Neonatalogists differ on antifungal prophylaxis practices

June 2005

WASHINGTON — Antifungal prophylaxis to prevent candidemia was only used by one-third of neonatologists who responded to a recent survey.

The survey results, presented in an abstract here at the Pediatric Academic Societies meeting, underscore the need for clinical criteria to identify high-risk infants who may benefit from prophylaxis, according to the researchers.

“About 50,000 very low birth weight infants (weight <1,500g) are born each year in the United States, and approximately 4% of these develop bloodstream infections with Candida,” said the study’s lead researcher Lauren Burwell, MD. Burwell is an epidemic intelligence service officer in the Mycotic Diseases Branch of the CDC.

Because the rates of invasive candidiasis in neonatal care units rates range between 1% and 4%, criteria to establish which babies are most at risk is very important.

Researchers surveyed 20% of the 2,354 members of the AAP’s Perinatal Section. The survey asked about prophylactic use and indications for use.

Forty-eight of the 216 respondents used fluconazole (Diflucan, Pfizer) extensively to prevent candidemia, and 73 reported using any type of prophylaxis, such as nystatin (59%), amphotericin B (21%), or some other agent.

The abstract’s researchers noted that gestational age or a very low birth weight often dictated the respondent’s decision to initiate antifungal prophylaxis.

“Of the 57 who used birth weight or gestational age as an indication to start antifungal prophylaxis, many required additional criteria before the initiation of antifungal prophylaxis — the presence of a central venous catheter, colonization with Candida spp., prior antimicrobial use, prior abdominal surgery or disease or mechanical ventilation,” they wrote.

The researchers said those who were surveyed and did not use antifungal prophylaxis were most concerned about antifungal resistance. Many of the surveyed participants said that they needed more guidance for prophylaxis use before they used it routinely. However, the researchers added, “respondents who used antifungal prophylaxis were as likely as those who did not use antifungal prophylaxis to believe that further efficacy studies … were needed (69% vs. 74%, P = 0.49).”

Burwell told Infectious Diseases in Children that her team’s findings indicated a need for a more “standardized approach to antifungal prophylaxis.”

For more information:

• Burwell LA, Kaufman D, Stoll BJ, et al. Prevention of neonatal candidemia in the United States: description of current antifungal prophylaxis practices of neonatologists. #646. Presented at the Pediatric Academic Societies Annual Meeting. May 14-17, 2005. Washington.