Antifungal Prophylaxis in the Preterm Infant

Survival of extremely preterm infants is increasing and invasive fungal infection is an emerging problem in this vulnerable population. Fungal sepsis is associated with higher mortality and worse neurodevelopmental outcome than bacterial sepsis alone. The reported incidence varies widely amongst units, but can be as high as 20% of babies less than 1000g birth weight. Prophylactic antifungal drugs reduce fungal colonisation and infection rates in very low birth weight babies. However to date there is insufficient data to determine the impact on long term outcomes, and there are concerns about widespread use of antifungals because of the potential for toxic side effects and drug resistance. Nystatin, miconazole, fluconazole, and amphotericin B with flucytosine have all been used for antifungal prophylaxis. Of these, only nystatin and fluconazole have been shown to reduce invasive fungal infection in newborns. Recent surveys have shown that clinicians remain in equipoise regarding antifungal prophylaxis. Some centres have attempted to limit exposure to prophylactic fluconazole by selecting babies with additional risk factors for fungal sepsis and they report similar reductions in fungal infection rates. In this review we discuss the potential benefits and risks of fungal prophylaxis in very low birth weight babies.