Empirical Candida Coverage

Empirical Therapy for Neonatal Candidemia in Very Low Birth Weight Infants . Benjamin DK, DeLong ER, Steinbach WJ, et al. Pediatrics (Sept 2003) ; 112: 543-547.

Objective. Neonatal Candidemia is often fatal. Empirical antifungal therapy is associated with improved survival in neonates and patients with fever and neutropenia. Although guidelines for empirical therapy exist for patients with fever and neutropenia, these do not exist for neonates.

Methods. A multicenter, retrospective, cohort study was conducted of neonatal intensive care unit patients (N = 6172) who had a blood culture (N = 21 233) after day of life 3 and whose birth weight was 1250 g. We performed multivariable conditional logistic regression of risk factors for Candidemia. From the regression modeling coefficients, we developed a Candidemia score.

Results. In multivariable modeling, thrombocytopenia (odds ratio [OR]: 3.56; 95% confidence interval [CI]: 2.68–4.74) and cephalosporin or carbapenem use in the 7 days before obtaining the blood culture (OR: 1.77; 95% CI: 1.33–2.29) were risk factors for subsequent Candidemia. Children who were 25 to 27 weeks’ estimated gestational age (OR: 2.02; 95% CI: 1.52–3.05) and children who were born at <25 weeks (OR: 4.15; 95% CI: 3.12–6.29) were at higher risk of developing Candidemia than were children who were born at 28 weeks. We developed a Candidemia score on the basis of the ORs from the multivariable model. Children with a Candidemia score 2 points were classified as having a "positive" score, and a score of 2 points had a sensitivity of 85% and a specificity of 47%.

Conclusions. We developed a clinical predictive model for neonatal Candidemia with high sensitivity and moderate specificity for Candidemia. On the basis of our model, when a physician obtains a blood culture, the physician should consider providing antifungal therapy to neonates who are < 25 weeks’ estimated gestational age and to neonates who have thrombocytopenia at the time of blood culture. In addition, if a physician obtains a blood culture from a child who is 25 to 27 weeks’ estimated gestational age and is not thrombocytopenic but has a history of third-generation cephalosporin or carbapenem exposure in the 7 days before the blood culture, then the physician should consider administration of empirical antifungal therapy.

Comments. Fungal sepsis in very low birth weight infants is a rare occurrence in some NICUs, and is more common in others. The higher incidence in some is units is likely to be associated with increased use of broad-spectrum antibiotics, more central line days, more days on hyperal and Intralipids, routine use of ranitidine, and/or less-aggressive enteral feeding practices. If nosocomial fungal sepsis is not uncommon in your NICU, then consider adding empirical fungal coverage when sepsis is suspected if EGA < 25 weeks, or if EGA < 28 weeks and baby has thrombocytopenia or recent exposure to third-generation cephalosporin or carbapenem antibiotics. You might also consider adding routine fluconazole prophylaxis for all babies born at < 1 Kg (see 2-002). ABK

Date: 02 Nov 2003
Time: 05:23:47

Routine fluconazole prophylaxis for all babies born at < 1 Kg has not been successful in our unit (observation only). We are left with no choice but to be more agressive (treating earlier) when we have the infections. Oxxasionally we felt that since the baby was on prophylactic fluconazole, the "infection" must be bacterial so we were often delayed in actually treating yeast sepsis.

UserName: Mitchell Stern, MD
Institution: Plantation General
email: neomd@aol.com

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