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Use of Prophylactic Fluconazole - Paediatrics - Lecture Slides, Slides of Pediatrics

Use of Prophylactic Fluconazole, Fungal Infections, Case Mortality Rates, Antifungal Prophylaxis, Intra-Abdominal Involvement, Eye Involvement, Factors for Candidiasis, Central Line Placement. The word pediatrics and its cognates mean healer of children; they derive from two Greek words: παῖς (pais = child) and ἰατρός (iatros = doctor or healer). THis is one of lectures on Paediatrics. Main points are give above.

Typology: Slides

2011/2012

Uploaded on 12/23/2012

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The use of prophylactic fluconazole
in very low birth weight infants
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Download Use of Prophylactic Fluconazole - Paediatrics - Lecture Slides and more Slides Pediatrics in PDF only on Docsity!

The use of prophylactic fluconazole

in very low birth weight infants

Incidence and burden of fungal infections

in the NICU

  • Candida spp third most common cause of late onset

sepsis (>72 h) in VLBW (<1500g)

  • 75% of infected VLBW infants will die or survive with

handicap

  • Overall mortality rates estimated at 10-15%
  • Case mortality rates as high as 44%
  • In Canada (2003-2005): incidence 6.7% infants <

weeks*

Risk factors for candidiasis

• ELBW

• Low gestational age

• Therapies

– Intubation

– Ventilation

– Central line placement

– TPN

– Medications

  • Steroids
  • H2 blockers
  • antibiotics

Strategies

• Optimal infection control practices

• Avoid broad spectrum antibiotic coverage

• Prompt removal of infected devices

• Prevention of colonization

30% of NICUs use some form of antifungal prophylaxis*
  • Fluconazole
  • Topical nystatin
  • Amphoteracin B
*AAP/Neo-Peri Section questionnaire

RCTs of oral antifungal agents

Study Enrolment
Criteria
N Dosing
Schedule
Protocol Treatment
Group
Control
Group
P-value
Sims et al
<1250 67 Nystatin po
every 8 hours
Single-centre
placebo
Violaris et
al (1998)
<1500 g 21 Fluconazole vs.
nystatin
Single-centre 0/8 (0%) 4/
Wainer et
al (1992)
<1750 g 600 Miconazole po
every 8 hours
Single-centre
placebo
NS
Ozturk et
al
All infants 3991 Nystatin po
every 8 hours,
variable
Single-centre 36/

*adapted from Healy,M: NeoReviews, 2008

RCTs of fluconazole prophylaxis in neonates

Study Enrolment Criteria

N Protocol Dosing Schedule Treatment Group (IC)

Control Group (IC)

P-value

Kaufman et al (2001)

<1000 g ETT or CVC ≤ 5 days of life

100 Single-centre placebo

3mg/kg x 6 wks or less if no IV needed q72h (0-14d) q48h (15-28d) q24h (29-42d)

(4 Candida- related deaths)

Kicklighter et al (2001)

<1500 g ≤ 3 days of life

103 Single-centre placebo

6 mg/kg IV/PO For 28 days

(1 Candida- related death)

0/50 (0%) NS

Cabrera et al (2002)

<1500 g 11 Single-centre, placebo

6 mg/kg IV then PO 0/6 1/5 NS

Parikh et al (2007)

<1500 g 120 Single-centre, placebo

6 mg/kg IV then po for 28 days

15/60 (25%) NS

Manzoni et al (2007)

<1500 g ≤ 3 days of life

322 Multi-centre, placebo

6 mg/kg or 3 mg/kg qod x 30d (100- 1500g) or 45d (<1000g) or less if no IV needed

(0 Candida- related deaths)

(4 Candida- related deaths)

Optimal dosing and schedule

• Trials:

– 3-6 mg/kg

– 24-72 h intervals

– 7 different schedules

• Kaufman:

– 3mg/kg PO starting on Day 1 or 2

– Twice per week

– For up to 6 weeks

Who should receive fluconazole

prophylaxis?

  • BW ≤ 750 gm
  • GA ≤27 weeks
  • IF BASELINE FUNGAL INFECTION RATES ARE

HIGH (eg: >5%)

  • Why not ≤ 1500 gm BWs?