Elsevier

Seminars in Perinatology

Volume 31, Issue 1, February 2007, Pages 39-46
Seminars in Perinatology

Prevention and Treatment of Candida Infections in Neonates

https://doi.org/10.1053/j.semperi.2007.01.006Get rights and content

Invasive Candia infections have become the third most common cause of late-onset infection among very low birth weight infants in most neonatal intensive care units. Significant risk factors include birth weight less than 1000 g, exposure to more than two antibiotics, third generation cephalosporin exposure, parenteral nutrition including lipid emulsion, central venous catheter, and abdominal surgery. The majority of neonatal Candida infections are caused by C. albicans and C. parapsilosis, although other nonalbicans species are being reported more frequently. Standard therapy has been amphotericin B; however, successful use of fluconazole as a single agent has also been reported and a small comparison trial demonstrated similar efficacy. The addition of new antifungal agents, including voriconazole and the echinocandins may further improve our ability to effectively treat these infections and possibly reduce the development of complications. Antifungal chemoprophylaxis has been studied in single-center and cohort studies, primarily using fluconazole. Although it is clear that fluconazole prophylaxis decreases the risk of fungal colonization and infection, identification of potential harm, particularly the development of or selection for resistant strains, requires further investigation with multicenter trials before widespread use is recommended outside of the clinical trial setting.

Section snippets

Epidemiology

The majority of fungal infections in the VLBW population are caused by C. albicans and C. parapsilosis, although almost all species of Candida have been implicated.20, 21, 22, 23 Epidemiologic studies have demonstrated that the pattern of transmission is most commonly vertical (from mother to infant) with C. albicans, and horizontal with C. parapsilosis (primarily in the presence of a central catheter).24, 25, 26, 27, 28 Bayley and colleagues first demonstrated the association between fungal

Diagnosis

Diagnosis of candidemia in this population is still primarily limited to standard blood culture, although the sensitivity of blood cultures for detection of Candida can be as low as 50% to 80%.41, 42 Recovery of Candida and/or a positive fungal smear from other normally sterile body fluids, such as urine and cerebrospinal fluid, also aids in the diagnosis. The use of other diagnostic testing methods, including biochemical markers, antigen assays, and polymerase chain reaction, is currently

Treatment

Despite the use of antifungal therapy, persistent infection, focal complications, and death are not uncommon sequelae of systemic Candida infections in premature neonates.17, 18, 19 In addition to pharmacologic treatment, prompt removal or replacement of any indwelling central catheter is recommended, if at all feasible.43 A small retrospective review of pediatric patients documented a significantly increased incidence of persistent candidemia, as well as a suggested increased risk of morality

Prevention

Difficulty with diagnosis and the persistence of significant morbidity and mortality despite antifungal agents have directed significant research efforts toward preventative strategies, including antifungal chemoprophylaxis. The wide variability in center-to-center reported rates of fungal infections suggest the potential relationship to center-specific practices. Standard preventative methods include strict hand washing, prompt removal of central catheters when no longer necessary, and prudent

Summary

Invasive Candida infections remain a significant cause of morbidity and mortality among the smallest infants in the neonatal intensive care unit. Improvement in diagnostic testing, further clinical investigation of the role of the newer generation azoles and echinocandins in the neonatal population, and well-designed multi-center trials of therapeutic and prophylactic pharmacologic agents as well as further delineations of best practices in infection control have significant potential for

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