Fungal Infections In Neonates

Fungal Infections: Mucocutaneous Candidiasis

Candida sp. is a normal commensal flora after the newborn period and infrequently causes major disease in the immunocompetent host.  Infections by fungi in well-term infants are mostly restricted to mucocutaneous diseases involving C. albicans.

Nosocomial transmission in the nursery setting is achievable with the use of bottles and pacifiers. Candida can be acquired through the birth canal or the mother's hands/breast. Oral and GI colonization with candida occurs prior to developing oral candidiasis or diaper dermatitis.

Oral Candidiasis

Nonabsorbable oral antifungal medications are used to treat it; these medications have the advantages of little systemic toxicity and simultaneous therapy of the intestinal tract.  The usual course of treatment is 10–14 days of oral nystatin suspension (1 lakh units/ml).

After lesions resolve, treatment should ideally be continued for a few days.  In the event that oral nystatin therapy is unsuccessful, fluconazole may be administered to treat severe oral candidiasis. e Chronic mucocutaneous candidiasis in immunocompromised hosts is efficiently treated with systemic fluconazole.

The patient has persistent, severe thrush that is not responding to medication; immunodeficiency should be assessed.

Severe severe ductal candidiasis in the mother's breast is frequently linked to oral candidiasis in the breastfed child.

In order to prevent ongoing cross-infection, the mother and the child must receive treatment at the same time. Term babies can stay breastfed while receiving therapy.

It is advisable to encourage mothers suffering with breast ductal candidiasis who are supplying expressed milk to vegetarian lactation patients to hold off on giving the milk until after therapy has started.  Freezing does not remove candida from expressed breast milk; instead, lactoferrin slows the growth of candida in the culture, making it harder to detect candida in breast milk.

Topical medications, such as 1% clotrimazole cream, 2% miconazole ointment, or 2% nystatin ointment, are beneficial in treating candidal diaper dermatitis. It is frequently advised to treat intestinal colonization concurrently with oral nystatin; however, this has not been well investigated.  It makes sense to treat refractory candidal diaper dermatitis with topical and oral medication concurrently.

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Risk Factors for Candida lons

• BW <1,000g
• Presence of central catheter.
• Delay in enteral feeding 
• Broad-spectrum antibiotic

Risk Factors for the Development of Invasive Fungal Infection

• Presence of candidal diaper dermatitis
• Vaginal delivery
• Lower gestational age
• Significant hypoglycemia
• Thrombocytopenia 
• H2 blockers
• Systemic steroids

Systemic Candidiasis

• In VLBW newborns, systemic candidiasis is a dangerous nosocomial infection.
LONS caused by C. albicans and C. parapsilosis are common species.
• Higher rates of ROP and overall worse neurodevelopmental outcomes are linked to invasive candidiasis.
• In LBW (low body weight) babies, GI colonization frequently occurs prior to invasive infection.

Microbiology of Systemic Candidiasis

• C. albicans and C. parapsilosis in preterm infants primarily cause disseminated candidiasis.
• Other species reported less frequently:
  • C. tropicalis
  • C. lusitaniae
  • C. guilliermondii
  • C. glabrata
  • C. krusei
• The development of several toxins, including an endotoxin, is correlated with the pathogenicity of Candida albicans.
• It is possible for C. albicans to be acquired both during and after pregnancy.
• The second most frequent cause of widespread newborn candidiasis is now known to be C. parapsilosis.
• Mostly a nosocomial pathogen, Candida parapsilosis is acquired later than Candida albicans and is linked to healthcare workers' hands becoming colonized.

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Clinical Manifestations of Systemic Candidiasis

Though most cases of systemic candidiasis present as LOS in VLBW (very low body weight) infants, most often after the 2nd / 3rd week of life, In-utero infections can cause candidiasis.

Congenital cutaneous candidiasis can present with severe, widespread, and desquamating skin involvement.  Initial clinical features of late-onset invasive candidiasis are often nonspecific (system overlap with other types of LONS).

In the early stages of infection, the differential and total WBC may be normal.  Although it is a continuous feature, not all cases of thrombocytopenia are present at presentation.  At first, it might be challenging to differentiate the clinical presentation from sepsis brought on by a CONS infection.

This is in contrast to the sudden onset of septic shock that frequently accompanies late-onset sepsis (LOS) brought on by gram-negative bacteria.  Meningitis, brain abscess, and end-organ involvement of the kidney, heart, joints, and eyes (endophthalmitis) can aggravate candidiasis.  Disseminated candidiasis has a significant death rate.

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Diagnosis of Systemic Candidiasis

A standard pediatric blood culture system can be used to culture candida;  It typically takes 48 hours to identify a positive culture, while late identification (beyond 72 hours) does happen more commonly than with bacterial species.

Fungal urine staining produced by SPA and fungal culture can both be applied.  CSF should be acquired for fungal culture and cell count prior to starting antifungal medication.

Treatment of Systemic Candidiasis

For systemic candidiasis, if the infection is related to a catheter and the catheter has been removed right away, administer amphotericin B for 7–14 days following a confirmed negative blood culture.If not, the length for neonatal candidemia should be three weeks, and more if the particular end-organ infection is present.

 Amphotericin is sensitive to all common strains of candida, with the exception of certain strains of C. lusitaniae, C. glabrata, and C. krusei.Though renal and electrolyte disruption can happen, febrile reactions to amphotericin infusion do not typically occur in babies from low birth weights.

If urinary tract and central nervous system involvement are ruled out, liposomal formulations of amphotericin B may be utilized for invasive candidiasis.  The idea that liposomal preparations work less well in newborns raises certain concerns. Non-liposomal amphotericin alone is sufficient to treat CNS disease; fluconazole (6 mg/kg/day) or 5-fluorocytosine (flucytosine[5-FC]) should only be administered as a second treatment if amphotericin therapy fails.

Flucytosine is safe for newborns and has good CNS penetration; however, it can only be administered enterally, which limits its use for unwell VLBW infants.  Adults have had bone marrow and liver damage, which is associated with increased serum levels of the drug.Since C. krusei and C. glabrata frequently exhibit fluconazole resistance, fluconazole should not be utilized until candidal speciation is complete.

Fluconazole is safe to use in newborns and can be effectively used for the primary treatment of candidemia.  Prolonged central catheter removal is linked to increased mortality and chronic candidemia; Central catheter removal must occur as soon as candidemia is discovered in order to eradicate the infection.

Prophylactic Fluconazole

Individual NICUs should decide based on their epidemiology.
It was being used in the early 90s. Risk factors should be identified in infants before giving this.

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