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NEONATAL INVASIVE FUNGAL INFECTIONS IN ENGLAND 2004-2011
St George's, University of London Division of Clinical Sciences, Paediatric Infectious Diseases Research Group,
John Radcliffe Hospital,
Croydon University Hospital,
St Mary's Hospital,
Norfolk & Norwich University Hospital,
Royal Devon & Exeter NHS Foundation Trust,
Royal Victoria Infirmary,
City Hospitals Sunderland,
St George's Healthcare NHS Trust,
The Evelina Children's Hospital,
Medway Maritime Hospital, Gilingham,
University Hospital of North Tees, Stockton,
Portsmouth Hospitals HNS Trust, Portsmouth,
Heart of England NHS Foundation Trust, Birmingham,
Guy's and St Thomas' NHS Foundation Trust, London, UK,
Summary
This study conducted in England between 2004-2010 shows that extremely low birth weight infants are at increased risk of invasive fungal infection. The vast majority of infants were exposed to known treatment related risk factors. C. albicans remains the most prevalent causal organism. Use of antifungal prophylaxis and treatment varied amongst neonatal units. Improved knowledge on the epidemiology of the disease will enable the development of strategies for targeted prevention and improved outcome.
Background and Aims
Rates of invasive fungal infection (IFI) are highest amongst neonates. Premature and very low birth weight (VLBW) / extremely low birth weight (ELBW) infants are at particular risk, as their treatment usually requires prolonged central vascular catheter (CVC) use and they are exposed to multiple courses of broad-spectrum antibiotics and parenteral nutrition. This study aimed to describe the epidemiology of neonatal IFI in England by determining the incidence, risk factors and clinical presentation as well as prophylaxis and treatments used.
Methods
Prospective multicentre surveillance was conducted by 14 neonatal intensive care units within neonIN, a neonatal infection surveillance network. Clinicians completed a standardized proforma for each positive fungal blood and/or CSF culture and also reported the units’ annual number of live births and admissions categorized by birth weight and gestational age.
Results
From 2004-2010 14 Units reported 82 unique cases. Only 47 (57%) had a lumbar puncture performed, out of which 6 cases (13%) had a positive fungal CSF culture.
Incidence
The overall incidence was 2.1/1000 NICU admissions.
The highest incidence was reported amongst ELBW infants, with the majority of cases (57%) occurring in the second week of life, 78% by 3 weeks and 89% by 4 weeks of age. The incidence has been decreasing since 2004. The most prevalent causal fungus was C.albicans.
Prophylaxis and colonization
19 (23%) were known to be colonized
25 (30%) received antifungal prophylaxis, median duration of prophylaxis was 5 days
Outcome
The overall case fatality was 30%; in 24% death was attributed to the fungal infection.
Conclusion
Extremely low birth weight infants are most at risk of invasive fungal infections, with peak risk in the second week of life. Recognised risk factors such as bacterial infections requiring broad spectrum antibiotics and prolonged use of central lines, total parenteral nutrition and invasive ventilation are common and inevitable components of the care of premature infants. Prevention strategies should be targeted at extremely birth weight infants. Administration of prophylaxis for the first 3-4 weeks of life would cover the period of greatest susceptibility.
