Fluconazole prophylaxis in the very low birth weight infant: not ready for prime time.

Abstract

Candida species are now the fourth leading cause of nosocomial bloodstream infections (8%) across all age groups with the highest crude mortality (40%).1Among children, neonates, particularly the increasing numbers of very low birth weight (VLBW) premature infants (<1500 g), are at great risk. The National Epidemiology of Mycosis Study Group reported that over a 2-year period, in 6 neonatal intensive care units (NICUs) across the country, 1.2% of all neonates developed candidemia, and of these, 82% were VLBW. The crude mortality of the infants with candidemia was 23%, compared with 4.7% of those without fungal disease.2 Furthermore, invasive candidiasis in the NICU is becoming more common. From 1981 to 1995, the number of cases of candidemia in one NICU increased from 2.5/1000 to 28.5/1000.3 In this issue of Pediatrics , Kicklighter et al4provide a well-designed, prospective, double-blinded, randomized, placebo-controlled, intention-to-treat study to determine if prophylactic fluconazole given to VLBW infants during the first 28 days of life decreases the incidence of candidal colonization. This is an important question to address, not so much because colonization with Candida is unusual, but because in this age group it is a primary risk factor for the subsequent development of invasive candidiasis and meningitis.5,6 They found an overall reduction in rectal colonization of approximately two-thirds from 46% to 15% in the placebo and treated groups, respectively. Despite these results, one must consider several criteria before using prophylactic antimicrobial agents: 1) What is the most appropriate clinical variable to monitor, and does the medication positively affect that variable? 2) Which patients are at high risk and could benefit from prophylaxis? 3) Do adverse effects outweigh benefits? 4) How long should prophylaxis continue? 5) What is the effect on population organism resistance patterns? 6) Is it cost-effective to use …