Strategies to prevent invasive candidal infection in extremely preterm infants

Area of Science:

• Neonatal Medicine
• Infectious Diseases
• Pharmacology

Background:

• Extremely preterm infants (<1000 g birth weight, ≤27 weeks' gestation) have the highest incidence of invasive candidal infection (ICI).
• ICI in this vulnerable population leads to high mortality, significant neurodevelopmental impairment, and increased healthcare costs.
• Current practices debate the superiority of empiric therapy or infection control over prophylaxis, and the optimal strategy for managing ICI in neonates.

Purpose of the Study:

• To evaluate the efficacy and safety of antifungal prophylaxis in preventing ICI in preterm infants.
• To compare the effectiveness of fluconazole versus nystatin for antifungal prophylaxis.
• To advocate for universal implementation of antifungal prophylaxis in neonatal intensive care units (NICUs).

Main Methods:

• Review of randomized clinical trials and retrospective studies on antifungal prophylaxis in preterm infants (<1000 g).
• Comparison of fluconazole prophylaxis efficacy against nystatin prophylaxis.
• Analysis of clinical trial evidence for the safety and effectiveness of antifungal prophylaxis.

Main Results:

• Fluconazole prophylaxis decreased ICI by 88% in infants <1000 g, significantly outperforming nystatin (54% reduction).
• Fluconazole is more efficacious, cost-effective, requires less frequent dosing, and offers administration flexibility compared to nystatin.
• No emergence of azole resistance has been observed with targeted prophylaxis in high-risk infants.

Conclusions:

• Antifungal prophylaxis, particularly with fluconazole, is a highly effective and safe strategy for preventing ICI in preterm infants.
• Universal implementation of antifungal prophylaxis in all NICUs is recommended to maximize the reduction of ICI, Candida-related mortality, and neurodevelopmental impairment.
• Despite strong evidence, universal adoption of antifungal prophylaxis remains inconsistent, highlighting a need for improved clinical practice guidelines.