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Fluconazole prophylaxis: can we eliminate invasive Candida infections in the neonatal ICU?
1Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia 22908, USA. dak4r@virginia.edu
Insights
Fluconazole prophylaxis in extremely preterm infants significantly reduces invasive Candida infections and mortality. This preventative measure is safe, effective, and can eliminate Candida as a cause of death and neurodevelopmental impairment in neonatal intensive care units.
Area of Science:
- Neonatal Medicine
- Infectious Diseases
- Pharmacology
Background:
- Invasive fungal infections, particularly Candida, pose a significant threat to extremely preterm neonates, leading to high mortality and neurodevelopmental impairment.
- Current treatments for invasive Candida infections in neonates have high mortality rates and risk of long-term complications.
Purpose of the Study:
- To evaluate the efficacy and safety of fluconazole prophylaxis in preventing invasive Candida infections in high-risk neonatal populations.
- To determine the impact of fluconazole prophylaxis on mortality and neurodevelopmental outcomes in extremely preterm infants.
Main Methods:
- Systematic review and analysis of multiple studies, including a recent multicenter randomized controlled trial, investigating fluconazole prophylaxis in infants.
- Analysis focused on infants weighing less than 1000 grams and less than or equal to 27 weeks gestational age.
Main Results:
- Fluconazole prophylaxis demonstrated significant reductions in invasive Candida infections: 91% in infants <1000 g and 85% in infants <1500 g.
- Overall mortality was reduced by 25% in infants receiving fluconazole prophylaxis.
- No increase or emergence of fungal resistance was observed with fluconazole use.
Conclusions:
- Targeted fluconazole prophylaxis in infants <1000 g or < or =27 weeks is a highly effective, safe, and inexpensive strategy.
- This preventative approach can eliminate invasive Candida infections as a cause of mortality and neurodevelopmental impairment in neonatal intensive care units.
Purpose Of Review:
Owing to the high mortality, risk of neurodevelopmental impairment and end-organ involvement with fungal infections in the neonate, prevention of invasive Candida infections in extremely preterm infants should be a priority for each neonatal ICU.
Recent Findings:
Even with prompt or empiric treatment, mortality and neurodevelopmental impairment is high (57%) in infants <1000 g. Multiple studies have been performed with fluconazole prophylaxis, including a recent multicenter randomized controlled trial. All of the studies have demonstrated efficacy and safety with no increase or emergence of fungal resistance. Analysis of these studies demonstrates that fluconazole prophylaxis decreased the incidence of invasive Candida infections in high-risk infants <1000 g by 91% (P = 0.0004) and all infants <1500 g by 85% (P < 0.0001). The mortality rate from all causes was 25% lower (P = 0.029). Furthermore, studies have demonstrated that all Candida-related mortality can be eliminated in an entire neonatal ICU by targeting fluconazole prophylaxis in infants <1000 g.
Summary:
Targeting fluconazole prophylaxis to infants who are either <1000 g or < or =27 weeks is highly effective, safe and inexpensive, and can eliminate these infections as a cause of neurodevelopmental impairment and mortality.
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