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Neonatal Fungal Consumption – Can We Agree to Disagree?

Reviewed by Joseph Ting, MBBS, MPH, University of British Columbia

Neonatal antifungal prophylaxis is commonly prescribed outside the recommendations based on known risk profiles. Neonates are vulnerable to invasive candidiasis (IC), which is associated with poor outcomes in terms of mortality and neurodevelopmental morbidity.  The clinical presentation of IC in neonates and young infants is indistinguishable from late-onset bacterial sepsis. The majority of antifungal agents licensed for use in older infants and children and/or adults have no neonatal dosing recommendations. Due to the diagnostic difficulties combined with the vulnerability of neonates to develop IC, antifungals may be prescribed prophylactically or empirically to prevent delayed treatment and a worse outcome. The drawback of these approaches is the risk of overuse and potentially inappropriate use of antifungal drugs.

Ferreras-Antolin L et al conducted a modified point-prevalence study, including neonates and infants ≤90 days of age receiving systemic antifungals from 12 centers in England. Data were collected prospectively during 26 consecutive weeks.This study included two hundred eighty neonates and infants, with the majority (68.2%). ≤1 month of age. Prematurity was the commonest underlying condition (68.9%). Antifungals were prescribed for prophylactic reason in 79.6%; of those, 64.6% and 76.3% were extreme low birth weight infants and prematurely born neonates, respectively. Additional risk factors were present in almost all patients, but only 44.7% had ≥3 risk factors rendering them more susceptible to IC. Non-premature and non-extremely low birth weight premature infants only scored ≥3 risk factors in 32.6% and 15%, respectively. Fluconazole was the most common antifungal used (76.7% of all prescriptions) and was commonly under dosed. The number of microbiologic proven IC was low at 5.4%.

These observations should be taken into consideration to develop a national pediatric Antifungal Stewardship program aiming to guide rational prescribing.

Reference:

Ferreras-Antolín L, Irwin A, Atra A, Dermirjian A, Drysdale SB, Emonts M, McMaster P, Paulus S, Patel S, Kinsey S, Vergnano S, Whittaker E, Warris A. “Neonatal Antifungal Consumption Is Dominated by Prophylactic Use; Outcomes From The Pediatric Antifungal Stewardship: Optimizing Antifungal Prescription Study.” Pediatr Infect Dis J. 2019; 38(12): 1219-1223. https://www.ncbi.nlm.nih.gov/pubmed/31568253 

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