Aiming for Zero: Preventing Invasive Candida Infections in Extremely Preterm Infants

Abstract

Strong evidence shows that prevention of invasive Candida infections (ICI) can be achieved by every neonatal intensive care unit (NICU). Due to the incidence of ICI and high infection-associated mortality and neurodevelopmental impairment, antifungal prophylaxis should be targeted to infants weighing less than 1,000 g or born at or before 27 weeks' gestation. Even in NICUs that have low rates of ICI, antifungal prophylaxis is crucial to improving survival and neurodevelopmental outcomes in this vulnerable population. Strong evidence supports the use of both fluconazole and nystatin for such prophylaxis. Fluconazole is preferred in high-risk preterm infants because intravenous (IV) fluconazole prophylaxis has greater efficacy compared with enteral nystatin prophylaxis, is effective in the most immature patients, is less expensive, requires fewer doses, and can be administered to infants who have gastrointestinal disease or hemodynamic instability. For infants weighing 1,000 to 1,500 g, either drug could be chosen for prophylaxis. Fluconazole prophylaxis administered at 3 mg/kg twice a week, starting after birth and requiring central or peripheral access, appears to be the safest and most effective schedule in preventing ICI while attenuating the emergence of fungal resistance.