Antifungal Prophylaxis in the Neonatal Intensive Care Unit (NICU)

In the NICU neonates at highest risk for invasive Candida infections are extremely preterm infants and neonates with complicated gastrointestinal diseases. Due to the high mortality, neurodevelopmental impairment, end-organ involvement and need for central venous catheter removal in the management of fungal bloodstream infections, prevention of invasive Candida infections should be paramount in each NICU. Even with prompt treatment, the mortality rate is as high as 40% and neurodevelopmental impairment 57% in infants <1000 grams. Multiple studies have been performed with fluconazole prophylaxis, including a recent multicenter randomized controlled trial. All of the studies have demonstrated efficacy, safety and no increase or emergence of fungal resistance. Analysis of these studies demonstrates that fluconazole prophylaxis reduces the risk of developing invasive fungal infection in high risk infants <1000g at birth by 90% (P<0.0001) and all infants <1500g at birth by 85% (P<0.0001). The mortality rate from all causes was also decreased by 24% (P = 0.02). Additionally, studies have demonstrated that Candida-related mortality can be eliminated in an entire NICU by targeting fluconazole prophylaxis in infants <1000 grams birth weight. In preventing invasive Candida infections, fluconazole prophylaxis can eliminate these infections as a cause of neurodevelopmental impairment and mortality and should be combined with infection control practices in every NICU.