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Selective Fluconazole Prophylaxis
McCrossan BA, McHenry E, O’Neill F, et al. Selective fluconazole prophylaxis in high-risk babies to reduce invasive fungal infection. Archives of Disease in Childhood – Fetal and Neonatal Edition 2007;92:F454-F458. Full Text | Full Text (PDF)
Objectives:
To evaluate the impact of selective fluconazole prophylaxis on
incidence of invasive fungal infection and emergence of fluconazole
resistance in neonatal intensive care.
Design:
Retrospective study of very low birth weight (VLBW) babies (<1500 g
birth weight) admitted to a neonatal intensive care unit (NICU) in
the period 1 year before and after the implementation of an
antifungal prophylaxis guideline.
Patients:
VLBW babies with an additional risk factor: colonization of
Candida species from surface sites with a central venous catheter;
third generation cephalosporin treatment; or total duration of
antibiotic treatment >10 days.
Fluconazole protocol:
Fluconazole 6 mg/kg for 3 weeks. Dose interval is every 72 h during
the first 2 weeks of life. Thereafter, dose interval is reduced to
every 48 h until 3 weeks old when daily fluconazole is given.
Fluconazole is administered orally when enteral feeding achieved.
Results:
121 and 107 VLBW babies were admitted to the NICU in the year before
and after the guideline were implemented, respectively. Data were
available in 110 and 102 charts. 33/110 and 31/102 babies were
eligible for fluconazole prophylaxis in the period before and after
guideline implementation. 6/33 babies eligible for prophylaxis
developed culture proven Candida sepsis before compared with
no (0/31) babies after the guideline was implemented (p = 0.03). One
baby (1/31) did develop probable Candida sepsis in the post
guideline implementation period. During both study periods all
Candida isolates remained fully susceptible to fluconazole.
Conclusions:
Selective antifungal prophylaxis has reduced invasive fungal sepsis
in one NICU without evidence of fluconazole resistance emerging.
Additional comments:
Date: 02 Dec 2007
Time: 20:26:08
Ample data now exist that either prophylaxis of all babies with fluconazole will
prevent colonization and invasive disease. There is a nice Cochrane review on
the topic which concludes that the main concern is development of resistant
strains of yeast. This current study, however needs to be viewed with some level
of skepticism in that it was entirely retrospective and unblinded. However, the
approach is rational. In the Kaufman studies, all babies were treated, but there
are ways to choose babies at higher risk and not over-expose lower risk
patients, which this retrospecive analysis does. I agree that units with a high
attack rate for yeast should consider prophylaxis, but I am not sure what is a
high attack rate. If, like Andy says, it's >4%, then one would need to treat >25
babies to prevent one infection, and that seems to be a lot to me.
UserName: David Burchfield, MD
Institution: University of Florida
telephone: 352-392-4195
email: burchdj@peds.ufl.edu
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