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Smith B, Rajapakse N, Sauer HE, Ellsworth K, Dinnes L, Madigan T. A Quality Improvement Project Aimed at Standardizing the Prescribing of Fluconazole Prophylaxis in a Level IV Neonatal Intensive Care Unit. Pediatr Qual Saf 2022; 7:e579. [PMID: 38585424 PMCID: PMC10997225 DOI: 10.1097/pq9.0000000000000579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 06/27/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Invasive candidiasis has a high morbidity and mortality among premature neonates. Antifungal prophylaxis with fluconazole significantly lowers the risk of invasive fungal infection in this population. We noted the use of fluconazole prophylaxis in our level IV neonatal intensive care unit (NICU) was variable and sought to standardize prescribing of prophylactic fluconazole. Methods We formed a multidisciplinary team to develop an evidence-based protocol using literature and expert consensus to guide appropriate use of fluconazole prophylaxis in our level IV NICU. After determining baseline fluconazole prophylaxis prescribing before protocol implementation, we used plan-do-study-act (PDSA) cycles to introduce protocolized prescribing and incorporate it into daily practice. A 6-month intervention phase was followed by a 2-year control phase, in which monthly audits were performed to evaluate protocol adherence. Results were displayed in a statistical process control chart. Results Before protocol implementation, fluconazole prophylaxis prescribing adhered to the protocol in 81% of patients. During the first PDSA cycle, adherence increased significantly to 94.5% (86/91 patients), which further increased to 98.7% (74/75 patients) during the second PDSA cycle and remained at 96% (120/125 patients) during the control phase (P < 0.0001). Conclusions A multidisciplinary group-designed protocol was successful in standardizing fluconazole prophylaxis prescribing for infants in the level IV NICU. Adherence to protocol was high following implementation and was sustained for the duration of the project. There were no cases of invasive candidiasis noted.
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Affiliation(s)
- Brandi Smith
- From the Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Nipunie Rajapakse
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hannah E. Sauer
- Pharmacy Department, Texas Children’s Hospital, Houston, Texas
| | | | - Laura Dinnes
- From the Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Theresa Madigan
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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2
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Fluconazole Population Pharmacokinetics after Fosfluconazole Administration and Dosing Optimization in Extremely Low-Birth-Weight Infants. Microbiol Spectr 2022; 10:e0195221. [PMID: 35266811 PMCID: PMC9045325 DOI: 10.1128/spectrum.01952-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
A prospective single-center study was conducted to characterize the pharmacokinetics (PK) of fluconazole (FLCZ) in extremely low-birth-weight infants (ELBWIs) who received fosfluconazole (F-FLCZ). Intravenous F-FLCZ was administered at a dose of 3 mg/kg of body weight every 72 h during the first 2 weeks of life, every 48 h during the third and fourth weeks of life, and every 24 h after 5 weeks of life. Blood samples from ELBWIs treated with F-FLCZ were collected using scavenged samples. The concentration of FLCZ was determined using liquid chromatography-tandem mass spectrometry. The population pharmacokinetic model was established using Phenix NLME 8.2 software. In total, 18 ELBWIs were included in this analysis. Individual PK parameters were determined by a one-compartment analysis with first-order conversion. Postmenstrual age (PMA), serum creatinine (SCr), and alkaline phosphatase were considered covariates for clearance (CL). The mean population CL and the volume of distribution were 0.011 L/h/kg0.75 and 0.95 L/kg, respectively. Simulation assessments with the final model revealed that the current regimen (3 mg/kg every 72 h) could achieve the proposed target FLCZ trough concentration (>2 μg/mL) in 43.3% and 72.2% of infants with a PMA of ≥37 and 30 to 36 weeks, respectively, and an SCr level of <0.5 mg/dL. Shortened dosing intervals (every 48 or 24 h) might improve the probability of target attainment. This study was the first to assess the PK of F-FLCZ in ELBWI, as well as the first to provide fundamental information about FLCZ exposure after F-FLCZ administration, with the goal of facilitating dose optimization in the ELBWI population. IMPORTANCE Invasive fungal infection is an important cause of mortality and morbidity in very preterm or very-low-birth-weight infants. In order to limit the risk of invasive fungal infections in this population, the administration of fluconazole is generally recommended for extremely low-birth-weight infants admitted to a neonatal intensive care unit with a Candida species colonization prevalence rate of >10%, under the guidelines of the Infectious Diseases Society of America. Fosfluconazole can reduce the volume of solution required for intravenous therapy compared to fluconazole because it has increased solubility, which is a major advantage for infants undergoing strict fluid management. To date, no study has demonstrated the fluconazole pharmacokinetics after fosfluconazole administration in neonates and infants, and this needs to be clarified. Here, we characterized the pharmacokinetics of fluconazole in extremely low-birth-weight infants who received F-FLCZ and explored the appropriate dosage in this patient population.
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3
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Abdel-Haq N, Smith SM, Asmar BI. Micafungin injection for the treatment of invasive candidiasis in pediatric patients under 4 months of age. Expert Rev Anti Infect Ther 2021; 20:493-505. [PMID: 34882043 DOI: 10.1080/14787210.2022.2013807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Neonates and young infants with invasive candidiasis are particularly at increased risk of dissemination including hematogenous Candida meningoencephalitis. The echinocandins including micafungin have emerged as a preferred agent in most cases of candidemia and invasive candidiasis but data in pediatric patients under 4 months of age are limited. AREAS COVERED In this report, we review the micafungin use in infants younger than 4 months of age. Animal studies as well as clinical data that support its use in neonatal candidiasis are reviewed. In addition, the status of FDA approval and the rationale of micafungin dosing recommendations in infants <4 months are discussed. EXPERT OPINION A dose of 4 mg/kg was approved for treatment of candidemia, Candida peritonitis and abscesses excluding meningoencephalitis or ocular involvement in patients younger than 4 months of age. However, because of the risk of central nervous system dissemination as well as the difficulty in establishing this diagnosis, this dose is inadequate to treat ill infants with candidemia. More studies are needed to establish the safety and efficacy of micafungin daily dose of at least 10 mg/kg in infants younger than 4 months of age when hematogenous Candida meningoencephalitis or ocular involvement cannot be excluded.
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Affiliation(s)
- Nahed Abdel-Haq
- Division of Infection Diseases, Children's Hospital of Michigan, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Department of Pediatrics, Central Michigan University, Mount Pleasant, MI, USA.,Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | | | - Basim I Asmar
- Division of Infection Diseases, Children's Hospital of Michigan, Detroit, MI, USA.,Children's Hospital of Michigan, Detroit, MI, USA.,Department of Pediatrics, Central Michigan University, Mount Pleasant, MI, USA.,Department of Pediatrics, Wayne State University, Detroit, MI, USA
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Kilpatrick R, Scarrow E, Hornik C, Greenberg RG. Neonatal invasive candidiasis: updates on clinical management and prevention. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 6:60-70. [PMID: 34672994 DOI: 10.1016/s2352-4642(21)00272-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/30/2021] [Accepted: 08/13/2021] [Indexed: 01/15/2023]
Abstract
Neonatal invasive candidiasis is an important cause of morbidity and mortality in preterm infants. The incidence of invasive candidiasis in this population has been declining in high-income settings, largely due to preventive measures, although there are still considerable variations in incidence between health-care centres. Surveillance data and large, multicentre studies in lower-income settings are not available, although preventive measures in these settings have been shown to decrease the incidence of neonatal invasive candidiasis. Understanding risk factors and pathogenesis are key to the prevention of invasive candidiasis. The difficulty of a definitive diagnosis of invasive candidiasis and the high risk for death or substantial neurodevelopmental impairment, even with appropriate treatment, further increase the need for effective preventive measures. In this Review, we examine the pathogenesis, clinical presentation, and diagnosis of invasive candidiasis. We highlight commonly used and emerging preventive and prophylactic measures, including standardised central line care, antibiotic stewardship, antifungal prophylaxis, and probiotics. Finally, we provide updates on empirical treatment, clinical management in confirmed cases of invasive candidiasis, and antifungal pharmacotherapy.
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Affiliation(s)
- Ryan Kilpatrick
- Department of Pediatrics, Duke Clinical Research Institute, Durham, NC, USA
| | - Evelyn Scarrow
- Department of Pediatrics, Duke Clinical Research Institute, Durham, NC, USA
| | - Chi Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Durham, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke Clinical Research Institute, Durham, NC, USA.
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5
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Robati Anaraki M, Nouri-Vaskeh M, Abdoli Oskoei S. Fluconazole prophylaxis against invasive candidiasis in very low and extremely low birth weight preterm neonates: a systematic review and meta-analysis. Clin Exp Pediatr 2021; 64:172-179. [PMID: 32683818 PMCID: PMC8024115 DOI: 10.3345/cep.2019.01431] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/29/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Evidence shows that fluconazole prophylaxis is an effective treatment against invasive fungal infections in preterm neonates, however, the most efficient schedule of fluconazole prophylaxis for the colonization and mortality of invasive candidiasis (IC) is unknown. PURPOSE This systematic review and meta-analysis aimed to assess the efficiency of different prophylactic fluconazole schedules in controlling IC colonization, infection, and mortality in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants in neonatal intensive care units. METHODS We searched the PubMed, Scopus, Embase, and Cochrane databases using the keywords "candida," "invasive candidiasis," "IC," "fluconazole prophylaxis," "preterm infants," "very low birth weight infants," "VLBW," "extremely low birth weight," and "ELBW." RESULTS Mortality was significantly decreased in a metaanalysis of studies using different fluconazole prophylaxis regimens. The meta-analysis also indicated a significant decrease in the incidence of IC-associated mortality in ELBW infants using the same fluconazole prophylaxis schedules. CONCLUSION Future studies should explore the effectiveness of other different fluconazole prophylaxis schedules on IC colonization, infection, and mortality.
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Affiliation(s)
- Mahmoud Robati Anaraki
- Dental and Periodontal Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Prosthodontics, Dental School, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoud Nouri-Vaskeh
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shahram Abdoli Oskoei
- Pediatric Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Hornik CD, Bondi DS, Greene NM, Cober MP, John B. Review of Fluconazole Treatment and Prophylaxis for Invasive Candidiasis in Neonates. J Pediatr Pharmacol Ther 2021; 26:115-122. [PMID: 33603574 PMCID: PMC7887891 DOI: 10.5863/1551-6776-26.2.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 09/17/2020] [Indexed: 01/29/2023]
Abstract
Invasive candidiasis accounts for approximately 10% of nosocomial infections in preterm infants, with an incidence of 1% to 4% among neonatal intensive care unit (NICU) admissions and a mortality as high as 20% to 30%. These outcomes warrant improved treatment and prevention strategies for infants at highest risk. The Infectious Diseases Society of America provides guidelines on antifungal medications for the prophylaxis and treatment of candidiasis in NICUs; however, there are still variations in practice on the use of fluconazole for prophylaxis and treatment of invasive candidiasis. This review provides specific information regarding fluconazole activity, pharmacokinetics, and a literature evaluation of dosing strategies and comparisons to other treatments in the neonatal population.
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Abstract
Vesicles, pustules and vesiculopustules are frequent in newborns and infants and mostly self-limiting. In order to differentiate the rare life-threatening diseases and to therefore initiate the treatment in a timely manner, knowledge of vesicular, pustular and vesiculopustular dermatoses in early childhood is necessary.
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Affiliation(s)
- Regina Fölster-Holst
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Rosalind-Franklin-Straße 7, 24105, Kiel, Deutschland.
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8
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Dima M, Enatescu I, Craina M, Petre I, Iacob ER, Iacob D. First neonates with severe acute respiratory syndrome coronavirus 2 infection in Romania: Three case reports. Medicine (Baltimore) 2020; 99:e21284. [PMID: 32871986 PMCID: PMC7437790 DOI: 10.1097/md.0000000000021284] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, which quickly spread throughout the world, has been putting medical workers all over the world in difficulty because of the high number of cases combined with the lack of information about the disease. Although pediatric cases are rare, the group age under 12 months has been in general more susceptible to develop severe forms of the disease compared with the patients in the age interval of 1 to 18 years. PATIENT CONCERNS Three newborns have been tested positive for SARS-CoV-2 infection. One of them presented bilateral decreased air entry, while the other 2 had no respiratory symptomatology. All 3 developed diaper erythema and oral candidiasis. DIAGNOSIS For building up the report, newborns that were positive for coronavirus disease 2019 (COVID-19) infection were included in the case series. The chest X-ray of the symptomatic patient revealed a medium degree of hilar parenchymal infiltration and a slight infiltration of the visceral pleura. INTERVENTIONS The patients were admitted in our isolated neonatology ward. All of them received antifungal treatment for the oral candidiasis and topic cream for diaper erythema. The symptomatic patient also received prophylactic antibiotherapy, human immunoglobulins, aminophylline, and parenteral nutrition. OUTCOMES All 3 neonates were discharged after 2 consecutive negative tests for SARS-CoV-2. Patients 1 and 2 fully recovered, whereas the condition of patient 3 improved. LESSONS Even if there are only a few reported cases of neonates infected with COVID-19 and most of them present mild manifestations, newborns need a more careful insight because of the nonspecific symptomatology.
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Affiliation(s)
| | | | | | | | - Emil Radu Iacob
- Department of Pediatric Surgery, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
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9
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Scott BL, Hornik CD, Zimmerman K. Pharmacokinetic, efficacy, and safety considerations for the use of antifungal drugs in the neonatal population. Expert Opin Drug Metab Toxicol 2020; 16:605-616. [PMID: 32508205 DOI: 10.1080/17425255.2020.1773793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Invasive fungal infections are an important cause of morbidity and mortality in infants, particularly in extreme prematurity. Successful systemic treatment requires consideration of antifungal efficacy, safety, and pharmacokinetics, including optimization of dosing in this population. AREAS COVERED This review summarizes published pharmacokinetic data on four classes of antifungal agents used in the neonatal population. Alterations in absorption, distribution, drug metabolism and clearance in infants compared to adult populations are highlighted. Additionally, pharmacodynamics, safety, and therapeutic drug monitoring are discussed. Recent advancements in neonatal antifungal pharmacotherapies are examined, with emphasis on clinical application. EXPERT OPINION Over the last two decades, published studies have provided increased knowledge on pharmacokinetic considerations in the neonatal population. Future research should focus on filling in the knowledge gaps that remain regarding the benefits and risks of combination antifungal therapy, the rising use of micafungin for invasive candidiasis given its fungicidal activity against polyene and azole-resistant Candida species and its minimal adverse effect profile, and the need for pharmacokinetic and safety data of broad spectrum triazoles, like voriconazole and posaconazole, in infants. Furthermore, efforts should focus on well-designed trials, including population pharmacokinetic studies, to develop dosing recommendations with subsequent implementation into clinical practice.
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Affiliation(s)
- Briana L Scott
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA
| | - Chi D Hornik
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA.,Duke University School of Medicine, Duke Clinical Research Institute , Durham, NC, USA
| | - Kanecia Zimmerman
- Department of Pediatrics, Division of Critical Care Medicine, Duke University Medical Center , Durham, NC, USA.,Duke University School of Medicine, Duke Clinical Research Institute , Durham, NC, USA
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10
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Population Pharmacokinetic Study of Prophylactic Fluconazole in Preterm Infants for Prevention of Invasive Candidiasis. Antimicrob Agents Chemother 2019; 63:AAC.01960-18. [PMID: 30910892 DOI: 10.1128/aac.01960-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 03/14/2019] [Indexed: 12/18/2022] Open
Abstract
Fluconazole is an antifungal agent with reported evidence for its prophylactic effect against systemic fungal infection in preterm infants. The aim of this study was to build a population pharmacokinetic model to evaluate the pharmacokinetic characteristics of intravenous and oral fluconazole in preterm infants with the current prophylactic fluconazole dosing regimen. A pharmacokinetic model was developed using 301 fluconazole concentrations from 75 preterm infants with a baseline body weight (WT) ranging from 0.5 to 1.5 kg and an estimated glomerular filtration rate (eGFR) ranging from 12.9 to 58.5 ml/min/1.73 m2 Eligible infants received an intravenous or oral dose of 3 mg/kg of body weight of fluconazole, twice weekly with a ≥72-h dose interval, for 4 weeks. The model was qualified with basic goodness-of-fit diagnostics, visual predictive checks, and bootstrapping. The fluconazole pharmacokinetics was well described with a one-compartment linear model with a proportional residual error. The population clearance (CL) and volume of distribution (V) were derived as 0.0197 × (WT/1.00)0.746 × (eGFR/25.0)0.463 × exp(η) and 1.04 × WT × exp(η), respectively. Such covariate analyses augment the awareness of the need for personalized dosing in preterm infants. (This study has been registered at ClinicalTrials.gov under identifier NCT01683760).
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11
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Autmizguine J, Smith PB, Prather K, Bendel C, Natarajan G, Bidegain M, Kaufman DA, Burchfield DJ, Ross AS, Pandit P, Schell WA, Gao J, Benjamin DK. Effect of fluconazole prophylaxis on Candida fluconazole susceptibility in premature infants. J Antimicrob Chemother 2018; 73:3482-3487. [PMID: 30247579 PMCID: PMC6927883 DOI: 10.1093/jac/dky353] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/06/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Extremely premature infants are at high risk of developing invasive candidiasis; fluconazole prophylaxis is safe and effective for reducing invasive candidiasis in this population but further study is needed. We sought to better understand the effect of prophylactic fluconazole on a selection of fluconazole-resistant Candida species. METHODS We evaluated the susceptibility to fluconazole of Candida isolates from premature infants (<750 g birth weight) enrolled in a multicentre, randomized, placebo-controlled trial of fluconazole prophylaxis. Candida species were isolated through surveillance cultures at baseline (study day 0-7), period 1 (study day 8-28) and period 2 (study day 29-49). Fluconazole MICs were determined for all Candida isolates. RESULTS Three hundred and sixty-one infants received fluconazole (n = 188) or placebo (n = 173). After the baseline period, Candida colonization was significantly lower in the fluconazole group compared with placebo during periods 1 (5% versus 27%; P < 0.001) and 2 (3% versus 27%; P < 0.001). After the baseline period, two infants (1%) were colonized with at least one fluconazole-resistant Candida in each group. Median fluconazole MIC was similar in both treatment groups at baseline and period 1. However, in period 2, median MIC was higher in the fluconazole group compared with placebo (1.00 versus 0.50 mg/L, P = 0.01). There was no emergence of resistance observed and no patients developed invasive candidiasis with a resistant Candida isolate. CONCLUSIONS Fluconazole prophylaxis decreased Candida albicans and 'non-albicans' Candida colonization and was associated with a slightly higher fluconazole MIC for colonizing Candida isolates.
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Affiliation(s)
- Julie Autmizguine
- Department of Pharmacology and Physiology, Université de Montréal, Montreal, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Canada
- Research Center, CHU Ste-Justine, Montréal, Canada
| | - P Brian Smith
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Kristi Prather
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | | | | | | | | | - Ashley S Ross
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Paresh Pandit
- Children’s Hospital of Philadelphia at Vitua West Jersey Hospital Voorhees, Voorhees, NJ, USA
| | - Wiley A Schell
- Department of Medicine, Duke University, Durham, NC, USA
| | - Jamie Gao
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Daniel K Benjamin
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Corresponding author. Duke University Medical Center, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA. Tel:+1-919-668-7081; Fax: +1-919-668-7058; E-mail:
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12
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Pemán J, Ruiz-Gaitán A. Candidemia from urinary tract source: the challenge of candiduria. Hosp Pract (1995) 2018; 46:243-245. [PMID: 30334630 DOI: 10.1080/21548331.2018.1538623] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/17/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Javier Pemán
- a Microbiology Department , Hospital Universitari i Politècnic La Fe; Severe Infection Research Group, Health Research Institute Hospital La Fe , Valencia , ( Spain )
| | - Alba Ruiz-Gaitán
- b Severe Infection Research Group , Health Research Institute Hospital La Fe , Valencia , ( Spain )
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13
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Iosifidis E, Papachristou S, Roilides E. Advances in the Treatment of Mycoses in Pediatric Patients. J Fungi (Basel) 2018; 4:E115. [PMID: 30314389 PMCID: PMC6308938 DOI: 10.3390/jof4040115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/05/2018] [Accepted: 10/07/2018] [Indexed: 12/16/2022] Open
Abstract
The main indications for antifungal drug administration in pediatrics are reviewed as well as an update of the data of antifungal agents and antifungal policies performed. Specifically, antifungal therapy in three main areas is updated as follows: a) Prophylaxis of premature neonates against invasive candidiasis; b) management of candidemia and meningoencephalitis in neonates; and c) prophylaxis, empiric therapy, and targeted antifungal therapy in children with primary or secondary immunodeficiencies. Fluconazole remains the most frequent antifungal prophylactic agent given to high-risk neonates and children. However, the emergence of fluconazole resistance, particularly in non-albicans Candida species, should be considered during preventive or empiric therapy. In very-low birth-weight neonates, although fluconazole is used as antifungal prophylaxis in neonatal intensive care units (NICU's) with relatively high incidence of invasive candidiasis (IC), its role is under continuous debate. Amphotericin B, primarily in its liposomal formulation, remains the mainstay of therapy for treating neonatal and pediatric yeast and mold infections. Voriconazole is indicated for mold infections except for mucormycosis in children >2 years. Newer triazoles-such as posaconazole and isavuconazole-as well as echinocandins, are either licensed or under study for first-line or salvage therapy, whereas combination therapy is kept for refractory cases.
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Affiliation(s)
- Elias Iosifidis
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
| | - Savvas Papachristou
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
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14
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Autmizguine J, Tan S, Cohen-Wolkowiez M, Cotten CM, Wiederhold N, Goldberg RN, Adams-Chapman I, Stoll BJ, Smith PB, Benjamin DK. Antifungal Susceptibility and Clinical Outcome in Neonatal Candidiasis. Pediatr Infect Dis J 2018; 37:923-929. [PMID: 29369937 PMCID: PMC6057841 DOI: 10.1097/inf.0000000000001913] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Invasive candidiasis is an important cause of sepsis in extremely low birth weight infants (ELBW, < 1000 g), is often fatal, and frequently results in neurodevelopmental impairment (NDI) among survivors. We sought to assess the antifungal minimum inhibitory concentration (MIC) distribution for Candida in ELBW infants and evaluate the association between antifungal resistance and death or NDI. METHODS This was a secondary analysis of a National Institute of Child Health and Human Development Neonatal Research Network study. MIC values were determined for fluconazole, amphotericin B and micafungin. NDI was assessed at 18-22 months adjusted age using the Bayley Scales of Infant Development. An infant was defined as having a resistant Candida isolate if ≥ 1 positive cultures from normally sterile sites (blood, cerebrospinal fluid, or urine) were resistant to ≥ 1 antifungal agent. In addition to resistance status, we categorized fungal isolates according to MIC values (low and high). The association between death/NDI and MIC level was determined using logistic regression, controlling for gestational age and Bayley Scales of Infant Development (II or III). RESULTS Among 137 ELBW infants with IC, MICs were determined for 308 isolates from 110 (80%) infants. Three Candida isolates from 3 infants were resistant to fluconazole. None were resistant to amphotericin B or micafungin. No significant difference in death, NDI, or death/NDI between groups with low and high MICs was observed. CONCLUSIONS Antifungal resistance was rare among infecting Candida isolates, and MIC level was not associated with increased risk of death or NDI in this cohort of ELBW infants.
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MESH Headings
- Amphotericin B/pharmacology
- Antifungal Agents/pharmacology
- Antifungal Agents/therapeutic use
- Candida/drug effects
- Candida/isolation & purification
- Candidiasis, Invasive/complications
- Candidiasis, Invasive/drug therapy
- Candidiasis, Invasive/mortality
- Cohort Studies
- Drug Resistance, Fungal
- Female
- Fluconazole/pharmacology
- Gestational Age
- Humans
- Infant
- Infant, Extremely Low Birth Weight
- Infant, Newborn
- Infant, Newborn, Diseases/drug therapy
- Infant, Newborn, Diseases/microbiology
- Intensive Care Units, Neonatal/statistics & numerical data
- Male
- Micafungin/pharmacology
- Microbial Sensitivity Tests
- Neurodevelopmental Disorders/etiology
- Prospective Studies
- Sepsis/complications
- Sepsis/microbiology
- Sepsis/mortality
- Treatment Outcome
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Affiliation(s)
- Julie Autmizguine
- From the Department of Pharmacology and Physiology, Université de Montréal, Montréal, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Canada
- Department of Pediatrics, Duke University, Durham, NC
| | - Sylvia Tan
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
| | | | | | - Nathan Wiederhold
- University of Texas Health Science Center at San Antonio, San Antonio, TX
| | | | | | - Barbara J Stoll
- Department of Pediatrics, Emory University, Atlanta, GA
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX
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15
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Benedict K, Roy M, Kabbani S, Anderson EJ, Farley MM, Harb S, Harrison LH, Bonner L, Wadu VL, Marceaux K, Hollick R, Beldavs ZG, Zhang AY, Schaffner W, Graber CR, Derado G, Chiller TM, Lockhart SR, Vallabhaneni S. Neonatal and Pediatric Candidemia: Results From Population-Based Active Laboratory Surveillance in Four US Locations, 2009-2015. J Pediatric Infect Dis Soc 2018. [PMID: 29522195 DOI: 10.1093/jpids/piy009] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Candida is a leading cause of healthcare-associated bloodstream infections in the United States. Infants and children have unique risk factors for candidemia, and the Candida species distribution in this group is different that among adults; however, candidemia epidemiology in this population has not been described recently. METHODS We conducted active population-based candidemia surveillance in 4 US metropolitan areas between 2009 and 2015. We calculated incidences among neonates (0-30 days old), infants (0-364 days old), and noninfant children (1-19 years old), documented their clinical features and antifungal drug resistance. RESULTS We identified 307 pediatric candidemia cases. Incidence trends varied according to site, but overall, the incidence in neonates decreased from 31.5 cases/100000 births in 2009 to 10.7 to 11.8 cases/100000 births between 2012 and 2015, the incidence in infants decreased from 52.1 cases/100000 in 2009 to 15.7 to 17.5 between 2012 and 2015, and the incidence in noninfant children decreased steadily from 1.8 cases/100000 in 2009 to 0.8 in 2014. Common underlying conditions were prematurity in neonates (78%), surgery in nonneonate infants (38%), and malignancy in noninfant children (28%). Most neonate cases were caused by C albicans (67%), whereas non-C. albicans species accounted for 60% of cases in nonneonate infants and noninfant children. Fluconazole and echinocandin resistance rates were low overall. Thirty-day crude mortality was 13%. CONCLUSIONS The incidence of candidemia among neonates and infants declined after 2009 but remained stable from 2012 to 2015. Antifungal drug resistance is uncommon. Reasons for the lack of recent declines in neonatal and infant candidemia deserve further exploration. In this article, we describe the epidemiology of candidemia in children in the United States and on the basis of data collected as part of US Centers for Disease Control and Prevention active population-based surveillance. Trends in incidence, clinical characteristics, species distribution, and resistance rates are presented.
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Affiliation(s)
- Kaitlin Benedict
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monika Roy
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah Kabbani
- Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center, Atlanta Research and Education Foundation, and Emory University School of Medicine, Georgia
| | - Evan J Anderson
- Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center, Atlanta Research and Education Foundation, and Emory University School of Medicine, Georgia
| | - Monica M Farley
- Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center, Atlanta Research and Education Foundation, and Emory University School of Medicine, Georgia
| | - Sasha Harb
- Georgia Emerging Infections Program, Atlanta Veterans Affairs Medical Center, Atlanta Research and Education Foundation, and Emory University School of Medicine, Georgia
| | - Lee H Harrison
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lindsay Bonner
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Vijitha Lahanda Wadu
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kaytlyn Marceaux
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rosemary Hollick
- Maryland Emerging Infections Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Zintar G Beldavs
- Acute and Communicable Disease Prevention, Oregon Health Authority, Portland
| | - Alexia Y Zhang
- Acute and Communicable Disease Prevention, Oregon Health Authority, Portland
| | | | | | - Gordana Derado
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tom M Chiller
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shawn R Lockhart
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Snigdha Vallabhaneni
- Mycotic Diseases Branch, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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16
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Prevention of Invasive Candidiasis in Premature Neonates: Administering Fluconazole or Not? CURRENT FUNGAL INFECTION REPORTS 2018. [DOI: 10.1007/s12281-018-0312-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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17
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Koklu E, Kalay S, Koklu S, Ariguloglu EA. Fluconazole administration leading to anaphylactic shock in a preterm newborn. Neonatal Netw 2018; 33:83-5. [PMID: 24589899 DOI: 10.1891/0730-0832.33.2.83] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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18
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Kaur H, Chakrabarti A. Strategies to Reduce Mortality in Adult and Neonatal Candidemia in Developing Countries. J Fungi (Basel) 2017; 3:E41. [PMID: 29371558 PMCID: PMC5715942 DOI: 10.3390/jof3030041] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/13/2017] [Accepted: 07/16/2017] [Indexed: 02/07/2023] Open
Abstract
Candidemia, the commonest invasive fungal infection, is associated with high morbidity and mortality in developing countries, though the exact prevalence is not known due to lack of systematic epidemiological data from those countries. The limited studies report a very high incidence of candidemia and unique epidemiology with a different spectrum of Candida species. The recent global emergence of multi-drug resistant Candida auris is looming large as an important threat in hospitalized patients of developing countries. While managing candidemia cases in those countries several challenges are faced, which include poor infrastructure; compromised healthcare and infection control practices; misuse and overuse of antibiotics and steroids; lack of awareness in fungal infections; non-availability of advance diagnostic tests and antifungal drugs in many areas; poor compliance to antifungal therapy and stewardship program. Considering the above limitations, innovative strategies are required to reduce mortality due to candidemia in adults and neonates. In the present review, we have unraveled the challenges of candidemia faced by low resource countries and propose a ten part strategy to reduce mortality due candidemia.
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Affiliation(s)
- Harsimran Kaur
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India.
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India.
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19
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Candiduria: Evidence-based approach to management, are we there yet? J Mycol Med 2017; 27:293-302. [PMID: 28501465 DOI: 10.1016/j.mycmed.2017.04.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/15/2017] [Accepted: 04/07/2017] [Indexed: 12/30/2022]
Abstract
Candiduria is considered one of the most controversial issues in patient management. Neither the diagnosis nor the optimal treatment options are standardized. This is further complicated by lack of defined laboratory criteria for diagnosis as most of the studies were set for bacterial rather than fungal urinary tract infection (UTI). Furthermore, since Candida species is a known commensal of the genitourinary tract its presence in the urine sample adds ambiguity to making a definitive diagnosis of candidal UTI. Guidelines for diagnosis and management of candiduria have changed considerably over the past decades. In 1960s, the condition was believed to be benign with no intervention required. However, over the years new dimensions were added to address the issues associated with candiduria until the latest Infectious Diseases Association of America (IDSA) guidelines were published in 2009, which indicated that there was an increase in the incidence of candiduria caused by more resistant non-Candida albicans species. Further complicating the issue is the observation that candiduria may be the only indicator of a more serious invasive candidiasis, especially in immunocompromised patients. Long-term urinary catheterization is considered to be the most significant risk factor for candiduria followed by antibiotic use and diabetes. Strategies for management are based on the evaluation of candiduria in the context of the clinical setting to determine its relevance and make an appropriate decision about the need for antifungal therapy. Fluconazole is the main drug used for its efficacy and least complications. Other options include bladder irrigation with amphotericin B, flucytosine or parenteral amphotericin B. Since azoles other than fluconazole and all echinocandins are poorly excreted in urine they have been found to be less effective in candiduric patients.
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20
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Hovijitra RS, Choonharuangdej S, Srithavaj T. Effect of essential oils prepared from Thai culinary herbs on sessile Candida albicans cultures. J Oral Sci 2017; 58:365-71. [PMID: 27665976 DOI: 10.2334/josnusd.15-0736] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Although medicinal herbs with fungicidal effects have been ubiquitously employed in traditional medicine, such effects of culinary herbs and spices still have to be elucidated. Therefore, it is noteworthy to determine the antifungal efficacy of some edible herbs used in Thai cuisine against sessile Candida albicans cultures, and to inquire if they can be further utilized as naturally-derived antifungals. Fourteen essential oils extracted from Thai culinary herbs and spices were tested for their antifungal activity against C. albicans using the agar disk diffusion method followed by broth micro-dilution method for the determination of minimum inhibitory concentration (MIC) and minimum fungicidal concentration. The oils with potent antifungal effects against planktonic fungi were then assessed for their effect against sessile fungus (adherent organisms and established biofilm culture). MIC of the oils against sessile C. albicans was evaluated by 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide reduction assay. All selected culinary herbs and spices, except galangal, garlic, and turmeric, exhibited inhibitory effects on planktonic yeast cells. Cinnamon bark and sweet basil leaf essential oils exhibited potent fungicidal effect on planktonic and sessile fungus. Sessile MICs were 8-16 times higher than planktonic MICs. Consequently, both cinnamon bark and sweet basil leaf herbal oils seem to be highly effective anti-Candida choices. (J Oral Sci 58, 365-371, 2016).
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Affiliation(s)
- Ray S Hovijitra
- Maxillofacial Prosthodontic Unit, Department of Prosthodontics, Faculty of Dentistry, Mahidol University
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21
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Rios JFDS, Camargos PAM, Corrêa LP, Romanelli RMDC. Fluconazole prophylaxis in preterm infants: a systematic review. Braz J Infect Dis 2017; 21:333-338. [PMID: 28286016 PMCID: PMC9428001 DOI: 10.1016/j.bjid.2017.01.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/20/2017] [Accepted: 01/23/2017] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE This article aims to review the use of antifungal prophylaxis with intravenous fluconazole in premature newborns and the occurrence of Invasive Candidiasis. METHODS This is a systematic review with search at databases: PubMed, Capes Portal, Virtual Health Library (BVS - Biblioteca Virtual em Saúde)/Lilacs, Scopus and Cochrane. The keywords used were: "Antifungal", "Candida" "Fluconazole prophylaxis" and "Preterm infants". RESULTS Invasive Candidiasis was evaluated in all the twelve items. In eleven of them, there was a statistically significant difference between the groups receiving prophylactic fluconazole, with lower frequency of Invasive Candidiasis, compared to placebo or no prophylaxis group. Colonization by Candida species was also evaluated in five studies; four of them presented statistically lower proportion of colonization in patients with Fluconazole prophylaxis, compared to placebo or no drugs. In one study, there was a significant difference, favoring the use of fluconazole, and reduction of death. CONCLUSION Studies indicate the effectiveness of prophylaxis with fluconazole, with reduction in the incidence of colonization and invasive fungal disease. The benefits of prophylaxis should be evaluated considering the incidence of candidiasis in the unit, the mortality associated with candidiasis, the safety and toxicity of short and long-term medication, and the potential for development of resistant pathogens.
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22
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Yan W, Hong L, Wang Y, Feng Y, Lu L, Tao Y, Wu J, Ruan H, Tang Q, Cai W. Retrospective Dual-Center Study of Parenteral Nutrition-Associated Cholestasis in Premature Neonates: 15 Years' Experience. Nutr Clin Pract 2017; 32:407-413. [PMID: 28135431 DOI: 10.1177/0884533616687532] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The pathogenesis of parenteral nutrition-associated cholestasis (PNAC) has not been clarified. The objective of this study was to explore the incidence of PNAC in premature infants without surgery and to identify associated risk factors. MATERIALS AND METHODS Premature neonates who received parenteral nutrition (PN) at least 14 days were included in a retrospective, dual-center study. Cholestasis was diagnosed as conjugated bilirubin ≥2 mg/dL. Infants with metabolic liver disease, cyanotic congenital heart disease, congenital syphilis, hepadnaviridae infection, and those who underwent surgery were excluded. Infants were divided into 3 groups chronologically: group A (2000-2004, n = 50), group B (2005-2009, n = 283), and group C (2010-2014, n = 741). A case-controlled study was conducted by comparing infants with PNAC to those without PNAC. RESULTS Of 1074 premature neonates, PNAC was confirmed in 53 infants (4.93%). There were 6.8% very low birth weight (BW) infants and 20.0% extremely low BW infants who developed PNAC. The incidence of PNAC decreased slightly during 2000-2014 (8.0%, 6.4%, and 4.2% in groups A, B, and C, respectively). Compared with those without PNAC, infants with PNAC (n = 53) had significantly younger gestational age, lower BW, longer PN duration, and higher rate of sepsis. Logistic regression showed male sex, PN duration ≥43 days, and sepsis were statistically correlated with PNAC. CONCLUSIONS Prolonged duration (≥43 days), male sex, and sepsis are probably independent risk factors for developing PNAC in premature neonates.
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Affiliation(s)
- Weihui Yan
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Li Hong
- 4 Department of Clinical Nutrition, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Wang
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Yi Feng
- 4 Department of Clinical Nutrition, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lina Lu
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Yijing Tao
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Jiang Wu
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Huijuan Ruan
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Qingya Tang
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Wei Cai
- 1 Department of Clinical Nutrition, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.,2 Shanghai Institute of Pediatric Research, Shanghai, China.,3 Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China.,5 Department of Pediatric Surgery, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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23
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Ericson JE, Kaufman DA, Kicklighter SD, Bhatia J, Testoni D, Gao J, Smith PB, Prather KO, Benjamin DK. Fluconazole Prophylaxis for the Prevention of Candidiasis in Premature Infants: A Meta-analysis Using Patient-level Data. Clin Infect Dis 2016; 63:604-10. [PMID: 27298330 PMCID: PMC4981761 DOI: 10.1093/cid/ciw363] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 05/14/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Invasive candidiasis (IC) is an important cause of sepsis in premature infants and is associated with a high risk of death and neurodevelopmental impairment. Prevention of IC has become a major focus in very low birth weight infants, with fluconazole increasingly used as prophylaxis. METHODS We identified all randomized, placebo-controlled trials evaluating fluconazole prophylaxis in premature infants conducted in the United States. We obtained patient-level data from the study investigators and performed an aggregated analysis. The occurrence of each endpoint in infants who received prophylaxis with fluconazole vs placebo was compared. Endpoints evaluated were IC or death, IC, death, Candida colonization, and fluconazole resistance among tested isolates. Safety endpoints evaluated included clinical and laboratory parameters. RESULTS Fluconazole prophylaxis reduced the odds of IC or death, IC, and Candida colonization during the drug exposure period compared with infants given placebo: odds ratios of 0.48 (95% confidence interval [CI], .30-.78), 0.20 (95% CI, .08-.51), and 0.28 (95% CI, .18-.41), respectively. The incidence of clinical and laboratory adverse events was similar for infants who received fluconazole compared with placebo. There was no statistically significant difference in the proportion of tested isolates that were resistant to fluconazole between the fluconazole and placebo groups. CONCLUSIONS Fluconazole prophylaxis is effective and safe in reducing IC and Candida colonization in premature infants, and has no impact on resistance.
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MESH Headings
- Antibiotic Prophylaxis/adverse effects
- Antibiotic Prophylaxis/methods
- Antibiotic Prophylaxis/statistics & numerical data
- Antifungal Agents/adverse effects
- Antifungal Agents/therapeutic use
- Candidiasis, Invasive/drug therapy
- Candidiasis, Invasive/epidemiology
- Candidiasis, Invasive/mortality
- Female
- Fluconazole/adverse effects
- Fluconazole/therapeutic use
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/drug therapy
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/mortality
- Infant, Premature
- Male
- Randomized Controlled Trials as Topic
- United States
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Affiliation(s)
- Jessica E Ericson
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - David A Kaufman
- Department of Pediatrics, University of Virginia, Charlottesville
| | | | - Jatinder Bhatia
- Department of Pediatrics, Georgia Regents University, Augusta
| | - Daniela Testoni
- Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
| | | | - P Brian Smith
- Duke Clinical Research Institute Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | | | - Daniel K Benjamin
- Duke Clinical Research Institute Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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Che D, Zhou H, Li T, Wu B. Duration and intensity of fluconazole for prophylaxis in preterm neonates: a meta-analysis of randomized controlled trials. BMC Infect Dis 2016; 16:312. [PMID: 27350534 PMCID: PMC4924264 DOI: 10.1186/s12879-016-1645-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 06/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The currently available evidence shows fluconazole is an effective prophylaxis treatment against invasive fungal infections in preterm neonates in neonatal intensive care units (NICUs). However, the duration and dosing of this prophylaxis treatment remain controversial. Thus, a meta-analysis and systematic review are necessary. METHODS PubMed and EMBASE were systematically searched with no restrictions. All relevant citations that compared prophylactic fluconazole and no prophylaxis were considered for inclusion. Pooled effect estimates were obtained through fixed- and random-effects meta-analyses, and a meta-regression was used to explore the sources of heterogeneity in the data. RESULTS Five independent randomized controlled clinical trials (RCTs) involving 1006 preterm neonates were identified. Compared with no prophylaxis, the overall combined relative risks (RRs) of invasive fungal infection with the 28- and 42-day durations of prophylactic fluconazole were 0.80 (95 % CI 0.48-1.35, p = 0.4048) and 0.30 (95 % CI 0.15-0.58, p = 0.0004), respectively. The fluconazole dose had no significant impact on the RR of invasive fungal infections. The RR of mortality presented no significant differences between prophylactic fluconazole and no prophylaxis (RR 0.82, 95 % CI 0.60 to 1.12, p = 0.2093). CONCLUSIONS Prophylaxis with fluconazole for 42 days was found to be superior to no prophylaxis as a strategy for preventing invasive fungal infection in preterm infants in NICUs except in terms of mortality. The dosing regimen of prophylactic fluconazole may have no impact on the outcome; however, due to the limitations of the available data, further research is needed.
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Affiliation(s)
- Datian Che
- Department of Respiratory Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hua Zhou
- Department of Emergency Care, Wuxi Children's Hospital, Affiliated with Nanjing Medical University, Wuxi, China
| | - Te Li
- Department of Pharmacy, Yuxi People's Hospital, Affiliated with the Kunming Medical College, Nieer Road 21, Yuxi, China
| | - Bin Wu
- Medical Decision and Economic Group, Department of Pharmacy, Ren Ji Hospital, South Campus, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
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Lee J, Kim HS, Shin SH, Choi CW, Kim EK, Choi EH, Kim BI, Choi JH. Efficacy and safety of fluconazole prophylaxis in extremely low birth weight infants: multicenter pre-post cohort study. BMC Pediatr 2016; 16:67. [PMID: 27184665 PMCID: PMC4869366 DOI: 10.1186/s12887-016-0605-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 05/11/2016] [Indexed: 12/02/2022] Open
Abstract
Background There have been many studies supporting fluconazole prophylaxis in preterm infants for prevention of invasive fungal infections (IFIs). However, the routine use of fluconazole prophylaxis in neonatal intensive care units (NICUs) raises concerns with respect to resistance development, including the selection of resistant Candida species. We aimed to evaluate the efficacy and safety of fluconazole prophylaxis in extremely low birth weight (ELBW) infants. Methods An interventional pre-post cohort study at two tertiary NICUs was conducted. Data from two 5-year periods with and without fluconazole prophylaxis (Mar 2008–Feb 2013 and Mar 2003–Feb 2008) was compared. Prophylactic fluconazole was administered starting on the 3rd day at a dose of 3 mg/kg twice a week for 4 weeks during the prophylaxis period. Results The fluconazole prophylaxis group consisted of 264 infants, and the non-prophylaxis group consisted of 159 infants. IFI occurred in a total of 19 neonates (4.7 %) during the 10-year study period. Fluconazole prophylaxis lower the fungal colonization rate significantly (59.1 % vs. 33.9 %, P <0.001). However, the incidence of IFIs in ELBW infants was not reduced after fluconazole prophylaxis (4.4 % vs. 5.5 %, P = 0.80). Rather, although the increase did not reach statistical significance, fluconazole prophylaxis tended to increase the incidence of invasive infections involving fluconazole-resistant C. parapsilosis (0 % vs. 41.7 %, P = 0.11). Conclusions Fluconazole prophylaxis was not efficacious in decreasing IFIs in ELBW infants. There is a need for targeting prophylaxis to greatest risk population and prospective studies to measure the long-term effect of fluconazole prophylaxis on the emergence of organisms with antifungal resistance. Electronic supplementary material The online version of this article (doi:10.1186/s12887-016-0605-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juyoung Lee
- Department of Pediatrics, Inha University School of Medicine, 100 Inharo, Incheon, Nam-gu, 22212, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea. .,Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.,Department of Pediatrics, Seoul National University Bundang Hospital, 82, Gumi-ro 173, Bundang-gu, Seongnam, Gyeonggi, 13620, Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea
| | - Eun Hwa Choi
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.,Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea
| | - Beyong Il Kim
- Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.,Department of Pediatrics, Seoul National University Bundang Hospital, 82, Gumi-ro 173, Bundang-gu, Seongnam, Gyeonggi, 13620, Korea
| | - Jung-Hwan Choi
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.,Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea
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26
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Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1-50. [PMID: 26679628 PMCID: PMC4725385 DOI: 10.1093/cid/civ933] [Citation(s) in RCA: 1836] [Impact Index Per Article: 229.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
| | - Carol A Kauffman
- Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor
| | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | - Thomas J Walsh
- Weill Cornell Medical Center and Cornell University, New York, New York
| | | | - Jack D Sobel
- Harper University Hospital and Wayne State University, Detroit, Michigan
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Chen J, Yu X, Zhou Y, Zhang Y, Zhu J, Xie L, Qian J, Yang Q, Xia H, Zhu T, Zhang Y, Chen Y, Zhao D, He Z. Integrated measures for prevention of invasive Candida infections in preterm infants in a Chinese neonatal intensive care unit. Am J Infect Control 2015; 43:1321-5. [PMID: 26416526 DOI: 10.1016/j.ajic.2015.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The increasing incidence of invasive Candida infections (ICIs) in preterm infants in the neonatal intensive care unit (NICU) of Xinhua Hospital aroused our concern. We undertook a retrospective study to evaluate the efficacy of different preventive measures for ICI in preterm infants. METHODS Preterm infants with gestational age (GA) <33 weeks admitted between 2010 and 2013 were divided into 3 groups according to the preventive measures applied in different periods: the control group (CG), fluconazole group (FG), and integrated measures group (IMG). We analyzed the incidence of ICI and distribution of fungal pathogens in these 3 groups, and also evaluated the efficiency of various measures in preventing ICIs in preterm infants. RESULTS The study sample comprised 261 preterm infants born at <33 weeks GA, including 94 in the CG, 99 in the FG, and 68 in the IMG. The differences among the groups were not significant at baseline. ICI developed in 41 of the 261 infants (15.7%). The incidence of ICI varied significantly among the groups: 22.3% in the CG (21/94), 18.2% in the FG (18/99), and only 2.9% in the IMG (2/68) (P = .003). ICI was less frequent in the IMG compared with the CG (P <.001) and the FG (P = .003). CONCLUSIONS The integrated measures approach is meaningful for the prevention of ICIs in preterm infants in NICUs with many patients but inadequate medical resources in some developing countries.
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Manipulation of Host Diet To Reduce Gastrointestinal Colonization by the Opportunistic Pathogen Candida albicans. mSphere 2015; 1:mSphere00020-15. [PMID: 27303684 PMCID: PMC4863630 DOI: 10.1128/msphere.00020-15] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/17/2015] [Indexed: 11/30/2022] Open
Abstract
Candida albicans, the most common human fungal pathogen, can cause infections with a mortality rate of ~40%. C. albicans is part of the normal gut flora, but when a patient’s immune system is compromised, it can leave the gut and cause infections. By reducing the amount of C. albicans in the gut of susceptible patients, infections (and the resulting fatalities) can be prevented. Currently, this is done using antimicrobial drugs; to “preserve” drugs for treating infections, we looked for a dietary change to reduce the amount of C. albicans in the gut. Using a mouse model, we showed that adding coconut oil to the diet could become the first drug-free way to reduce C. albicans in the gut. More broadly, this model lets us study the interactions between our diet and the microbes in our body and the reasons why some of those microbes, under certain conditions, cause disease. Candida albicans, the most common human fungal pathogen, can cause systemic infections with a mortality rate of ~40%. Infections arise from colonization of the gastrointestinal (GI) tract, where C. albicans is part of the normal microflora. Reducing colonization in at-risk patients using antifungal drugs prevents C. albicans-associated mortalities. C. albicans provides a clinically relevant system for studying the relationship between diet and the microbiota as it relates to commensalism and pathogenicity. As a first step toward a dietary intervention to reduce C. albicans GI colonization, we investigated the impact of dietary lipids on murine colonization by C. albicans. Coconut oil and its constituent fatty acids have antifungal activity in vitro; we hypothesized that dietary coconut oil would reduce GI colonization by C. albicans. Colonization was lower in mice fed a coconut oil-rich diet than in mice fed diets rich in beef tallow or soybean oil. Switching beef tallow-fed mice to a coconut oil diet reduced preexisting colonization. Coconut oil reduced colonization even when the diet also contained beef tallow. Dietary coconut oil also altered the metabolic program of colonizing C. albicans cells. Long-chain fatty acids were less abundant in the cecal contents of coconut oil-fed mice than in the cecal contents of beef tallow-fed mice; the expression of genes involved in fatty acid utilization was lower in C. albicans from coconut oil-fed mice than in C. albicans from beef tallow-fed mice. Extrapolating to humans, these findings suggest that coconut oil could become the first dietary intervention to reduce C. albicans GI colonization. IMPORTANCECandida albicans, the most common human fungal pathogen, can cause infections with a mortality rate of ~40%. C. albicans is part of the normal gut flora, but when a patient’s immune system is compromised, it can leave the gut and cause infections. By reducing the amount of C. albicans in the gut of susceptible patients, infections (and the resulting fatalities) can be prevented. Currently, this is done using antimicrobial drugs; to “preserve” drugs for treating infections, we looked for a dietary change to reduce the amount of C. albicans in the gut. Using a mouse model, we showed that adding coconut oil to the diet could become the first drug-free way to reduce C. albicans in the gut. More broadly, this model lets us study the interactions between our diet and the microbes in our body and the reasons why some of those microbes, under certain conditions, cause disease. Podcast: A podcast concerning this article is available.
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Cleminson J, Austin N, McGuire W. Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants. Cochrane Database Syst Rev 2015; 2015:CD003850. [PMID: 26497056 PMCID: PMC7156892 DOI: 10.1002/14651858.cd003850.pub5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very preterm and very low birth weight infants. Early diagnosis is difficult and treatment is often delayed. Systemically absorbed antifungal agents (usually azoles) are increasingly used as prophylaxis against invasive fungal infection in this population. OBJECTIVES To assess the effect of prophylactic systemic antifungal therapy on mortality and morbidity in very preterm or very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 8), MEDLINE, EMBASE, and CINAHL (to May 2015), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic systemic antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS We identified 15 eligible trials enrolling a total of 1690 infants. Ten trials (1371 infants) compared systemic antifungal prophylaxis versus placebo or no drug. These trials were generally of good methodological quality. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection (typical risk ratio (RR) 0.43, 95% confidence interval (CI) 0.31 to 0.59; risk difference (RD) -0.09, 95% CI -0.12 to -0.06). The average incidence of invasive fungal infection in the control groups of the trials (16%) was much higher than that generally reported from large cohort studies. Meta-analysis did not find a statistically significant difference in the risk of death prior to hospital discharge (typical RR 0.79, 95% CI 0.61 to 1.02; typical RD -0.04, 95% CI -0.07 to 0.00). Very limited data on long-term neurodevelopmental outcomes were available. Three trials that compared systemic versus oral or topical non-absorbed antifungal prophylaxis did not detect any statistically significant effects on invasive fungal infection or mortality. Two trials that compared different dose regimens of prophylactic intravenous fluconazole did not detect any significant differences in infection rates or mortality. AUTHORS' CONCLUSIONS Prophylactic systemic antifungal therapy reduces the incidence of invasive fungal infection in very preterm or very low birth weight infants. This finding should be interpreted and applied cautiously since the incidence of invasive fungal infection was very high in the control groups of many of the included trials. Meta-analysis does not demonstrate a statistically significant effect on mortality. There are currently only limited data on the long-term neurodevelopmental consequences for infants exposed to this intervention. In addition, there is a need for further data on the effect of the intervention on the emergence of organisms with antifungal resistance.
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Affiliation(s)
- Jemma Cleminson
- University of YorkAcademic Clinical Fellow in Child Health NIHR Centre for Reviews & DisseminationYorkUK
| | - Nicola Austin
- Christchurch Womens HospitalNICUChristchurchNew Zealand
| | - William McGuire
- Hull York Medical School & Centre for Reviews and Dissemination, University of YorkYorkY010 5DDUK
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Botero-Calderon L, Benjamin DK, Cohen-Wolkowiez M. Advances in the treatment of invasive neonatal candidiasis. Expert Opin Pharmacother 2015; 16:1035-48. [PMID: 25842986 PMCID: PMC4402277 DOI: 10.1517/14656566.2015.1031108] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Invasive candidiasis is responsible for ∼ 10% of nosocomial sepsis in very-low-birth-weight infants and is associated with substantial morbidity and mortality. Over the last two decades, the antifungal armamentarium against Candida spp. has increased; however, efficacy and safety studies in this population are lacking. AREAS COVERED We reviewed the medical literature and extracted information on clinical and observational studies evaluating the use of antifungal agents in neonates with invasive candidiasis. EXPERT OPINION Efficacy and safety data for antifungals in neonates are lacking, and the majority of studies conducted to date have concentrated on pharmacokinetic/pharmacodynamic evaluations. Unlike other anti-infective agents, efficacy data in the setting of neonatal candidiasis cannot be extrapolated from adult studies due to differences in the pathophysiology of the disease in this population relative to older children and adults. Data for amphotericin B deoxycholate, fluconazole, and micafungin suggest that these are the current agents of choice for this disease in neonates until data for newer antifungal agents become available. For prophylaxis, data from fluconazole randomized controlled trials will be submitted to the regulatory agencies for labeling. Ultimately, the field of therapeutics for neonatal candidiasis will require multidisciplinary collaboration given the numerous challenges associated with conducting clinical trials in neonates.
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Schulman J, Dimand RJ, Lee HC, Duenas GV, Bennett MV, Gould JB. Neonatal intensive care unit antibiotic use. Pediatrics 2015; 135:826-33. [PMID: 25896845 DOI: 10.1542/peds.2014-3409] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay. METHODS In a retrospective cohort study of 52,061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles. RESULTS Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile. CONCLUSIONS Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.
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Affiliation(s)
- Joseph Schulman
- California Department of Health Care Services, California Children's Services, Sacramento, California;
| | - Robert J Dimand
- California Department of Health Care Services, California Children's Services, Sacramento, California
| | - Henry C Lee
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and California Perinatal Quality Care Collaborative, Stanford, California
| | - Grace V Duenas
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and California Perinatal Quality Care Collaborative, Stanford, California
| | - Mihoko V Bennett
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and California Perinatal Quality Care Collaborative, Stanford, California
| | - Jeffrey B Gould
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California; and California Perinatal Quality Care Collaborative, Stanford, California
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Abstract
Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency among premature infants. Although a large body of research has focused on understanding its pathogenesis, the exact mechanism has not been elucidated. Of particular interest is the potential causative role of infectious culprits in the development of NEC. A variety of reports describe bacterial, viral, and fungal infections occurring in association with NEC; however, no single organism has emerged as being definitively involved in NEC pathogenesis. In this review, the authors summarize the literature on infectious causes of NEC.
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Affiliation(s)
- Sarah A Coggins
- Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN 37232, USA
| | - James L Wynn
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, 2215 B Garland Avenue, 1125 MRB IV/Light Hall, Nashville, TN 37232, USA
| | - Jörn-Hendrik Weitkamp
- Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, 2215 B Garland Avenue, 1125 MRB IV/Light Hall, Nashville, TN 37232, USA.
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Oxidative stress responses in the human fungal pathogen, Candida albicans. Biomolecules 2015; 5:142-65. [PMID: 25723552 PMCID: PMC4384116 DOI: 10.3390/biom5010142] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 02/07/2023] Open
Abstract
Candida albicans is a major fungal pathogen of humans, causing approximately 400,000 life-threatening systemic infections world-wide each year in severely immunocompromised patients. An important fungicidal mechanism employed by innate immune cells involves the generation of toxic reactive oxygen species (ROS), such as superoxide and hydrogen peroxide. Consequently, there is much interest in the strategies employed by C. albicans to evade the oxidative killing by macrophages and neutrophils. Our understanding of how C. albicans senses and responds to ROS has significantly increased in recent years. Key findings include the observations that hydrogen peroxide triggers the filamentation of this polymorphic fungus and that a superoxide dismutase enzyme with a novel mode of action is expressed at the cell surface of C. albicans. Furthermore, recent studies have indicated that combinations of the chemical stresses generated by phagocytes can actively prevent C. albicans oxidative stress responses through a mechanism termed the stress pathway interference. In this review, we present an up-date of our current understanding of the role and regulation of oxidative stress responses in this important human fungal pathogen.
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Kirpal H, Gathwala G, Chaudhary U, Sharma D. Prophylactic fluconazole in very low birth weight infants admitted to neonatal intensive care unit: randomized controlled trial. J Matern Fetal Neonatal Med 2015; 29:624-8. [DOI: 10.3109/14767058.2015.1013933] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Uma Chaudhary
- Department of Microbiology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India, and
| | - Deepak Sharma
- Department of Neonatology, Fernandez Hospital, Hyderguda, Hyderabad, Andhra Pradesh, India
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Pana ZD, Kougia V, Roilides E. Therapeutic strategies for invasive fungal infections in neonatal and pediatric patients: an update. Expert Opin Pharmacother 2015; 16:693-710. [PMID: 25676454 DOI: 10.1517/14656566.2015.1013936] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Invasive fungal infections (IFIs) in neonatal and pediatric patients are still associated with high morbidity and mortality, increased length of hospital stay and high healthcare cost. Two key components are prerequisite to combat pediatric IFIs; first, definition of the 'at-risk' populations that could benefit the most from prophylactic treatment and second, prompt initiation of effective antifungal therapy. AREAS COVERED In this article, updated prevention and targeted therapeutic approaches for IFIs in neonates and immunocompromised children are reviewed. Furthermore, European and American guidelines concerning IFI treatment in neonates and children are compared. EXPERT OPINION IFIs in neonates and children present substantial differences from adults in respect to their epidemiology, pharmacokinetics of antifungal agents and dosing as well as absence of interventional Phase III and IV clinical trials for guidance of evidence-based decisions. In the therapeutic armamentarium of these age groups, although amphotericin B formulations remain widely indicated, azoles with broader spectrum activity as well as echinocandins have been added in the updated antifungal treatment algorithm. Recent European guidelines (ESCMID and ECIL) contain specific recommendations for pediatric patients with IFIs. In both age groups, definitive updated guidance for prophylaxis and more importantly targeted treatment need to be further evaluated by large, multicenter, randomized controlled trials.
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Affiliation(s)
- Zoi-Dorothea Pana
- Aristotle University School of Health Sciences, 3rd Department of Pediatrics, Infectious Diseases Unit, Faculty of Medicine , Thessaloniki , Greece
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Tragiannidis A, Tsoulas C, Groll AH. Invasive candidiasis and candidaemia in neonates and children: update on current guidelines. Mycoses 2014; 58:10-21. [PMID: 25350572 DOI: 10.1111/myc.12268] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 10/03/2014] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
Abstract
Invasive candidiasis (IC) and candidaemia are leading causes of infectious morbidity and mortality among immunocompromised paediatric patients and those admitted to intensive care units. Despite improvements in diagnosis, prevention and treatment, both mortality rates and the economic burden of disease still remain high. To address this issue, several international societies and organisations have proposed guidelines for the management of IC/candidaemia in both neonates and children. In this article, we review current recommendations of the Infectious Diseases Society of America, the European Conference on Infection in Leukaemia, the European Society of Clinical Microbiology and Infectious Diseases and the German Speaking Mycological Society/Paul-Ehrlich Society for Chemotherapy for the management and prevention of IC/candidaemia in children and neonates.
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Affiliation(s)
- Athanasios Tragiannidis
- Hematology Oncology Unit, 2nd Pediatric Department, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
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Costa S, Barone G, Vento G, Tirone C, Perelli S, Romagnoli C. Adrenocortical insufficiency is not a problem in preterm infants treated with antifungal prophylaxis with fluconazole. Acta Paediatr 2014; 103:e234-7. [PMID: 24575768 DOI: 10.1111/apa.12613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 02/24/2014] [Indexed: 11/30/2022]
Abstract
AIM Fluconazole prophylaxis of invasive fungal infections is a cornerstone of neonatal care, but in vitro studies have shown that it inhibits corticosteroid production. This study assessed whether preterm infants demonstrated an association between fluconazole administration, and its duration, and symptoms of adrenocortical insufficiency. METHODS We compared two groups who were treated before and after we introduced the use of fluconazole to our neonatal intensive care unit. Infants with a gestational age of ≤27 weeks or with a birth weight of ≤750 g were considered for the retrospective analysis. In order to assess whether the duration of prophylaxis was related to adrenocortical insufficiency, regression models were performed in all preterm infants in the fluconazole group. RESULTS The fluconazole group (n = 37) and nonfluconazole group (n = 41) were compared. No differences were found in the percentage of infants with symptoms of adrenocortical insufficiency, such as hypotension or need of vasopressor therapy. The incidence of hypotension and the use of vasopressor therapy were not related to duration of fluconazole prophylaxis. CONCLUSION Fluconazole and it duration were not associated with the incidence of symptoms related to adrenocortical insufficiency. Further prospective trials are needed to better define the relationship between fluconazole and adrenocortical insufficiency.
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Affiliation(s)
- S Costa
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - G Barone
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - G Vento
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - C Tirone
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - S Perelli
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - C Romagnoli
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
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Abstract
PURPOSE OF REVIEW Invasive candidiasis is a serious infection in hospitalized infants that results in significant mortality and morbidity. Fluconazole is approved by the US Food and Drug Administration for prophylaxis of invasive candidiasis in patients undergoing bone marrow transplantation but is not approved for use in infants. This review will describe the history of fluconazole use for prophylaxis in infants. RECENT FINDINGS Limiting fluconazole prophylaxis to infants with risk factors, in addition to low birth weight and early gestational age, reduces the number of infants treated with fluconazole and the duration of fluconazole therapy for each infant. SUMMARY Fluconazole prophylaxis appears to be well tolerated for use in premature infants. Reduction in the incidence of invasive candidiasis is observed even when prophylaxis is limited to infants with multiple risk factors. Centers with a low incidence of invasive candidiasis may not benefit from fluconazole prophylaxis. Significant short-term and long-term toxicity and increases in fluconazole-resistant organisms have not been observed with fluconazole use in the intensive care nursery.
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Affiliation(s)
- Jessica E. Ericson
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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Swanson JR, Gurka MJ, Kaufman DA. Risk Factors for Invasive Fungal Infection in Premature Infants: Enhancing a Targeted Prevention Approach. J Pediatric Infect Dis Soc 2014; 3:49-56. [PMID: 26624907 DOI: 10.1093/jpids/pit068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 07/27/2013] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
| | - Matthew J Gurka
- Department of Biostatistics, West Virginia University, Morgantown
| | - David A Kaufman
- Department of Pediatrics, University of Virginia, Charlottesville
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Evaluation of Parenteral Nutrition–Associated Liver Disease in Infants With Necrotizing Enterocolitis Before and After the Implementation of Feeding Guidelines. Nutr Clin Pract 2014; 29:234-7. [DOI: 10.1177/0884533614522834] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Hundalani S, Pammi M. Invasive fungal infections in newborns and current management strategies. Expert Rev Anti Infect Ther 2014; 11:709-21. [DOI: 10.1586/14787210.2013.811925] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Shane AL, Stoll BJ. Neonatal sepsis: Progress towards improved outcomes. J Infect 2014; 68 Suppl 1:S24-32. [DOI: 10.1016/j.jinf.2013.09.011] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2013] [Indexed: 10/26/2022]
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Klein CJ, Havranek TG, Revenis ME, Hassanali Z, Scavo LM. Plasma fatty acids in premature infants with hyperbilirubinemia: before-and-after nutrition support with fish oil emulsion. Nutr Clin Pract 2013; 28:87-94. [PMID: 23319354 DOI: 10.1177/0884533612469989] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Infants who are dependent on parenteral nutrition (PN) sometimes develop PN-associated cholestasis (PNAC). A compassionate use protocol, approved by the U.S. Food and Drug Administration and the institutional review board, guided enrollment of hospitalized infants with PNAC (<1 year of age, PN dependence for >3 weeks). Plasma concentrations of essential fatty acids were monitored before and after a soybean-based PN lipid, infused at 3 g/kg body weight/d, was replaced by an experimental fish oil-based intravenous fat emulsion (FO-IVFE) at 1.0 g/kg/d. All participants were born premature (n = 10; 20% male). At enrollment, infants were (mean ± SD) 86.5 ± 53.5 days of life and weighed 2.24 ± 0.87 kg; direct bilirubin was 5.5 ± 1.3 mg/dL. After treatment, blood concentrations significantly increased from baseline (P < .017) for circulating eicosapentaenoic acid (6.3 ± 3.0 to 147.8 ± 53.1 µg/mL), docosahexaenoic acid (20.7 ± 6.5 to 163.7 ± 43.4 µg/mL), pristanic acid (0.01 ± 0.01 to 0.17 ± 0.03 µg/mL), and phytanic acid (0.06 ± 0.03 to 0.64 ± 0.15 µg/mL). In contrast, total plasma ω-6 fatty acids (including linoleic acid) decreased (P < .017). The triene/tetraene ratio remained below the threshold value of 0.2 that defines ω-6 deficiency. No adverse effects were observed attributable to FO-IVFE. Discontinuation of FO-IVFE was typically due to infants (body weight 3.76 ± 1.68 kg) transitioning to enteral feeding rather than for resolution of hyperbilirubinemia (direct bilirubin 7.9 ± 4.8 mg/dL). These exploratory results suggest that FO-IVFE raises circulating ω-3 fatty acids in premature infants without development of ω-6 deficiency in the 8.3 ± 5.8-week time frame of this study.
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Santolaya ME, Alvarado Matute T, de Queiroz Telles F, Colombo AL, Zurita J, Tiraboschi IN, Cortes JA, Thompson-Moya L, Guzman-Blanco M, Sifuentes J, Echevarría J, Nucci M. Recommendations for the management of candidemia in neonates in Latin America. Latin America Invasive Mycosis Network. Rev Iberoam Micol 2013; 30:158-70. [PMID: 23756219 DOI: 10.1016/j.riam.2013.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/30/2013] [Accepted: 05/31/2013] [Indexed: 11/28/2022] Open
Abstract
Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. 'Recommendations for the diagnosis and management of candidemia' are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, 'Recommendations for the management of candidemia in neonates in Latin America', was written to provide guidance to healthcare professionals on the management of neonates who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. 'Recommendations for the management of candidemia in neonates in Latin America' includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, central venous catheter management, and management of complications. This manuscript is the fourth of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: 'Recommendations for the diagnosis of candidemia in Latin America', 'Recommendations for the management of candidemia in adults in Latin America', and 'Recommendations for the management of candidemia in children in Latin America'.
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Affiliation(s)
- María E Santolaya
- Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; Latin America Invasive Mycosis Network.
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Santolaya ME, Alvarado Matute T, de Queiroz Telles F, Colombo AL, Zurita J, Tiraboschi IN, Cortes JA, Thompson-Moya L, Guzman-Blanco M, Sifuentes J, Echevarría J, Nucci M. [Recommendations for the management of candidemia in neonates in Latin America. Grupo Proyecto Épico]. Rev Iberoam Micol 2013; 30:158-70. [PMID: 23764559 DOI: 10.1016/j.riam.2013.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 05/31/2013] [Indexed: 10/26/2022] Open
Abstract
Candidemia is one of the most frequent opportunistic mycoses worldwide. Limited epidemiological studies in Latin America indicate that incidence rates are higher in this region than in the Northern Hemisphere. Diagnosis is often made late in the infection, affecting the initiation of antifungal therapy. A more scientific approach, based on specific parameters, for diagnosis and management of candidemia in Latin America is warranted. 'Recommendations for the diagnosis and management of candidemia' are a series of manuscripts that have been developed by members of the Latin America Invasive Mycosis Network. They aim to provide a set of best-evidence recommendations for the diagnosis and management of candidemia. This publication, 'Recommendations for the management of candidemia in neonates in Latin America', was written to provide guidance to healthcare professionals on the management of neonates who have, or who are at risk of, candidemia. Computerized searches of existing literature were performed by PubMed. The data were extensively reviewed and analyzed by members of the group. The group also met on two occasions to pose questions, discuss conflicting views, and deliberate on a series of management recommendations. 'Recommendations for the management of candidemia in neonates in Latin America' includes prophylaxis, empirical therapy, therapy for proven candidemia, patient work-up following diagnosis of candidemia, central venous catheter management, and management of complications. This manuscript is the fourth of this series that deals with diagnosis and treatment of invasive candidiasis. Other publications in this series include: 'Recommendations for the diagnosis of candidemia in Latin America', 'Recommendations for the management of candidemia in adults in Latin America', and 'Recommendations for the management of candidemia in children in Latin America'.
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Affiliation(s)
- María E Santolaya
- Hospital Luis Calvo Mackenna, Universidad de Chile, Santiago, Chile; Latin America Invasive Mycosis Network.
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Egunsola O, Adefurin A, Fakis A, Jacqz-Aigrain E, Choonara I, Sammons H. Safety of fluconazole in paediatrics: a systematic review. Eur J Clin Pharmacol 2013; 69:1211-21. [PMID: 23325436 PMCID: PMC3651820 DOI: 10.1007/s00228-012-1468-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 11/27/2012] [Indexed: 11/12/2022]
Abstract
PURPOSE To determine the safety of fluconazole in neonates and other paediatric age groups by identifying adverse events (AEs) and drug interactions associated with treatment. METHODS A search of EMBASE (1950-January 2012), MEDLINE (1946-January 2012), the Cochrane database for systematic reviews and the Cumulative Index to Nursing and Allied Health Literature (1982-2012) for any clinical study about fluconazole use that involved at least one paediatric patient (≤17 years) was performed. Only articles with sufficient quality of safety reporting after patients' exposure to fluconazole were included. RESULTS We identified 90 articles, reporting on 4,209 patients, which met our inclusion criteria. In total, 794 AEs from 35 studies were recorded, with hepatotoxicity accounting for 378 (47.6 %) of all AEs. When fluconazole was compared with placebo and other antifungals, the relative risk (RR) of hepatotoxicity was not statistically different [RR 1.36, 95 % confidence interval (CI) 0.87-2.14, P = 0.175 and RR 1.43, 95 % CI 0.67-3.03, P = 0.352, respectively]. Complete resolution of hepatoxicity was achieved by 84 % of patients with follow-up available. There was no statistical difference in the risk of gastrointestinal events of fluconazole compared with placebo and other antifungals (RR 0.81, 95 % CI 0.12-5.60, P = 0.831 and RR 1.23, 95 %CI 0.87-1.71, P = 0.235, respectively). There were 41 drug withdrawals, 17 (42 %) of which were due to elevated liver enzymes. Five reports of drug interactions occurred in children. CONCLUSION Fluconazole is relatively safe for paediatric patients. Hepatotoxicity and gastrointestinal toxicity are the most common adverse events. It is important to be aware that drug interactions with fluconazole can result in significant toxicity.
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Affiliation(s)
- Oluwaseun Egunsola
- Academic Division of Child Health, Derbyshire Children's Hospital, University of Nottingham, Derby, DE22 3DT, UK.
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Abstract
BACKGROUND Candida is the third most common cause of late-onset neonatal sepsis in infants born at <1500 g. Candida parapsilosis infections are increasingly reported in preterm neonates in association with indwelling catheters. METHODS We systematically reviewed neonatal literature and synthesized data pertaining to percentage of C. parapsilosis infections and mortality by meta-analyses. We also reviewed risk factors, virulence determinants, antimicrobial susceptibility patterns and outlined clinical management strategies. RESULTS C. parapsilosis infections comprised 33.47% (95% confidence interval [CI]: 30.02, 37.31) of all neonatal Candida infections. C. parapsilosis rates were similar in studies performed before the year 2000, 33.53% (95% CI: 30.06, 37.40) (28 studies), to those after 2000, 27.00% (95% CI: 8.25, 88.37) (8 studies). The mortality due to neonatal C. parapsilosis infections was 10.02% (95% CI: 7.66, 13.12). Geographical variations in C. parapsilosis infections included a low incidence in Europe and higher incidence in North America and Australia. Biofilm formation was a significant virulence determinant and predominant risk factors for C. parapsilosis infections were prematurity, prior colonization and catheterization. Amphotericin B remains the antifungal drug of choice and combination therapy with caspofungin or other echinocandins may be considered in resistant cases. CONCLUSION C. parapsilosis is a significant neonatal pathogen, comprises a third of all Candida infections and is associated with 10% mortality. Availability of tools for genetic manipulation of this organism will identify virulence determinants and organism characteristics that may explain predilection for preterm neonates. Strategies to prevent horizontal transmission in the neonatal unit are paramount in decreasing infection rates.
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Austin N, McGuire W. Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants. Cochrane Database Syst Rev 2013:CD003850. [PMID: 23633315 DOI: 10.1002/14651858.cd003850.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Invasive fungal infection is an important cause of mortality and morbidity in very low birth weight infants. Early diagnosis is difficult and treatment is often delayed. Systemic antifungal agents (usually azoles) are increasingly used as prophylaxis against invasive fungal infection. OBJECTIVES To assess the effect of prophylactic systemic antifungal therapy on mortality and morbidity in very low birth weight infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 3), MEDLINE, EMBASE, and CINAHL (to August 2012), conference proceedings, and previous reviews. SELECTION CRITERIA Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic systemic antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors. MAIN RESULTS We identified 11 eligible trials enrolling a total of 1136 infants. Seven trials (involving 880 infants) compared systemic antifungal prophylaxis versus placebo or no drug. These trials were generally small but of good methodological quality. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection in infants who received systemic antifungal prophylaxis (typical risk ratio (RR) 0.41, 95% confidence interval (CI) 0.27 to 0.61; risk difference (RD) -0.09, 95% CI -0.14 to -0.05). The average incidence of invasive fungal infection in the control groups of the trials (16%) was much higher than that generally reported from large cohort studies (< 5%). Meta-analysis did not find a statistically significant difference in the risk of death prior to hospital discharge (typical RR 0.74, 95% CI 0.52 to 1.05; RD -0.04, 95% CI -0.08 to 0.01). Very limited data on long-term neurodevelopmental outcomes were available. Two trials that compared systemic versus oral or topical non-absorbed antifungal prophylaxis did not detect any statistically significant effects on invasive fungal infection or mortality. Two trials that compared different dose regimens of prophylactic intravenous fluconazole did not detect any significant differences in infection rates or mortality. AUTHORS' CONCLUSIONS Prophylactic systemic antifungal therapy reduces the incidence of invasive fungal infection in very low birth weight infants. This finding should be interpreted and applied cautiously since the incidence of invasive fungal infection was very high in the control groups of most of the included trials. Meta-analysis does not demonstrate a statistically significant effect on mortality. There are currently only limited data on the long-term neurodevelopmental consequences for infants exposed to this intervention. In addition, there is a need for further data on the effect of the intervention on the emergence of organisms with antifungal resistance.
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Affiliation(s)
- Nicola Austin
- NICU, Christchurch Womens Hospital, Christchurch, New Zealand
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Abstract
Neonatal sepsis remains a feared cause of morbidity and mortality in the neonatal period. Maternal, neonatal, and environmental factors are associated with risk of infection, and a combination of prevention strategies, judicious neonatal evaluation, and early initiation of therapy are required to prevent adverse outcomes. This article reviews recent trends in epidemiology and provides an update on risk factors, diagnostic methods, and management of neonatal sepsis.
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Affiliation(s)
- Andres Camacho-Gonzalez
- Division of Pediatric Infectious Diseases, Emory Department of Pediatrics, Children's Healthcare of Atlanta, Emory University, Atlanta, GA 30322, USA.
| | - Paul W. Spearman
- Nahmias-Schinazi Professor and Chief, Pediatric Infectious Diseases, Vice Chair for Research, Emory Department of Pediatrics, Emory University, Chief Research Officer, Children’s Healthcare of Atlanta, Georgia, 2015 Uppergate Drive, Suite 500, Atlanta, GA 30322, P:404-727-5642, F:404-727-9223
| | - Barbara J. Stoll
- George W. Brumley, Jr. Professor and Chair of the Department of Pediatrics, Medical Director of Children’s Healthcare of Atlanta at Egleston, President of the Emory-Children’s Center, 2015 Uppergate Drive, Suite 200, Atlanta, GA 30322
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Chang YJ, Choi IR, Shin WS, Lee JH, Kim YK, Park MS. The control of invasive Candida infection in very low birth weight infants by reduction in the use of 3rd generation cephalosporin. KOREAN JOURNAL OF PEDIATRICS 2013; 56:68-74. [PMID: 23482686 PMCID: PMC3589593 DOI: 10.3345/kjp.2013.56.2.68] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 08/24/2012] [Accepted: 10/24/2012] [Indexed: 12/21/2022]
Abstract
Purpose To evaluate the effectiveness of new management policies on the incidence of invasive Candida infections Methods This observational study involved a retrospective analysis of the patients' medical records. In total, 99 very low birth weight infants, who were admitted to the neonatal intensive care unit at Ajou University Hospital from January 2010 to December 2011, were enrolled for the study. Period I, defined as the period before the revision of management policies, comprised 57 infants; whereas, period II, defined as the period after the implementation of new management policies, comprised 42 infants. The new management policies entailed a reduction in antibiotic and histamine type 2 receptor blocker (H2 blocker) use, duration of central venous catheterization, and duration of endotracheal intubation. Results There was a significant overall decrease in the use of antibiotics including 3rd generation cephalosporin and H2 blockers (P<0.05), and a significantly lower incidence of invasive Candida infections in period II as compared to period I (0/42 vs. 6/57, respectively; P=0.037). Comparison between infants with invasive Candida infections (n=6) and those without (n=93) showed that gestational age (odds ratio [OR], 0.909; 95% confidence interval [CI], 0.829 to 0.996; P=0.042) and the duration of 3rd generation cephalosporin use (OR, 1.093; 95% CI, 1.009 to 1.183; P=0.029) were statistically significant risk factors. Conclusion The new management policies effectively decreased overall use of antibiotics, especially 3rd generation cephalosporin, and H2 blockers, which led to a significantly lower incidence of invasive Candida infections.
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Affiliation(s)
- Yu Jin Chang
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
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