Outcomes of neonatal candidiasis: the impact of delayed initiation of antifungal therapy

Current Trends in Antifungal Prophylaxis for High-Risk Neonates in Neonatal Intensive Care Units in India: A Nationwide Survey

Background Prophylactic antifungals are often used in high-risk babies in neonatal intensive care units (NICUs) to reduce invasive fungal infections (IFIs). However, existing guidelines regarding prophylactic antifungal usage do not clearly define the high-risk population. This study aimed to assess the practices related to prophylactic antifungal use in NICUs in India. Methods For this cross-sectional study, an online structured questionnaire was completed by neonatologists who worked in level 3 NICUs in 12 states in India during the period June 2022 to August 2022. Results Data from 151 NICUs were analyzed. 71.7% of respondents were from private hospitals, and 28.3% were from government hospitals. Nearly one-fourth of the units (28.5%) used antifungal prophylaxis in all extremely low birth weight (ELBW) babies, while another one-fourth (25.8%) used a case-based approach. The remaining NICUs (45.7%) did not use prophylactic antifungals. Among the users, the preferred antifungal was fluconazole; 3 mg/kg and 6 mg/kg were the dosage regimens used. The commonly used interval for administering fluconazole was 72 hours (69.2% of units). The intravenous route was the preferred route of administration (84.1%). Factors that influenced the non-users were the low incidence of fungal infections in their NICUs and concern about the development of resistance. It was noted that the users felt strongly about the need for further recommendations from pediatric societies and more studies on the efficacy of antifungals. Conclusion There is considerable variation in the use of prophylactic antifungals across NICUs in India. Among the users, uniformity in the choice of antifungal and interval of administration was observed. Further recommendations from pediatric societies, including the definitions of neonates at-risk of fungal infections, are required to ensure consistency in practice and help clinicians decide whether or not to use prophylactic antifungals.

Neonatal invasive candidiasis: updates on clinical management and prevention

Neonatal invasive candidiasis is an important cause of morbidity and mortality in preterm infants. The incidence of invasive candidiasis in this population has been declining in high-income settings, largely due to preventive measures, although there are still considerable variations in incidence between health-care centres. Surveillance data and large, multicentre studies in lower-income settings are not available, although preventive measures in these settings have been shown to decrease the incidence of neonatal invasive candidiasis. Understanding risk factors and pathogenesis are key to the prevention of invasive candidiasis. The difficulty of a definitive diagnosis of invasive candidiasis and the high risk for death or substantial neurodevelopmental impairment, even with appropriate treatment, further increase the need for effective preventive measures. In this Review, we examine the pathogenesis, clinical presentation, and diagnosis of invasive candidiasis. We highlight commonly used and emerging preventive and prophylactic measures, including standardised central line care, antibiotic stewardship, antifungal prophylaxis, and probiotics. Finally, we provide updates on empirical treatment, clinical management in confirmed cases of invasive candidiasis, and antifungal pharmacotherapy.

Postnatal Sepsis and Bronchopulmonary Dysplasia in Premature Infants: Mechanistic Insights into "New BPD"

Bronchopulmonary dysplasia (BPD) is a debilitating disease in premature infants resulting from lung injury that disrupts alveolar and pulmonary vascular development. Despite the use of lung-protective ventilation and targeted oxygen therapy, BPD rates have not significantly changed over the last decade. Recent evidence suggests that sepsis and conditions initiating the systemic inflammatory response syndrome in preterm infants are key risk factors for BPD. However, the mechanisms by which sepsis-associated systemic inflammation and microbial dissemination program aberrant lung development are not fully understood. Progress has been made within the last 5 years with the inception of animal models allowing mechanistic investigations into neonatal acute lung injury and alveolar remodeling due to endotoxemia and NEC. These recent studies begin to unravel the pathophysiology of early endothelial immune activation via pattern recognition receptors such as Toll Like Receptor 4 and disruption of critical lung developmental processes such as angiogenesis, extracellular matrix deposition, and ultimately alveologenesis. Here we review scientific evidence from preclinical models of neonatal sepsis-induced lung injury to new data emerging from clinical literature.

[Clinical value of droplet digital PCR in rapid diagnosis of invasive fungal infection in neonates]

OBJECTIVE

To evaluate the clinical value of droplet digital PCR (ddPCR) in rapid and accurate diagnosis of invasive fungal infection (IFI) in neonates.

METHODS

The highly conserved sequence of fungi 18S RNA was selected as the target sequence, and primers were designed to establish a ddPCR fungal detection system. Blood samples were collected from 83 neonates with high-risk factors for IFI and/or related clinical symptoms in the neonatal intensive care unit (NICU) of a hospital in Shenzhen, China. Blood culture and ddPCR were used for fungal detection.

RESULTS

The ddPCR fungal detection system had a specificity of 100% and a sensitivity of 3.2 copies/μL, and had a good reproducibility. Among the 22 blood samples from neonates with a confirmed or clinical diagnosis of IFI, 19 were detected positive by ddPCR. Among the 61 blood samples from neonates who were suspected of IFI or had no IFI, 2 were detected positive by ddPCR.

CONCLUSIONS

The ddPCR technique can be used for the detection of neonatal IFI and is a promising tool for the screening and even diagnosis of neonatal IFI.

Invasive Fungal Infections in Neonates in Canada: Epidemiology and Outcomes

BACKGROUND

Neonatal fungemia is associated with adverse neonatal outcomes and higher overall healthcare expenditure. Our objective is to review the epidemiology of invasive fungal infections (IFIs) in neonates in Canada.

METHODS

A retrospective cohort study using data collected by the Canadian Neonatal Network (CNN) was conducted. Using a nested matched cohort study design, risk factors and outcomes of neonates born <33 weeks gestation (n = 39,305) during 2003-2013 were compared between neonates diagnosed with an IFI during their stay to infection-free controls.

RESULTS

Overall incidence of IFI among all admitted neonates was 0.22% (n = 286), while the incidence of IFI in the group of neonates born <33 weeks gestation was 0.64%. Of the isolates, 170 (59%) had Candida albicans and 59 (21%) had Candida parapsilosis. Risk factors for IFI were lower gestation, male sex, Apgar score <7 at 5 minutes, higher severity of illness score, maternal diabetes and vaginal birth. Neonates with IFI had higher odds of mortality [adjusted odds ratio (aOR): 1.60; 95% confidence interval (CI): 1.06-2.43], necrotizing enterocolitis (aOR: 2.97; 95% CI: 1.76-5.01) and severe retinopathy of prematurity (aOR: 2.15; 95% CI: 1.26-3.67).

CONCLUSIONS

The overall incidence of IFI in neonates was low in Canada in comparison to other large population cohort studies; however, the mortality and morbidity remained high.

Role of Early Onset Neutropenia in Development of Candidemia in Premature Infants

BACKGROUND

The aim of the study was to assess the effect of early-onset neutropenia (EON) on the development of candidemia in premature infants and evaluate other risk factors.

MATERIALS AND METHODS

This prospective study was carried out in a neonatal intensive care unit of Cairo University Hospital. Fifty neutropenic premature infants were matched to 50 non-neutropenics. Subjects were then regrouped into candidemics and non-candidemics to study other risk factors such as central venous catheters, mechanical ventilation, parenteral nutrition, drugs as corticosteroids and others. Candidemia was assessed by Bactec and then seminested polymerase chain reaction for culture negatives.

RESULTS

Candidemia developed in 28 neutropenic preterms and in 8 non-neutropenics (odds ratio  = 6.68, 95% confidence interval = 2.61-17.1, p <0.001). Risk factors for invasive fungal infection in univariate analysis included bacterial septicemia, mechanical ventilation, parenteral nutrition and steroid therapy. Independent predictors of candidemia in multivariate regression analysis included EON, mechanical ventilation and steroid therapy.

CONCLUSION

EON is an independent risk factor for candidemia in premature infants.

Epidemiology of Invasive Fungal Disease in Children

Considerable progress has been made in the prevention, diagnosis, and management of pediatric patients with invasive fungal disease (IFD). The reported decreasing trend in the incidence of invasive candidiasis (IC) over the past 15 years in both neonates and children has been encouraging. Nevertheless, due to the growing number of immunocompromised children at risk for IFD, this disease continues to be associated with significant morbidity and death and with increased financial burden to the health care system. Therefore, it is important to understand the contemporary epidemiology of IFD. Incidence rates of IFD in children are affected by geographical, population, and time variability. There is an ongoing effort to constantly document and update the incidence of IFD and species distribution among different pediatric populations as a means to direct preventative, diagnostic, and therapeutic resources to the most appropriate subset of patients. Children with a hematologic malignancy or a primary or secondary immunodeficiency, those undergoing solid organ or hematopoietic stem cell transplantation, and premature neonates are the major subsets of pediatric patients at risk of developing IFD. In this review, we focus on fungal disease epidemiology with a specific emphasis on the 2 most common pediatric IFDs, IC and invasive aspergillosis (IA).

Fatal Neonatal Peritoneal Candidiasis Mimicking Mucormycosis-A Case Report and Review of Literature

Candida species have been implicated as significant contributors to morbidity in the neonatal period and are associated with 25-50% of mortality in invasive neonatal candidiasis. Peritoneal candidiasis, being paucisymptomatic, cannot often be correctly identified in a preterm neonate. The correct approach to diagnosis of neonatal peritoneal candidiasis is taking into account the epidemiology along with a strong clinical suspicion and appropriate timely diagnostic interventions. We report a case of fatal neonatal peritoneal candidiasis which was misdiagnosed as mucormycosis.

Blood product transfusions are associated with an increase in serum (1-3)-beta-d-glucan in infants during the initial hospitalization in neonatal intensive care unit (NICU)

INTRODUCTION

Serum (1-3)-beta-d-glucan (BDG) assay has been proposed as an adjunct for the rapid diagnosis of invasive fungal infection (IFI). However, false-positive results have been reported following transfusion of blood products in adults.

AIMS

To assess the relationship between blood product transfusion and elevated BDG in neonates.

METHOD

Retrospective study including neonates ≤32 weeks, with no fungal colonization or infection, in whom BDG assay was performed for suspicion of IFI. Patients were classified in Transfusion (n = 78) and No Transfusion (n = 55) groups depending on whether or not they were transfused. Clinical, biochemical and microbiological characteristics were recorded. A BDG assay >80 pg/mL was considered as positive.

STATISTICAL ANALYSES

bivariate and multivariate logistic regression. Results (median, IQR): One hundred and thirty-three infants were included (gestational age 28.4 weeks, 26.9-30; birth weight 1000 g, 847-1300). BDG was higher in the Transfusion group (170 pg/mL, 65-317) than in the No Transfusion group (57 pg/mL, 34-108; p < 0.001). False-positive BDG assay results were associated with red blood cells (RBC) and fresh frozen plasma (FFP) transfusions.

CONCLUSION

BDG is increased after RBC and FFP transfusions in neonates, leading to overdiagnosis of IFI. Fungal colonization status in peripheral sites and central cultures could help to reduce the risk of misdiagnosis.

Species-based comparison of disease severity and risk factors for disseminated Candida infections in pediatric patients

Background

Pediatric Candida infections are associated with worse clinical outcomes and increased costs. Yet, it is not definitively known if particular species are associated with more severe illness. Differential risk factor exposures among the species group may also exist. We aimed to determine whether certain Candida species are more strongly associated with worse outcomes, and whether certain risk factors more strongly predispose patients to infection with certain species.

Methods

Microbiology lab records from patients seen from 2003 to 2010 at an urban children’s hospital were reviewed for invasive or disseminated Candida infections. Data on measures of disease severity/outcome and risk factors were abstracted and analyzed to determine differences associated with various Candida species.

Results

Exactly 106 cases of infection were analyzed. Non-albicans species were associated with a significantly longer length of stay postdiagnosis (P=0.03), as well as longer treatment (P=0.02). Candida albicans was associated with a higher number of antihypotensive medications required (P=0.03) and length of mechanical ventilation postdiagnosis (P=0.05). Candida tropicalis was associated with the highest mortality (45.5%). Hypotension, which was found to be significantly associated with concurrent infection, was significantly associated with increased risk of mortality (odds ratio =5.85, P=0.005). Initial choice of antifungal therapy was not associated with differences in eventual patient mortality. Multivariate logistic regression modeling revealed a trend toward C. albicans infection in patients receiving antineoplastic chemotherapy and non-albicans infection in patients with >96 hours mechanical ventilation.

Conclusion

Interspecies differences may exist for Candida in terms of disease severity and risk factors. Underlying morbidity and the role of concurrent infections may play a key role in poor outcomes.

The epidemiology and diagnosis of invasive candidiasis among premature infants

Invasive candidiasis is a leading infectious cause of morbidity and mortality in premature infants. Improved recognition of modifiable risk factors and antifungal prophylaxis has contributed to the recent decline in the incidence of this infection among infants. Invasive candidiasis typically occurs in the first 6 weeks of life and presents with nonspecific signs of sepsis. Definitive diagnosis relies on the growth of Candida in blood culture or cultures from other normally sterile sites, but this may identify fewer than half of cases. Improved diagnostics are needed to guide the initiation of antifungal therapy in premature infants.

Invasive candidiasis and candidaemia in neonates and children: update on current guidelines

Invasive candidiasis (IC) and candidaemia are leading causes of infectious morbidity and mortality among immunocompromised paediatric patients and those admitted to intensive care units. Despite improvements in diagnosis, prevention and treatment, both mortality rates and the economic burden of disease still remain high. To address this issue, several international societies and organisations have proposed guidelines for the management of IC/candidaemia in both neonates and children. In this article, we review current recommendations of the Infectious Diseases Society of America, the European Conference on Infection in Leukaemia, the European Society of Clinical Microbiology and Infectious Diseases and the German Speaking Mycological Society/Paul-Ehrlich Society for Chemotherapy for the management and prevention of IC/candidaemia in children and neonates.

Neonatal invasive fungal infection in England 2004-2010

Rates of invasive fungal infection are highest among neonates, especially those of low birthweight. This study aimed to describe the current epidemiology of invasive neonatal fungal infections in a UK neonatal infection surveillance network. From 2004 to 2010 prospective multicentre surveillance was conducted by 14 neonatal units using a web-based database. Clinicians then completed a standardized pro forma for each positive fungal blood and/or cerebrospinal fluid culture. The overall incidence was 2.4/1000 neonatal unit admissions and was highest among babies <1000 g (extreme low birthweight, 18.8/1000). Only five infants (6%) were >1500 g. The majority of infections were caused by Candida albicans (59; 69%) and Candida parapsilosis (17; 20%); 33% of infants had received antifungal prophylaxis. Known risk factors (use of central venous catheter, parenteral nutrition, previous antibiotic use) were common among cases. The attributable case fatality rate was 21% (18/84). Extreme low birthweight infants remain at highest risk of invasive fungal infection and prophylaxis should be particularly considered for this group. The number needing to receive prophylaxis to prevent one case varies significantly among units, hence unit-specific decisions are required. Further research is still needed into the optimal empiric and therapeutic strategies.

Invasive candidiasis and oral manifestations in premature newborns

Objective:

To investigate prevalence of invasive candidiasis in a Neonatal Intensive Care Unit and to evaluate oral diseases and Candida spp. colonization in low birth weight preterm newborns.

Methods:

A descriptive epidemiological study performed in two stages. First, prevalence of candidiasis was analyzed in a database of 295 preterm patients admitted to hospital for over 10 days and birth weight less than 2,000g. In the second stage, oral changes and Candida spp. colonization were assessed in 65 patients weighing less than 2,000g, up to 4 week-old, hospitalized for over 10 days and presenting oral abnormalities compatible with fungal lesions. Swab samples were collected in the mouth to identify fungi.

Results:

Prevalence of candidiasis was 5.4% in the database analyzed. It correlated with prolonged hospital length of stay (p<0.001), in average, 31 days, and 85% risk of developing infection in the first 25 days. It correlated with low birth weight (p<0.001), with mean of 1,140g. The most frequent alterations were white soft plaques, detachable, in oral mucosa and tongue. Intense oral colonization by Candida spp was observed (80%).

Conclusions:

The frequency of invasive candidiasis was low and correlated with low birth weight and prolonged hospital stay. The most common oral changes were white plaques compatible with pseudomembranous candidiasis and colonization by Candida spp. was above average.

Bacterial and fungal viability in the preterm gut: NEC and sepsis

BACKGROUND AND AIMS

Evidence suggests that microbial communities in the preterm gut may influence the development of necrotising enterocolitis (NEC) and sepsis. Existing data often neglect fungi and whether bacteria were metabolically active or not. We sought to characterise the bacterial and fungal stool flora of preterm neonates and organism viability and evaluate any associations with NEC and sepsis.

PATIENTS

136 stools from 32 patients (<32 weeks gestation) were collected between birth and day 95. Seven infants developed NEC and 13 sepsis.

METHODS

Stools were analysed by PCR-DGGE for assessment of the total bacterial and fungal communities by analysis of 16S rRNA and 28S rRNA, respectively. In 65 samples (25 infants), the viable (RNA) bacterial and fungal communities were analysed. Analyses were performed to examine the possible effects of demographic or treatment related factors and the development of NEC or sepsis.

RESULTS

80 (66 viable) bacterial species were identified overall and 12 fungal (none viable). Total bacterial communities significantly differed between healthy infants and those with NEC or sepsis, with Sphingomonas spp. significantly associated with NEC. Significant drivers of community structure differed based on either total or viable analysis. Antifungal prophylaxis was associated with altered bacterial community and a reduction in bacterial richness was observed in week 4, correlating with high antibiotic exposure.

CONCLUSIONS

Total and viable communities differ in preterm infants, and non-viable fungal species are present in infants on fungal prophylaxis. Exploration of viability and non-bacterial contributors to the total community may increase understanding of NEC and sepsis.