Fluconazole prophylaxis in the very low birth weight infant: not ready for prime time

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.

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

BACKGROUND

Invasive fungal infection is an important cause of mortality and morbidity in very preterm and very low birth weight infants. Early diagnosis is difficult and treatment is often delayed. Systemically absorbed antifungal agents (usually azoles) are increasingly used as prophylaxis against invasive fungal infection in this population.

OBJECTIVES

To assess the effect of prophylactic systemic antifungal therapy on mortality and morbidity in very preterm or very low birth weight infants.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 8), MEDLINE, EMBASE, and CINAHL (to May 2015), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic systemic antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very low birth weight infants.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We identified 15 eligible trials enrolling a total of 1690 infants. Ten trials (1371 infants) compared systemic antifungal prophylaxis versus placebo or no drug. These trials were generally of good methodological quality. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection (typical risk ratio (RR) 0.43, 95% confidence interval (CI) 0.31 to 0.59; risk difference (RD) -0.09, 95% CI -0.12 to -0.06). The average incidence of invasive fungal infection in the control groups of the trials (16%) was much higher than that generally reported from large cohort studies. Meta-analysis did not find a statistically significant difference in the risk of death prior to hospital discharge (typical RR 0.79, 95% CI 0.61 to 1.02; typical RD -0.04, 95% CI -0.07 to 0.00). Very limited data on long-term neurodevelopmental outcomes were available. Three trials that compared systemic versus oral or topical non-absorbed antifungal prophylaxis did not detect any statistically significant effects on invasive fungal infection or mortality. Two trials that compared different dose regimens of prophylactic intravenous fluconazole did not detect any significant differences in infection rates or mortality.

AUTHORS' CONCLUSIONS

Prophylactic systemic antifungal therapy reduces the incidence of invasive fungal infection in very preterm or very low birth weight infants. This finding should be interpreted and applied cautiously since the incidence of invasive fungal infection was very high in the control groups of many of the included trials. Meta-analysis does not demonstrate a statistically significant effect on mortality. There are currently only limited data on the long-term neurodevelopmental consequences for infants exposed to this intervention. In addition, there is a need for further data on the effect of the intervention on the emergence of organisms with antifungal resistance.

Recommendations for the management of candidemia in neonates in Latin America. Latin America Invasive Mycosis Network

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'.

[Recommendations for the management of candidemia in neonates in Latin America. Grupo Proyecto Épico]

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'.

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

BACKGROUND

Invasive fungal infection is an important cause of mortality and morbidity in very low birth weight infants. Early diagnosis is difficult and treatment is often delayed. Systemic antifungal agents (usually azoles) are increasingly used as prophylaxis against invasive fungal infection.

OBJECTIVES

To assess the effect of prophylactic systemic antifungal therapy on mortality and morbidity in very low birth weight infants.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 3), MEDLINE, EMBASE, and CINAHL (to August 2012), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic systemic antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very low birth weight infants.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We identified 11 eligible trials enrolling a total of 1136 infants. Seven trials (involving 880 infants) compared systemic antifungal prophylaxis versus placebo or no drug. These trials were generally small but of good methodological quality. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection in infants who received systemic antifungal prophylaxis (typical risk ratio (RR) 0.41, 95% confidence interval (CI) 0.27 to 0.61; risk difference (RD) -0.09, 95% CI -0.14 to -0.05). The average incidence of invasive fungal infection in the control groups of the trials (16%) was much higher than that generally reported from large cohort studies (< 5%). Meta-analysis did not find a statistically significant difference in the risk of death prior to hospital discharge (typical RR 0.74, 95% CI 0.52 to 1.05; RD -0.04, 95% CI -0.08 to 0.01). Very limited data on long-term neurodevelopmental outcomes were available. Two trials that compared systemic versus oral or topical non-absorbed antifungal prophylaxis did not detect any statistically significant effects on invasive fungal infection or mortality. Two trials that compared different dose regimens of prophylactic intravenous fluconazole did not detect any significant differences in infection rates or mortality.

AUTHORS' CONCLUSIONS

Prophylactic systemic antifungal therapy reduces the incidence of invasive fungal infection in very low birth weight infants. This finding should be interpreted and applied cautiously since the incidence of invasive fungal infection was very high in the control groups of most of the included trials. Meta-analysis does not demonstrate a statistically significant effect on mortality. There are currently only limited data on the long-term neurodevelopmental consequences for infants exposed to this intervention. In addition, there is a need for further data on the effect of the intervention on the emergence of organisms with antifungal resistance.

Evaluation of efficacy of probiotics in prevention of candida colonization in a PICU-a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of probiotics in prevention of Candida colonization in a PICU.

DESIGN

Prospective double blinded, randomized controlled trial.

SETTING

PICU of a tertiary care teaching hospital in north India.

SUBJECTS

One hundred fifty children (106 boys, 44 girls), 3 months to 12 yrs old, on broad spectrum antibiotics for at least 48 hrs were randomized using computer-generated random numbers to receive probiotic mix (EUGI) (n = 75) or placebo (n = 75).

INTERVENTION

Patients received one sachet twice a day of either probiotics or placebo for 7 days. Probiotics contained Lactobacillus acidophillus, Lactobacillus rhamnosum, Bifidobacterium longum, Bifidobacterium bifidum, Saccharomyces boulardi, Saccharomyces thermophilus, fructo-oligosaccharides; and placebo-contained lactose packed in similar-looking sachets. Rectal swabs for fungal culture were taken at day 0, 7, and 14 of enrollment. Primary outcome measure was prevalence of rectal colonization with Candida on day 14 postenrollment; secondary outcomes were growth of Candida in urine (candiduria) and blood (candidemia). Patients were followed until completion of 14 days study period or death of patient.

RESULTS

Demographic and clinical variables were comparable in two groups. Prevalence of Candida colonization on day 0 was similar (15 of 75) in both the groups. On day 7, 27.9% (19 of 68) patients in the probiotic group and 42.6% (29 of 68) patients in the placebo group were colonized (relative risk 0.65; 95% confidence interval 0.41-1.05; p = 0.07), whereas, on day 14, colonization was observed in 31.3% (21 of 67) patients in the probiotic group and 50% (34 of 68) in the placebo group (relative risk 0.63; 95% confidence interval 0.41-0.96; p = 0.02). Thus, the relative reduction in prevalence of Candida colonization on day 7 and 14 in the probiotic group was 34.5% and 37.2%, respectively. The increase in number of colonized patients from day 0 to 7 and day 0 to 14 was significant in the placebo group (p = 0.004 and 0.001, respectively) but not in the probiotic group (p = 0.30 and 0.19, respectively; McNemar test). Candiduria was significantly less common in the probiotic group than in the placebo group (17.3% vs. 37.3%; relative risk 0.46; 95% confidence interval 0.26-0.82; p = 0.006). However, prevalence of candidemia did not differ significantly in two groups (1.6% in the probiotic group vs. 6.35% in placebo group; relative risk 0.46; 95% confidence interval 0.08-2.74; p = 0.39).

CONCLUSIONS

Supplementation with probiotics could be a potential strategy to reduce gastrointestinal Candida colonization and candiduria in critically ill children receiving broad spectrum antibiotics.

Role of probiotics in prevention of Candida infection in critically ill children

Candidiasis accounts for 10-20% of bloodstream infections in paediatric intensive care units (PICUs) and a significant increase in morbidity, mortality, and length of hospital stay. Enteric colonisation by Candida species is one of the most important risk factor for invasive candidiasis. The local defence mechanisms may be altered in critically ill patients, thus facilitating Candida overgrowth and candidiasis. Systemic antifungals have been proven to be effective in reducing fungal colonisation and invasive fungal infections, but their use is not without harms. Early restoration or maintenance of intestinal microbial flora using probiotics could be one of the important tools for reducing Candida infection. A few studies have demonstrated that probiotics are able to prevent Candida growth and colonisation in neonates, whereas their role in preventing invasive candidiasis in such patients is still unclear. Moreover, there are no published data on role of probiotics supplementation in the prevention of candidiasis in critically ill children beyond neonatal period. There are gap in our knowledge regarding efficacy, cost effectiveness, risk-benefit potential, optimum dose, frequency and duration of treatment of probiotics in prevention of fungal infections in critically ill children. Studies exploring and evaluating the role of probiotics in prevention of Candida infection in critically ill children are needed.

Antifungal therapy for newborn infants with invasive fungal infection

BACKGROUND

A variety of antifungal drugs, drug preparations and drug combinations are available to treat newborn infants with suspected or confirmed invasive fungal infection. There is a need to assess their relative merits.

OBJECTIVES

To assess the effect of treatment with different antifungal drugs, drug preparations or drug combinations on mortality and morbidity in newborn infants with suspected or confirmed invasive fungal infection.

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 (The Cochrane Library, 2012, Issue 2), MEDLINE, EMBASE, CINAHL (to March 2012), conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised control trials comparing one antifungal agent or combination of agents with another in newborn infants with suspected or confirmed invasive fungal infection.

DATA COLLECTION AND ANALYSIS

We extracted the data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author, and synthesis of data using risk ratio and risk difference.

MAIN RESULTS

We identified only one small trial in which 24 newborn infants participated. This trial compared the use of fluconazole versus amphotericin B (plus 5-fluorocytosine if fungal meningitis present). The trial did not detect a statistically significant effect on mortality (risk ratio 0.73; 95% confidence interval 0.26 to 2.05).

AUTHORS' CONCLUSIONS

There are insufficient data to inform practice. Large randomised controlled trials are required to compare antifungal drugs, drug preparations or drug combinations for treating newborn infants with invasive fungal infection.

Impact of routine fluconazole prophylaxis for premature infants with birth weights of less than 1250 grams in a developing country

Systemic fungal infections are associated with substantial case-morbidity and fatality rates in premature infants. Considerable evidence indicates that prophylaxis with fluconazole given to premature infants reduces the risk of invasive fungal infection. There is scant information from developing countries. A comparative study of 2 years, one with fluconazole prophylaxis and the other without was conducted in all premature babies weighing less than 1250 g at birth. Fluconazole was administered in 3 mg/kg doses, given every 48 hours, starting on day 3 of life, for a period of 6 weeks. Documented systemic Candida infection was the primary outcome. A total of 271 and 252 patients, respectively, were evaluated during the year before (control group) and after (treatment group) routine fluconazole prophylaxis. The control group developed 21 Candida infections (7.7%) while the treatment group had only 3 Candida infections (1.1%). This difference was statistically significant (P = 0.007; odds ratio, 0.13; 95% confidence interval, 0.03-0.47). The number needed to treat to prevent one case was 7. Although case-fatality rates for documented Candida infection were similar in both periods (76% vs. 67%), fewer deaths attributed to the fungal infection were noted in the prophylaxis year (6% vs. 1%, P = 0.003). Routine fluconazole prophylaxis given to premature infants of less than 1250 g at birth is associated with a significant impact on frequency of documented systemic Candida infections.

Once-weekly liposomal amphotericin B as Candida prophylaxis in very low birth weight premature infants: a prospective, randomized, open-label, placebo-controlled pilot study

OBJECTIVE

This study was conducted to evaluate once-weekly liposomal amphotericin B (L-AmB) for Candida prophylaxis in very low birth weight (VLBW) neonates.

METHODS

This prospective, randomized, open-label, placebo-controlled study included neonates who were <32 weeks' gestational age, <7 days old, and weighing <1500 g at birth. Subjects were randomized to receive L-AmB 5 mg/kg per week or placebo (dextrose water) and were followed until 6 weeks of age. Surveillance cultures were obtained at baseline, at 72 hours, and weekly thereafter. Study drug was continued until 6 weeks after birth or the discontinuation of high-risk treatments and invasive devices, whichever occurred first. Blood cultures were obtained as clinically indicated. The primary end point was development of Candida colonization by 6 weeks' postnatal age; secondary end points included development of invasive candidiasis and occurrence of treatment-related adverse events. Safety variables included renal and hepatic function tests, incidence of grade III-IV intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC), and mortality.

RESULTS

Forty subjects were enrolled and randomized to receive L-AmB (12 males, 8 females; 50% white) or placebo (12 males, 8 females; 35% white). Subjects were evenly distributed by gestational age, age at enrollment, birth weight, race, and sex. Consent was withdrawn after completion of study treatment in 1 subject (L-AmB); 1 subject in each study arm died during the study; and 3 subjects were transferred back to their referring institutions (1 L-AmB, 2 placebo). Thus, 17 subjects in each arm completed all study procedures, although all 40 subjects were evaluable. Colonization before administration of study drug was noted in 4 L-AmB subjects (20%) and 1 placebo subject (5%); 1 (5%) and 3 (15%) subjects in the respective groups developed colonization while receiving study drug. No L-AmB subjects and 1 placebo subject developed candidiasis. One subject in each group died; these deaths were not considered related to study drug or fungal infection. There were no clinical differences between groups in the incidence of grade III-IV IVH, NEC, hypokalemia, nephrotoxicity, need for platelet or packed red blood cell transfusion, or mortality.

CONCLUSIONS

L-AmB 5 mg/kg once weekly was generally well tolerated in these VLBW infants. The data did not allow evaluation of efficacy. A larger, multicenter, randomized clinical trial of L-AmB for Candida prophylaxis that is appropriately powered is warranted.

Efficacy of fluconazole prophylaxis for prevention of invasive fungal infection in extremely low birth weight infants

BACKGROUND

Invasive fungal infections (IFI) are an important cause of late-onset disease in extremely low birth weight (ELBW) infants. Despite prior trials of fluconazole prophylaxis in neonates, application of this regimen remains controversial. Review of our neonatal intensive care unit aggregate annual number of fungal isolates from sterile sites in ELBW infants from 1997 to 2006 suggested a significant decrease following the institution of routine prophylactic fluconazole in February 2002. We undertook a retrospective study to document the efficacy and adverse effects of routine fluconazole prophylaxis.

METHODS

ELBW infants admitted during 2000 to 2006 were divided into 2 groups: Control group-admitted before the institution of fluconazole prophylaxis, and Fluconazole group-admitted after institution of fluconazole prophylaxis. Primary outcome was the frequency of IFI. Secondary outcome was the frequency of cholestasis, which has been rarely reported with fluconazole use.

RESULTS

Data were extracted from 262 infant records: control 99, fluconazole 163. Baseline demographics and potentially confounding variables differed between the 2 groups with greater birth weight, greater gestational age, shorter durations of ventilation and central catheter use, and earlier start of feeding in the control group, reflecting healthier control infants. Frequency of IFI was 7.1% in the control group versus 1.8% in the fluconazole group, P = 0.045. Logistic regression revealed that fluconazole prophylaxis was independently associated with a lower risk of IFI. There was no difference in the frequency of cholestasis between the control and fluconazole groups.

CONCLUSIONS

Prophylactic administration of fluconazole to all ELBW infants was associated with significantly decreased rates of IFI without associated adverse effects.

Fluconazole Prophylaxis in High-Risk Neonates

OBJECTIVE

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

DATA SOURCES

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

DATA SELECTION AND DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

Neonatal Candida spp. infections: an update

Candida-related morbidity and mortality have increased in neonatal intensive care units (NICUs) in the last 20 years. Invasive fungal infections (IFIs) in preterm infants are associated with high severity, high attributable mortality, substantial morbidity and poor outcomes owing to the frequent association with late neurodevelopmental impairment and retinopathy of prematurity in the survivors. Preterm very-low birth weight infants in NICUs have a specific, increased risk for IFIs, mainly because up to 60% of them may become colonized during their first month of life. Prevention of Candida colonization and infection is the key in these settings of unique patients, and solid data have recently been added to the very first promising results obtained in the early 2000’s with administation of fluconazole. In a multicenter randomized trial, this azole caused a striking reduction in the incidences of Candida spp. colonization (from 33 to 9%) and infection (from 13.2 to 3.2%), with no occurrence of significant side-effects and no signs of selective resistance during the 15-month study period. New guidelines incorporating the recent multicenter results are urgently needed.

Use of Lactobacillus casei subspecies Rhamnosus GG and gastrointestinal colonization by Candida species in preterm neonates

Candida species increasingly cause morbidity and mortality in the premature infant in neonatal intensive care units, and the gut reservoir is the site from which dissemination most frequently starts in such patients. Specific antifungal prophylaxis is the most suitable strategy with which to limit the severity and the frequent neurodevelopmental impairment in survivors that is associated with neonatal invasive fungal infections. Recent interest has focused on the use of probiotics for the treatment of several diseases in neonatal patients. Pilot studies have implicated these organisms in necrotizing enterocolitis, sepsis, and urinary tract infections. Other applications of probiotic therapy in preterm neonates may also include the prevention of fungal colonization and of Candida-related disorders. Probiotics could provide an innovative and less invasive approach because they modify the bowel flora by colonizing the gastrointestinal tract. Basic research has shown that in mice models, the Lactobacillus casei subsp Rhamnosus GG (LGG) is effective in preventing Candida gut colonization and systemic dissemination. A pilot, randomized, double-blind, placebo-controlled trial in human preterm neonates has demonstrated that LGG administered in the first month of life significantly reduces enteric Candida colonization. The present article summarizes the state of the art about probiotics and Candida-related diseases in the preterm neonate and emphasizes the need for further investigations to determine unequivocally the possible role of LGG in the prevention and management of the fungal diseases in preterm neonates.

Selective fluconazole prophylaxis in high-risk babies to reduce invasive fungal infection

OBJECTIVES

To evaluate the impact of selective fluconazole prophylaxis on incidence of invasive fungal infection and emergence of fluconazole resistance in neonatal intensive care.

DESIGN

Retrospective study of very low birthweight (VLBW) babies (<1500 g birth weight) admitted to a neonatal intensive care unit (NICU) in the period 1 year before and after the implementation of an antifungal prophylaxis guideline.

PATIENTS

VLBW babies with an additional risk factor: colonisation of Candida species from surface sites with a central venous catheter; third generation cephalosporin treatment; or total duration of antibiotic treatment >10 days. Fluconazole protocol: Fluconazole 6 mg/kg for 3 weeks. Dose interval is every 72 h during the first 2 weeks of life. Thereafter, dose interval is reduced to every 48 h until 3 weeks old when daily fluconazole is given. Fluconazole is administered orally when enteral feeding achieved.

RESULTS

121 and 107 VLBW babies were admitted to the NICU in the year before and after the guideline was implemented, respectively. Data were available in 110 and 102 charts. 33/110 and 31/102 babies were eligible for fluconazole prophylaxis in the period before and after guideline implementation. 6/33 babies eligible for prophylaxis developed culture proven Candida sepsis before compared with no (0/31) babies after the guideline was implemented (p = 0.03). One baby (1/31) did develop probable Candida sepsis in the post guideline implementation period. During both study periods all Candida isolates remained fully susceptible to fluconazole.

CONCLUSIONS

Selective antifungal prophylaxis has reduced invasive fungal sepsis in one NICU without evidence of fluconazole resistance emerging.

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

BACKGROUND

Invasive fungal infection is an important cause of mortality and morbidity in very low birth weight infants. Early diagnosis is difficult, and treatment is often delayed. The available data are insufficient to conclude that topical/oral prophylaxis (usually nystatin and/or miconazole) prevents invasive fungal infection or mortality in very low birth weight infants. 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 STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Controlled Trials Register (The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

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

Data were extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author, and synthesis of data using relative risk, risk difference, and weighted mean difference. The pre-specified outcomes were death prior to hospital discharge, long-term neurodevelopment, incidence of invasive fungal infection, emergence of antifungal resistance, and adverse drug reactions.

MAIN RESULTS

Seven eligible trials enrolling a total of 638 participating infants were identified. Meta-analysis of data from four trials that compared prophylactic fluconazole versus placebo revealed a statistically significant reduction in the risk of invasive fungal infection in the infants who received prophylaxis [typical relative risk: 0.23 (95% confidence interval 0.11, 0.46); typical risk difference: -0.11 (95% confidence interval -0.16, -0.06); number needed to treat: 9 (95% confidence interval 6, 17)]. There was no statistically significant difference in the risk of death prior to hospital discharge [typical relative risk: 0.61 (95% confidence interval 0.37, 1.03); typical risk difference: -0.05 (95% confidence interval -0.11, -0.00)]. Only one trial reported long term neurodevelopmental outcomes. There were no statistically significant differences in the incidence of developmental delay, or motor or sensory neurological impairment in children assessed at a median age of 16 months. One small trial that compared systemic versus oral/topical prophylaxis did not detect a statistically significant effect on invasive fungal infection or mortality. Two trials compared different dosing regimens of prophylactic intravenous fluconazole. These 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 cautiously. The incidence of invasive fungal infection was very high in the control groups of some of the included trials. Furthermore, the trials may have been affected by ascertainment bias since use of prophylactic fluconazole may reduce the sensitivity of microbiological culture for detecting fungi in blood, urine, or cerebrospinal fluid. Meta-analysis does not demonstrate a statistically significant effect on overall mortality rates, but the 95% confidence interval around this estimate of effect is wide. 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.

Oral supplementation with Lactobacillus casei subspecies rhamnosus prevents enteric colonization by Candida species in preterm neonates: a randomized study

BACKGROUND

Colonization by Candida species is the most important predictor of the development of invasive fungal disease in preterm neonates, and the enteric reservoir is a major site of colonization. We evaluated the effectiveness of an orally supplemented probiotic (Lactobacillus casei subspecies rhamnosus; Dicoflor [Dicofarm spa]; 6 x 10(9) cfu/day) in the prevention of gastrointestinal colonization by Candida species in preterm, very low birth weight (i.e., < 1500-g) neonates during their stay in a neonatal intensive care unit.

METHODS

Over a 12-month period, a prospective, randomized, blind, clinical trial that involved 80 preterm neonates with a very low birth weight was conducted in a large tertiary neonatal intensive care unit. During the first 3 days of life, the neonates were randomly assigned to receive either an oral probiotic added to human (maternal or pooled donors') milk (group A) or human milk alone (group B) for 6 weeks or until discharge from the NICU, if the neonate was discharged before 6 weeks. On a weekly basis, specimens obtained from various sites (i.e., oropharyngeal, stool, gastric aspirate, and rectal specimens) were collected from all patients for surveillance culture, to assess the occurrence and intensity of fungal colonization in the gastrointestinal tract.

RESULTS

The incidence of fungal enteric colonization (with colonization defined as at least 1 positive culture result for specimens obtained from at least 1 site) was significantly lower in group A than in group B (23.1% vs. 48.8%; relative risk, 0.315 [95% confidence interval, 0.120-0.826]; P = .01). The numbers of fungal isolates obtained from each neonate (P = .005) and from each colonized patient (P = .005) were also lower in group A than in group B. L. casei subspecies rhamnosus was more effective in the subgroup of neonates with a birth weight of 1001-1500 g. There were no changes in the relative proportions of the different Candida strains. No adverse effects potentially associated with the probiotic were recorded.

CONCLUSIONS

Orally administered L. casei subspecies rhamnosus significantly reduces the incidence and the intensity of enteric colonization by Candida species among very low birth weight neonates.

Targeted short-term fluconazole prophylaxis among very low birth weight and extremely low birth weight infants

OBJECTIVES

To assess whether targeted short-term fluconazole prophylaxis reduces late-onset (>3 days of age) invasive fungal infection (IFI) among very low birth weight infants and extremely low birth weight (ELBW) infants and to assess mortality rates, toxicity, and costs associated with this intervention.

METHODS

An observational study of 2 subsequent epochs of inborn infants with birth weight of <1500 g or gestational age of <32 weeks, 1 before (control) and 1 after (fluconazole) initiation of routine targeted fluconazole prophylaxis in March 2003, was performed. Targeted fluconazole (3 mg/kg) prophylaxis was administered to infants for whom a decision was made to administer broad-spectrum antibiotics for >3 days.

RESULTS

IFI was observed for 13 (6.3%) of 206 infants in the control epoch and 2 (1.1%) of 178 in the fluconazole epoch, with a common odds ratio of 0.166. Logistic regression analysis taking into account all published factors (except for fungal colonization) showed that the fluconazole epoch was associated significantly with lower IFI rates. We observed no change in late (>3 days) mortality rates (11 of 206 infants in the control epoch vs 8 of 178 infants in the prophylaxis epoch). The mortality rate for ELBW infants with IFI was low (15%) in our study. Fluconazole was administered to 81% of ELBW infants, who received a median of 8 doses, and 41% of larger infants, who received a median of 5 doses. The intervention was cost-effective, and the effective number needed to treat to prevent 1 IFI was 10.

CONCLUSIONS

This study suggests that targeted short-course fluconazole prophylaxis in very low birth weight and ELBW infants may be efficacious and cost effective.

Prophylactic fluconazole is effective in preventing fungal colonization and fungal systemic infections in preterm neonates: a single-center, 6-year, retrospective cohort study

OBJECTIVE

Despite the promising preliminary results observed in extremely low birth weight (ELBW) populations, the use of fluconazole to prevent fungal colonization and infection in preterm neonates in the NICU is still an open question and not yet recommended as a standard of care. We have reviewed our 6-year series to assess the effectiveness and safety of this form of prophylaxis.

METHODS

This retrospective study consisted of 465 neonates who weighed < 1500 g at birth and were admitted to our NICU in the period 1998-2003. Those who were born between 1998 and 2000 and did not receive fluconazole prophylaxis (group A, n = 240) were compared with those who were born between 2001 and 2003 and treated with fluconazole until the 30th day of life (45th for neonates < 1000 g at birth; group B, n = 225). Weekly surveillance cultures were obtained from all patients. Incidence of fungal colonization, incidence of systemic fungal infection (SFI), rate of progression from colonization to infection, and mortality rates attributable to fungi were calculated for both groups and separately for neonates who were < 1000 g (ELBW) and were 1001 to 1500 g (NE-VLBW) at birth.

RESULTS

Overall fungal colonization was significantly lower in group B (24.0%) than in group A (43.8%; relative risk [RR]: 0.406; 95% confidence interval [CI]: 0.273-0.605). The same was true of neonates with colonization in multiple sites (2.6% vs 5.8%) and of those with colonization from high-risk sites (5.8% vs 19.2%). SFI incidence was significantly lower in group B (10 of 225 cases; 4.4%) than in group A (40 of 240 cases; 16.7%; RR: 0.233; 95% CI: 0.113-0.447). Reduction of both colonization and SFI in group B was greater in the ELBW neonates and also significant in the NE-VLBW neonates. Rate of progression from colonization to infection was significantly lower in group B (0.17 vs 0.38; RR: 0.369; 95% CI: 0.159-0.815). Crude mortality rate attributable to Candida species was 1.7% (4 of 240) in group A vs 0% (0 of 225) in group B. Overall mortality rate (any cause before hospital discharge) was similar in the two groups (11.2% vs 10.6%), but in colonized infants (n = 159), it was significantly lower in group B (3.7% vs 18.1%; RR: 0.174; 95% CI: 0.039-0.778). The incidence of natively fluconazole-resistant fungal species did not increase over the years, and patterns of sensitivity to fluconazole remained the same. No adverse reaction related to fluconazole occurred.

CONCLUSIONS

Prophylactic fluconazole significantly reduces the incidence of colonization and systemic infection by Candida species in both ELBW and NE-VLBW neonates and decreases the rates of progression from initial colonization to massive colonization and to systemic infection. All VLBW neonates may benefit from fluconazole prophylaxis.

Systemic antifungal drugs for invasive fungal infection in preterm infants

BACKGROUND

Invasive fungal infection is an increasingly common cause of mortality and morbidity in preterm infants. In addition to amphotericin B, a variety of newer antifungal drugs and drug preparations are available for treatment. There is a need to assess their relative merits.

OBJECTIVES

In preterm infants with suspected or confirmed invasive fungal infection, does treatment with newer systemic antifungal drugs or drug preparations, versus conventional amphotericin B alone, reduce mortality and adverse neurodevelopmental outcomes?

SEARCH STRATEGY

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, Issue 3, 2003), MEDLINE (1966 - August 2003), EMBASE (1980 - August 2003), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised control trials comparing one antifungal agent or combination of agents with another in preterm infants with suspected or confirmed invasive fungal infection.

DATA COLLECTION AND ANALYSIS

We extracted the data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author, and synthesis of data using relative risk and risk difference. The pre-specified outcomes were death prior to hospital discharge, longer term neurodevelopment, and adverse drug reactions resulting in discontinuation of therapy.

MAIN RESULTS

We identified only one small trial. This study compared the use of fluconazole with amphotericin B (5-Fluorocytosine added if fungal meningitis present). Three of 11 infants who were treated with fluconazole died and four of 10 infants who were treated with amphotericin B died : Relative risk: 0.68 (95% confidence interval 0.20, 2.33), Risk Difference -0.13 (95% confidence interval -0.53, 0.27) There were not any data on longer term outcomes.

REVIEWER'S CONCLUSIONS

From this one small study there are insufficient data to favour one antifungal agent or combination to reduce mortality and adverse neurodevelopmental outcomes in preterm infants with suspected or confirmed invasive fungal infection. A large randomised controlled trial is required to compare the newer antifungal preparations with conventional amphotericin B. Further research may also determine the relative convenience and cost effectiveness of the available drugs.

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

BACKGROUND

Invasive fungal infection is an increasingly common cause of mortality and morbidity in very low birth weight infants. As the diagnosis is often difficult, and treatment is often delayed, there is a need to assess whether antifungal prophylaxis is beneficial.

OBJECTIVES

To assess whether prophylactic intravenous antifungal therapy reduces mortality and adverse neurodevelopmental outcomes in very low birth weight infants.

SEARCH STRATEGY

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, Issue 4, 2003), MEDLINE (1966 - October 2003), EMBASE (1980 - October 2003), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised controlled trials that compared the effect of prophylactic intravenous antifungal therapy versus placebo, or no drug, or another antifungal agent, in very low birth weight infants.

DATA COLLECTION AND ANALYSIS

We extracted the data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author, and synthesis of data using relative risk and risk difference. The pre-specified outcomes were death prior to hospital discharge, longer term neurodevelopment, incidence of invasive fungal infection, emergence of antifungal resistance, and adverse drug reactions.

MAIN RESULTS

We identified three eligible trials enrolling a total of 214 infants. Each of the trials compared the effect of prophylactic intravenous fluconazole versus placebo. Two of the trials reported death prior to hospital discharge as an outcome. 29 of the 203 infants recruited to these studies died. Meta-analysis revealed a statistically significantly reduced risk of death prior to hospital discharge for the infants who received fluconazole prophylaxis: typical relative risk: 0.44 (95% confidence interval 0.21, 0.91); typical risk difference: -0.11 (95% confidence interval -0.21, -0.02); number needed to treat: 9 (95% confidence interval 5, 50). None of the trials reported data on longer term outcomes.

REVIEWER'S CONCLUSIONS

We have found some evidence that prophylactic intravenous fluconazole reduces mortality prior to hospital discharge in very low birth weight infants. The meta-analysis suggests that there will be one fewer death in every nine infants treated with this intervention, but the 95% confidence interval around this estimate of effect is wide. The longer term neurodevelopmental consequences for infants exposed to this intervention remain to be determined. It will be important to identify any subgroups of very low birth weight infants that receive the most benefit from this intervention. There is also a need for further data on the effect of the intervention on the emergence of organisms with stable antifungal resistance.