Neonatal candidiasis: Diagnosis, prevention, and treatment
Introduction
Infection with Candida species is associated with significant morbidity and mortality in infants. Extremely low birth weight (ELBW; <1000 g) infants carry the highest burden of disease. The incidence of candidiasis in ELBW infants is approximately 10%, although it varies as much as 20-fold between centers.1, 2 Neonatal candidiasis is associated with 20% mortality, and 50% of survivors have severe neurodevelopmental impairment.3 End-organ damage in the central nervous system, heart, and genitourinary tract is also common.4 Few clinical signs or laboratory assays have been validated for candidiasis in infants, thus prevention of infection is critical. When infection occurs, treatment with appropriate antimicrobial agents must be prompt.
Section snippets
Diagnosis
The blood culture is the gold standard for detection of candidiasis, although its sensitivity is poor.5 Even with multiple organs infected with candidiasis, the sensitivity of blood culture to detect infection in adults is only 50%.6 The small blood volume used for culture in infants makes isolation of Candida species in blood (candidemia) even more difficult. Because four or more vital organs are typically involved prior to documentation of candidemia, a positive blood culture for Candida
Prevention
Previous investigators have identified risk factors associated with Candida infection in infants.3, 13 Some of these risk factors, such as gestational age and birth weight, cannot be altered. However, multiple modifiable risk factors have been identified; foremost among these is prolonged exposure to empiric antibiotics (greater than 48 h despite negative blood cultures) and exposure to third-generation cephalosporins and other broadly-acting antibiotics such as carbapenems and
Treatment
Prompt treatment is critical to improving outcomes for infants with candidiasis. If clinicians await a positive blood culture prior to starting therapy, treatment can be delayed as much as 72 h. In ELBW infants, empirical antifungal therapy (receipt of therapy on the day of or the day before the first positive blood culture for Candida) is associated with increased survival without neurodevelopmental impairment.17 Thus, empirical antifungal therapy should be considered in high-risk infants once
Summary and recommendations
Candidiasis in the intensive care nursery results in substantial morbidity and mortality. Prevention of infection is possible via modification of risk factors. Early diagnosis is critical, and treatment should be initiated promptly with appropriate antifungal agents. Empirical antifungal therapy should be considered when Candida is suspected in ELBW infants. When infection with Candida is diagnosed, the following steps should be followed:
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Central venous and arterial catheters should be removed.
Conflicts of interest
Dr. Benjamin receives support from the United States Government for his work in pediatric and neonatal clinical pharmacology (1R01HD057956-05, 1K24HD058735-05, UL1TR001117, and NICHD contract HHSN275201000003I) and the nonprofit organization Thrasher Research Fund for his work in neonatal candidiasis (www.thrasherresearch.org); he also receives research support from industry for neonatal and pediatric drug development (www.dcri.duke.edu/research/coi.jsp). Dr. Greenberg has no potential
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