A Quality Improvement Initiative To Reduce Invasive Candidiasis In Extremely Low Birth Weight Neonates
DOI:
https://doi.org/10.51253/pafmj.v74i1.9446Keywords:
Candidiasis, Antifungal agents, Intensive care units\, Infant, Newborn, Very low birth weight, Length of stayAbstract
Objective: To evaluate the impact of a quality improvement (QI) initiative, which included a Fluconazole prophylaxis protocol and provider education on neonatal Candidiasis.
Study Design: Retrospective longitudinal study.
Place and Duration of Study: Neonatal Intensive Care Unit (NICU), Aga Khan University, Karachi Pakistan, from Apr 2015 to Dec 2019.
Methodology: All extremely low birth weight neonates (ELBW) neonates admitted to the NICU between April 2015 and March 2017 were included in the pre-implementation phase. All ELBW neonates admitted between April 2017 and December 2019 were included in the post-implementation phase. Data were collected from medical records. The primary outcome was the frequency of Invasive Candidiasis (IC) before and after the QI initiative.
Results: Altogether, 272 neonates were included in the study, with 115 neonates in the Pre-Implementation Group and 157 neonates in the Post-Implementation Group. The frequency of IC was 6(5.2%) in the pre-implementation and 1(0.6%) in the post-implementation period, (p=0.044). Candida parapsilosis 2(40%) and Candida glabrata 2(40%) were the organisms most commonly isolated from blood cultures. All organisms were sensitive to Fluconazole in both the pre-and post-implementation
cohorts. There was no difference in mortality (54(50.5%) vs. 69(44.2%), p=0.32) or length of stay (19.6±13.3 vs. 23.4±18.4 days,p=0.061) before and after Fluconazole prophylaxis.
Conclusion: The frequency of invasive Candidiasis in ELBW neonates was successfully reduced by introducing a Fluconazole prophylaxis protocol in the NICU as a QI initiative. A team-based approach and provider education ensured high compliance.
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Benjamin DK Jr, Stoll BJ, Gantz MG, Walsh MC, Sánchez PJ, Das
A, et al; Eunice Kennedy Shriver National Institute of Child
Health and Human Development Neonatal Research Network.
Neonatal candidiasis: epidemiology, risk factors, and clinica
judgment. Pediatrics 2010; 126(4): e865-873.
https://doi.org/10.1542/peds.2009-3412
Adams-Chapman I, Bann CM, Das A. Neurodevelopmental
Outcome of Extremely Low Birth Weight Infants with Candida
Infection. J Pediatr 2013; 163(4): 961-967.e3.
https://doi.org/10.1016/J.JPEDS.2013.04.034
Iosifidis E, Papachristou S, Roilides E. Advances in the
Treatment of Mycoses in Pediatric Patients. J Fungi 2018; 4(4):
https://doi.org/10.3390/jof4040115
Aliaga S, Clark RH, Laughon M. Changes in the incidence of
candidiasis in neonatal intensive care units. Pediatrics 2014;
(2): 236-242. https://doi.org/10.1542/peds.2013-0671
Roilides E. Invasive candidiasis in neonates and children. Early
Hum Dev 2011; 87 (Suppl 1): S75-S76.
https://doi.org/10.1016/j.earlhumdev.2011.01.017
Wadile RG, Bhate VM. Study of clinical spectrum and risk factors
of neonatal candidemia. Indian J Pathol Microbiol 2015; 58(4):
-474. https://doi.org/10.4103/0377-4929.168888
Leibovitz E. Strategies for the prevention of neonatal
candidiasis. Pediatr Neonatol 2012; 53(2): 83-89.
https://doi.org/10.1016/j.pedneo.2012.01.004
Lee J, Kim HS, Shin SH. Efficacy and safety of fluconazole
prophylaxis in extremely low birth weight infants: multicenter
pre-post cohort study. BMC Pediatr 2016; 16: 67.
https://doi.org/10.1186/s12887-016-0605-y
Ericson JE, Kaufman DA, Kicklighter SD, Bhatia J, Testoni D, Gao
J, et al; Fluconazole Prophylaxis Study Team on behalf of the Best
Pharmaceuticals for Children Act–Pediatric Trials Network
Steering Committeea; Fluconazole Prophylaxis Study Team on
behalf of the Best Pharmaceuticals for Children Act–Pediatric
Trials Network Steering Committee. Fluconazole Prophylaxis for
the Prevention of Candidiasis in Premature Infants: A Metaanalysis Using Patient-level Data. Clin Infect Dis 2016; 63(5): 604-
https://doi.org/10.1093/cid/ciw363
Ariff S, Saleem AF, Soofi SB, Sajjad R. Clinical spectrum and
outcomes of neonatal candidiasis in a tertiary care hospital in
Karachi, Pakistan. J Infect Dev Ctries 2011; 5(3): 216-223.
https://doi.org/10.3855/jidc.1232
Ascioglu S, Rex JH, de Pauw B. Defining opportunistic invasive
fungal infections in immunocompromised patients with cancer
and hematopoietic stem cell transplants: an international
consensus. Clin Infect Dis 2002; 34(1): 7-14.
https://doi.org/10.1086/323335
Muñoz P, Burillo A, Bouza E. Criteria used when initiating
antifungal therapy against Candida spp. in the intensive care
unit. Int J Antimicrob Agents 2000; 15(2): 83-90.
https://doi.org/10.1016/s0924-8579(00)00147-3
Cleminson J, Austin N, McGuire W. Prophylactic systemic
antifungal agents to prevent mortality and morbidity in very low
birth weight infants. Cochrane Database Syst Rev 2015; 2015(10):
CD003850. https://doi.org/10.1002/14651858.CD003850.pub5
Aydemir C, Oguz SS, Dizdar EA, Akar M, Sarikabadayi YU,
Saygan S, et al. Randomised controlled trial of prophylactic
fluconazole versus nystatin for the prevention of fungal
colonisation and invasive fungal infection in very low birth
weight infants.Arch Dis Child Fetal Neonatal Ed 2011; 96(3):
F164–F168. https://doi.org/10.1136/adc.2009.178996
Manzoni P, Stolfi I, Pugni L, Decembrino L, Magnani C, Vetrano
G, et al. A multicenter, randomized trial of prophylactic
fluconazole in preterm neonates. N Eng J Med 2007; 356(24):
–2495. https://doi.org/10.1056/NEJMoa065733
Cleminson J, Austin N, McGuire W. Prophylactic systemic
antifungal agents to prevent mortality and morbidity in very low
birth weight infants. Cochrane Database Syst Rev 2015; 2015(10):
CD003850. https://doi.org/10.1002/14651858.CD003850.pub5
Kaufman DA, Morris A, Gurka MJ, Kapik B, Hetherington S.
Fluconazole prophylaxis in preterm infants: a multicenter casecontrolled analysis of efficacy and safety. Early Human Dev
; 90(SUPPL.1): S87-S90. https://doi.org/10.1016/S0378-
(14)70026-X
da Silva Rios JF, Camargos PAM, Corrêa LP, de-Castro
Romanelli RM. Fluconazole prophylaxis in preterm infants: a
systematic review. Braz J Infect Dis 2017; 21(3): 333-338.
https://doi.org/10.1016/j.bjid.2017.01.008
Blyth CC, Barzi F, Hale K, Isaacs D. Chemoprophylaxis of
neonatal fungal infections in very low birthweight infants:
efficacy and safety of fluconazole and nystatin. J Paediatr Child
Health 2012; 48(9): 846-851. https://doi.org/10.1111/j.1440-
2012.02543.x
Robati Anaraki Mahmoud Nouri-Vaskeh Masoud AOS.
Fluconazole prophylaxis against invasive candidiasis in very low
and extremely low birth weight preterm neonates: a systematic
review and meta-analysis. Clin Exp Pediatr 2021; 64(4): 172-179.
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