Antifungal prophylaxis-Where are we today?

In the past decades more infants of lower gestational ages (GAs) have developed invasive Candida infection (ICI) from nonmodifiable risk factors of immature immunity and underdeveloped immune barriers (skin, gastrointestinal and respiratory tracts). Rates of ICI vary secondary to modifiable clinical practices, resuscitation practices and the nonmodifiable factor of the number of infants cared for at the lowest GAs of 22-24 weeks. Standardization of ICI definitions and reporting by each GA are needed to optimally elucidate actual rates, outcomes and differences across units, countries and regions. In extremely low birth weight (ELBW, <1000 g at birth) infants with ICI, mortality and neurodevelopmental impairment (NDI) have remained high despite appropriate antifungal therapy and (if candidemia) prompt removal of central venous catheters (CVC). Targeted fluconazole prophylaxis (3 or 6 mg/kg) twice a week in high-risk ELBW infants has been shown to be effective in preventing ICI and is safe without the emergence of azole resistance. Compared to nystatin, fluconazole prophylaxis for ELBW infants is more effective in preventing ICI and since it can be given intravenously, it is not dependent on enteral feeding status. Risk factors (e.g., receiving treatment with antibiotics or parenteral nutrition, presence of a CVC, vaginal delivery) can be used to both identify high-risk patients and define the time period when antifungal prophylaxis is beneficial. Independently of GA, high-risk infants also include those receiving third and fourth generation cephalosporins or carbapenems and those with complex gastrointestinal conditions (e.g. necrotizing enterocolitis, bowel perforation, gastroschisis).