous antibiotics, needle aspiration and biopsy were performed on day 35 of life. Aspirate was sterile and histopathology confirmed a liver abscess. The patient continued to be treated with antibiotics for 8 weeks with serial US scans of the liver showing resolution of the abscess. Increasing awareness among paediatric and neonatal fraternity about these new emerging bacterial infections can facilitate early diagnosis and treatment.
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Affiliation(s)
- Odattil Geetha
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore.,Yong Loo Lin School of Medicine, Singapore
| | - Chua Cherie
- Department of Pediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore
| | - Tan Woon Hui Natalie
- Duke-NUS Medical School, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore.,Yong Loo Lin School of Medicine, Singapore.,Department of Pediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore
| | - Khurshid Merchant
- Duke-NUS Medical School, National University of Singapore, Singapore.,Department of Pathology and Laboratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Rd, Singapore
| | - Chua Mei Chien
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore.,Yong Loo Lin School of Medicine, Singapore
| | - Suresh Chandran
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore.,Yong Loo Lin School of Medicine, Singapore
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4
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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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Intrahepatic Administration of Liposomal Amphotericin B (Ambisome) for the Management of a Liver Abscess from Candida albicans in a Preterm Infant. Antimicrob Agents Chemother 2018; 62:AAC.01239-18. [PMID: 30224526 DOI: 10.1128/aac.01239-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/02/2018] [Indexed: 12/24/2022] Open
Abstract
Hepatic fungal abscesses are rare in the neonatal period and often constitute a severe complication of the catheterization of the umbilical vessels. Such life-threatening lesions are observed more frequently in preterm than in other newborn infants and the optimal treatment remains uncertain. We present the case of a preterm neonate, who developed an intrahepatic lesion due to parenteral extravasation, successively contaminated by Candida albicans Despite the maximal pharmacological therapies, the treatment that led to the definitive resolution of the abscess was the placement of surgical drainage followed by the direct intralesional administration of liposomal amphotericin B (Ambisome), never described in neonates in the literature, which turned out to be a safe and effective approach.
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Semerci SY, Babayigit A, Cebeci B, Buyukkale G, Cetinkaya M. Hepatic Abscesses in Preterm Infants: Report of Three Cases and Review of the Literature. J Trop Pediatr 2016; 62:255-60. [PMID: 26758250 DOI: 10.1093/tropej/fmv103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
PURPOSE Hepatic abscess is a rare but potentially fatal entity in neonates. The aim of this study was to provide valuable data for diagnosis, management and prevention of hepatic abscess in preterm infants. METHODS A retrospective chart review was made for patients diagnosed with hepatic abscesses between 2012 and 2015. Methods included clinical and radiological review of records and evaluation of potential risk factors. RESULTS A total of three infants with hepatic abscesses were identified. All of them had low birth weight and low gestational age. Predisposing factors included prematurity, late sepsis, umbilical catheterization, necrotizing enterocolitis and previous antibiotic therapy. Isolated organisms from blood included Staphylococcus spp. in two cases and Pseudomonas spp. in one case. To the best of our knowledge, this is the first preterm case of hepatic abscess caused by Pseudomonas aeruginosa in the literature. All patients responded well to antibiotic therapy alone, and no interventional drainage was required. CONCLUSION We suggest evaluating all preterm neonates who have severe sepsis and/or necrotizing enterocolitis signs and who do not respond to prolonged antibiotic therapy with detailed abdominal ultrasound for possible hepatic abscesses as early diagnosis, and treatment favors prognosis.
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Affiliation(s)
- Seda Yilmaz Semerci
- Division of Neonatology, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Aslan Babayigit
- Division of Neonatology, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Burcu Cebeci
- Division of Neonatology, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Gokhan Buyukkale
- Division of Neonatology, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Merih Cetinkaya
- Division of Neonatology, Istanbul Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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Sharma D, Choudhary M, Shastri S, Sharma PK. Neonatal liver abscesses due to Candida infection in a preterm infant, secondary to malpositioned umbilical lines--a rare entity. Pathog Glob Health 2015; 109:84-7. [PMID: 25736870 DOI: 10.1179/2047773215y.0000000008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Neonatal liver abscess is an uncommon seen condition in neonatology and it holds a very high neonatal mortality because of difficulty in diagnosis and treatment. Till today, only few instances are reported that too are mainly in preterm. Its diagnosis requires a high index of suspicion. Fungal hepatic abscess is very rare and in medical literature very few case reports are there in the medical literature. Here, we report a case of Candida albicans liver abscess in a preterm neonate, secondary to malpositioned umbilical lines that presented with respiratory difficulty and other clinical features of sepsis that was managed medically and discharged successfully.
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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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9
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Rasti S, Asadi MA, Taghriri A, Behrashi M, Mousavie G. Vaginal candidiasis complications on pregnant women. Jundishapur J Microbiol 2014; 7:e10078. [PMID: 25147665 PMCID: PMC4138689 DOI: 10.5812/jjm.10078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 01/22/2013] [Accepted: 04/25/2013] [Indexed: 01/11/2023] Open
Affiliation(s)
- Sima Rasti
- Department of Parasitology and Mycology, Kashan University of Medical Sciences, Kashan, IR Iran
| | - Mohammad Ali Asadi
- Department of Parasitology and Mycology, Kashan University of Medical Sciences, Kashan, IR Iran
- Corresponding author: Mohammad Ali Asadi, Department of Parasitology and Mycology, Kashan University of Medical Sciences, Kashan, IR Iran. Tel/Fax: +98-3615553648, E-mail:
| | - Afsaneh Taghriri
- Department of Obstetric and Gynecology, Kashan University of Medical Sciences, Kashan, IR Iran
| | - Mitra Behrashi
- Department of Obstetric and Gynecology, Kashan University of Medical Sciences, Kashan, IR Iran
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Cascio A, Pantaleo D, Corona G, Barberi G, Delfino D, Romeo O, Iaria C, Barberi I. Neonatal liver abscesses associated with candidemia: three cases and review of literature. J Matern Fetal Neonatal Med 2013; 27:743-9. [PMID: 23981181 DOI: 10.3109/14767058.2013.837878] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Our aim was to identify risk factors for the development of neonatal Candida liver abscess and to find useful information to better manage this potentially fatal complication. METHODS A computerized search was conducted using PubMed. Overall, three articles describing the history of seven infants were finally considered. The characteristics of these seven cases were analyzed together with those of three new cases that we treated in the recent past. RESULTS All the neonates were premature. Previous antibiotic use was reported in all the cases, umbilical venous catheterization in 9/10 and total parenteral nutrition in 8/10. Candida albicans was isolated in 9/10. All the patients presented with aspecific signs of sepsis. Liver abscesses were described as "microabscesses" or "miliary abscesses" in three cases, as solitary lesion in two cases. In one case two lesions and in one four lesions were reported. Three infants died. CONCLUSIONS Liver ultrasonography should be performed in all the neonates with signs of sepsis, especially in the presence of candidemia and/or hepatomegaly and/or significant change in liver enzymes. Umbilical venous catheter should be removed, and peripheral IV access should be used until there is documented clearance from the blood with three or more negative blood cultures.
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11
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Picone S, Manzoni P, Bedetta M, Mostert M, Benjamin DK, Paolillo P. Pharmacological resolution of a multiloculated Candida spp. liver abscess in a preterm neonate. Early Hum Dev 2013; 89 Suppl 1:S47-50. [PMID: 23809351 DOI: 10.1016/s0378-3782(13)70015-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We report the case of a 31-week gestational age neonate with Candida albicans sepsis and a hepatic abscess. Diagnosis relied on clinical and radiological signs of sepsis, liver function impairment and culture isolation of Candida spp. from sterile sites. Liver ultrasound documented the presence of a multiloculated abscess. Treatment with micafungin (3 mg/kg/day) resulted in normalization of liver function and inflammatory laboratory values and improvement of clinical condition. After 30 days of treatment, the liver abscess resolved and at the 8-month follow up the infant is doing well. Prompt diagnosis and antifungal treatment avoided surgical drainage and liver surgery in this high-risk neonate.
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Affiliation(s)
- Simonetta Picone
- Division of Neonatology-NICU Policlinico Casilino General Hospital, Rome, Italy
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12
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Basu S, Suri S, Kumar A. Scrotal abscess owing to Candida albicans in a newborn. Paediatr Int Child Health 2013; 33:53-5. [PMID: 23485498 DOI: 10.1179/2046905512y.0000000021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Acute scrotal abscess in neonates is rare and may mimic testicular torsion. An unusual case of unilateral scrotal abscess caused by Candida albicans in a preterm infant is presented. As far as we are aware, this complication has not been reported before.
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Affiliation(s)
- Sriparna Basu
- Department of Paediatrics, Institute of Medical Sciences, Banaras Hindu University Varanasi, India.
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13
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Duigenan S, Anupindi SA, Nimkin K. Imaging of multifocal hepatic lesions in pediatric patients. Pediatr Radiol 2012; 42:1155-68; quiz 1285. [PMID: 22565297 DOI: 10.1007/s00247-012-2400-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 02/25/2012] [Accepted: 03/05/2012] [Indexed: 02/08/2023]
Abstract
Imaging plays a vital role in detection and characterization of multifocal liver lesions in children. Numerous causes for these lesions exist, including benign and malignant neoplasms, infectious lesions, and congenital and inflammatory conditions. The imaging spectrum of multifocal liver lesions in children is presented with emphasis on key imaging features, differential diagnoses and helpful relevant clinical features.
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Affiliation(s)
- Shauna Duigenan
- Division of Pediatric Radiology, Massachusetts General Hospital, Boston, MA, USA.
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Caudle KE, Inger AG, Butler DR, Rogers PD. Echinocandin use in the neonatal intensive care unit. Ann Pharmacother 2011; 46:108-16. [PMID: 22190252 DOI: 10.1345/aph.1q346] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the literature regarding the use of echinocandins to treat invasive fungal infections caused by Candida spp. in patients in the neonatal intensive care unit. DATA SOURCES Literature retrieval was accessed through MEDLINE (Jan 2000-September 2011) using the search terms echinocandin, caspofungin, micafungin, anidulafungin, and neonate with limits for age group (ie, birth to 1 month). Reference citations from identified articles were also reviewed. STUDY SELECTION AND DATA EXTRACTION Relevant information on the pharmacokinetics, efficacy, and safety of echinocandins in neonates was selected. Prospective studies, retrospective studies, and case series in English identified from MEDLINE were evaluated. DATA SYNTHESIS Neonates, especially preterm neonates, have many risk factors that predispose them for invasive fungal infections caused by Candida spp. To date, the only antifungals recommended for use in neonates for treatment of candidiasis are amphotericin B (deoxycholate or a lipid formulation) and fluconazole; however, the toxicities associated with amphotericin B and resistance of certain Candida spp. to fluconazole limit their use in neonates. There is a need for a broad-spectrum antifungal agent with limited toxicity for use in this patient population. The echinocandins may represent such a class of antifungals. To date, micafungin is the most studied echinocandin in the neonatal population, followed by caspofungin; however, studies evaluating their efficacy and pharmacokinetic parameters in neonates are few. CONCLUSIONS Although studies suggest that the echinocandins may have a favorable safety profile, the lack of pharmacokinetic data and standardized study designs limit current recommendations of use of echinocandins as first-line agents in neonates in the treatment of fungal infections. However, if an echinocandin is to be used in this population, the data presented in this review suggest the use of micafungin over the other echinocandins, and higher doses of micafungin (10-15 mg/kg/day) should be used when central nervous system involvement is suspected.
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Affiliation(s)
- Kelly E Caudle
- Division of Pharmacy Practice and Administrative Sciences, The James L Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA.
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Manzoni P, Rizzollo S, Franco C, Gallo E, Galletto P, Boano E, Mostert M, Benjamin DK, Jacqz-Aigrain E, Farina D. Role of echinocandins in the management of fungal infections in neonates. J Matern Fetal Neonatal Med 2011; 23 Suppl 3:49-52. [PMID: 20858036 DOI: 10.3109/14767058.2010.509914] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
As the incidence rates of neonatal systemic fungal infections (SFI) have been increasing over the last years, research efforts have been addressed towards identifying both effective preventative strategies, and efficacious and well-tolerated antifungal drugs. Historically, the first options in treatment of neonatal SFI have been – and currently are – fluconazole and amphotericin B. However, these two drugs carry limitations both in efficacy and in putative toxicity. Recently, new therapeutic alternatives have drawn the neonatologists' attention. Echinocandins are a new class of antifungal drugs with characteristics that might better meet the needs of this particular population of patients. Caspofungin (CSP), micafungin (MICA), and anidulafungin have inherent good activities both against biofilms, and against natively fluconazole-resistant strains of Candida spp, thus overcoming two of the major weaknesses of the commonly used antifungal drugs in nurseries. CSP and MICA have been recently studied in neonatal populations. The kinetics and appropriate dosing of this agent in premature and term infants have been described, but ongoing further studies are needed to better address this area. Case-report series show clinical efficacy and tolerability in critical neonatal patients given CSP and MICA. In addition, extrapolation of data from randomized trials conducted in pediatric and adult patients showed through a subgroup analysis that both CSP and MICA are effective and well tolerated also in neonates. Further studies properly designed for neonatal populations will better address long-term safety and ecological issues related to echinocandin use in neonates.
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Affiliation(s)
- Paolo Manzoni
- Neonatology and NICU, S. Anna Hospital, Azienda Ospedaliera Regina Margherita, S. Anna, Corso Spezia 60, Turin, Italy.
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