Antifungal prophylaxis: identification of preterm neonates at highest risk for invasive fungal infection

Empiric antifungal therapy and outcomes in extremely low birth weight infants with invasive candidiasis

OBJECTIVE

To assess the impact of empiric antifungal therapy for invasive candidiasis on subsequent outcomes in premature infants.

STUDY DESIGN

This was a cohort study of infants with a birth weight ≤ 1000 g receiving care at Neonatal Research Network sites. All infants had at least one positive culture for Candida. Empiric antifungal therapy was defined as receipt of a systemic antifungal on the day of or the day before the first positive culture for Candida was drawn. We created Cox proportional hazards and logistic regression models stratified on propensity score quartiles to determine the effect of empiric antifungal therapy on survival, time to clearance of infection, retinopathy of prematurity, bronchopulmonary dysplasia, end-organ damage, and neurodevelopmental impairment (NDI).

RESULTS

A total of 136 infants developed invasive candidiasis. The incidence of death or NDI was lower in infants who received empiric antifungal therapy (19 of 38; 50%) compared with those who had not (55 of 86; 64%; OR, 0.27; 95% CI, 0.08-0.86). There was no significant difference between the groups for any single outcome or other combined outcomes.

CONCLUSION

Empiric antifungal therapy was associated with increased survival without NDI. A prospective randomized trial of this strategy is warranted.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Risk factors associated with colonization by Candida spp in neonates hospitalized in a Neonatal Intensive Care Unit in Brazil]

The objectives of this study were to investigate the participation of Candida albicans and non-albicans as colonization and sepsis agents, along with the risk factors associated with the neonates in the neonatal intensive care unit of the clinical hospital of the Federal University of Uberlândia. Epidemiological surveillance was implemented through the National Healthcare Safety Network between August 2007 and April 2008. The incidence rate for sepsis with microbiological criteria was 6.7/1,000 patients/day, which was shown as only one case of candidemia. Approximately 19% of the neonates were colonized by Candida, which was identified as Candida albicans (50%) and Candida not-albicans (50%). The significant risk factors for Candida spp colonization were gestational age of between 26 and 30 weeks, previous antibiotic use and umbilical central vascular catheter. The overall mortality among the neonates hospitalized with sepsis over the study period was 11.8%. However, the neonate with candidemia did not die.