Original Article
Impact of Fluconazole Prophylaxis on Incidence and Outcome of Invasive Candidiasis in a Neonatal Intensive Care Unit

https://doi.org/10.1016/j.jpeds.2005.04.016Get rights and content

Objectives

We assessed the impact of intravenous fluconazole prophylaxis (FP) in extremely low birth weight (ELBW [<1000 g]) infants on the incidence of and outcome from invasive candidiasis (IC) in all infants admitted to a neonatal intensive care unit (NICU).

Study design

Beginning April 1, 2002, FP was given to ELBW infants aged < 5 days admitted to the NICU of Woman's Hospital of Texas. Infants in NICU in whom IC developed during the first 2 years of FP (FP period) were compared with those with IC during 2000–2001.

Results

During 2000–2001 and the FP period, the incidence of IC in ELBW infants decreased from 7% (15 of 206) to 2% (5 of 240) (P = .01), and the IC-related mortality rate decreased from 12% (4 of 33) to 0 (0 of 40) (P = .04); the incidence of IC increased from 0.1% (4 of 2806) to 0.2% (8 of 3372) in infants of birth weight ≥ 1000 g (P = .06), and no IC-related deaths occurred. During the FP period, IC developed in older infants (24 vs 12 days; P = .12) who had similar risk factors for IC.

Conclusion

Invasive candidiasis occurred in our NICU in spite of FP and shifted to bigger, more mature infants who had a better outcome.

Section snippets

Methods

WHT is a facility catering to women with uncomplicated and high-risk pregnancies, and more than 8000 deliveries have occurred annually since 1999. WHT has a 40-bed level III and 80-bed level II NICU staffed by 9 full-time neonatologists. In April 2002, a FP protocol based on that used by Kaufman et al4 was initiated in the NICU. Infants were eligible for FP if they were ELBW, aged ≤ 5 days, and did not have “liver failure” (defined as hepatomegaly, jaundice, conjugated hyperbilirubinemia, and

Infants Who Received Fluconazole Prophylaxis

During the FP period, 196 of 240 (82%) ELBW infants admitted to NICU received FP. Nineteen infants with BW ≥ 1000 g also received FP, so a total of 215 infants (median BW 765 g [range 315–1215]; median gestation 26 weeks [range 23–32]) received a median of 16 doses of fluconazole over a median of 32 days. Seventy of 215 (33%) infants completed 6 weeks of FP. Fluconazole was discontinued early in 117 (54%) because intravenous access no longer was needed, 17 (8%) died of unrelated causes, 5

Discussion

The emergence of Candida as a major pathogen in neonates is a phenomenon evolving in tandem with the survival of increasingly preterm and low BW infants.1, 2, 3, 5, 6, 7, 8, 9, 10 Many risk factors associated with the development of IC in these vulnerable infants are unavoidable because they represent the consequence of manipulations attendant to the intensive care required in the first few weeks of life. Like many neonatal conditions, the clinical manifestations of IC are nonspecific, and

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Presented in part at the Pediatric Academic Societies' Annual Meeting, May 1-4, 2004, San Francisco, CA (Abstract 2244) and at the Annual Meeting of Infectious Disease Society of America, September 30-October 3, 2004, Boston, MA (Abstract 249).

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