Summary Colonization with Candida is common in newborns. Candida albicans is the most prevalent species but others eg C. parapsilosis are also seen. Candidal infections range from relatively benign oral and cutaneous candidiasis to severe and fatal congenital and systemic infection. Acquisition of candida may occur in utero by the ascending route from the vagina or more commonly during birth or nosocomially from other colonized/infected babies. Topical decontamination of colonized babies may prevent cross infection and invasive disease. Amphotericin remains the treatment of choice for systemic candida infections New liposomal formulations of this drug have not been shown to have superior efficacy but may have reduced toxicity. Intervention threshold: Risk factors for invasive candidiasis include prematurity, intrauterine growth restriction, prolonged use of antibiotics, steroid use and the presence of an intravascular device particularly for parenteral nutrition. Action: Prophylaxis All preterm babies <32 weeks gestation should commence enteral nystatin as prophylaxis against fungal colonisation and invasive infection. The dose of nystatin for this purpose is 1ml 6 hourly. A small amount of the nystatin suspension should be used to coat the mouth and the remainder should be administered via the oro-gastric tube. All eligible babies are to receive this treatment, even if they are 'nil by mouth'. The only exceptions to this treatment are babies who are nil by mouth following a recent laparotomy. Other babies in whom there is concern about possible necrotising enterocolitis may also be excluded, but this decision must be made by a Consultant. This prophylaxis should be continued until the baby is no longer receiving intensive care and has a corrected gestation of greater than 32 weeks. Treatment of topical candidiasis Those babies with demonstrated colonization with candida sp. on routine screening or with clinical features of oral and/or cutaneous candidiasis and/or broken skin should be commenced on topical and enteral nystatin. Topical therapy should be stopped after 2 successive sets of negative swabs or when baby leaves the intensive care rooms. Treatment of systemic fungal sepsis Systemic antifungal therapy should be commenced when Candida sp. is isolated from a sterile site (e.g. blood culture, CSF, SPA), and should be considered when: (a) clinical evidence of sepsis fails to respond to empirical antibiotic therapy in a baby known to be colonized with candida, or (b) clinical evidence of sepsis fails to respond to empirical antibiotic therapy in a baby with risk factors for invasive candidal infection.
Enteral nystatin prophylaxis should be continued whist an eligible baby is on systemic treatment. The following specimens should be collected before commencing systemic antifungals: repeat peripheral blood cultures (and from line if present), CSF, SPA and any other involved site e.g. wound, joint. Intravascular devices should be removed and resited if possible. An ultrasound of the abdomen should be arranged to evaluate the liver and spleen for abscesses and the kidney and bladder for fungal involvement. An ophthalmological assessment should be undertaken to exclude endophthalmitis. Follow up: Weekly cultures of sterile sites from which candida was isolated (e.g. blood, CSF, SPA) should be performed to monitor the effect of therapy. Drugs: Topical decontamination - Nystatin cream. Enteral/oral decontamination - Nystatin suspension Systemic antifungals: 1st Line - Liposomal Amphotericin Additional agent: - 5-fluorocytosine (in addition to amphotericin B if evidence of deep candida infection e.g. meningitis/endopthalmitis or endocarditis or failure to respond to amphotericin) (on consultant advice after discussion with microbiologist). Serum levels must be monitored. Alternative Agents: Fluconazole (on consultant advice after discussion with microbiologist) Caspofungin (on consultant advice after discussion with microbiologist) References
Sanchez P J. Infections of the Newborn in Textbook of Paediatric Infectious Diseases. Feigin and Cherry (Eds) 4th Edition 1998 WB Saunders London. Remington JS and Klein JO (Eds) Infectious Diseases of the Fetus and Newborn Infant. 6th Edition 2006. WB Saunders London. Sims ME. Yoo Y. You H. et al Prophylactic oral nystatin and fungal infections in very-low-birthweight infants. American Journal of Perinatology 1998; 5: 33- 36. Weitkamp JH, Posts CF, Sievers R et al Candida infection in VLBW infants: outcome and nephrotoxicty of treatment with liposomal amphotericin. Infection 1998; 26: 11-15. LWH-RBP 'Suspected Infection' and 'Control of infection' - Neonatal Unit June 2006 June 25th 2010 (version7- NICU29)
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