Author(s): Shilpa Hundalani 1 , Mohan Pammi [*] 2
Candida; fungal infections; neonate; newborn
Invasive fungal infections due to Candida are the third most common late-onset infections (>72 h of age) in very low birth weight (VLBW) infants (birth weight <1500 g). Invasive Candida infections, in extremely low birth weight (ELBW) infants (birth weight 2500 g, 0.42 in infants 1501-2500 g, 0.9 in infants between 1001 and 1500 g and 3.51 in infants <1000 g. In this study, the overall incidence of Candida bloodstream infections was 1.53 per 1000 patient-days among infants admitted to the NICU  . Candida albicans and Candida parapsilosis were the causative agents in 6 and 4% of first episodes of late-onset sepsis, following coagulase negative Staphylococcus (48%) and Staphylococcus aureus (8%) in frequency  . C. albicans was the most commonly isolated Candida species (60%) followed by C. parapsilosis (34%) in the 1997 identified cases of Candida bloodstream infections. Other Candida species included Candida tropicalis , Candida lusitaniae , Candida glabrata and Candida krusei isolated in 4, 2, 2 and <1% of cases, respectively  . In another prospective study of 19 NICUs, invasive candidiasis (defined as a positive culture from a normally sterile fluid, such as blood, urine and cerebrospinal fluid [CSF]) occurred in 9% of 1515 ELBW infants (birth weight <1000 g)  . The rates of candidemia vary tenfold among tertiary care NICUs across the world, and it is possible that differences in clinical practice such as use of third-generation cephalosporins, steroids and gastric acid reducing agents, and feeding practices contribute to this wide range of incidence [4,5] .
A change in the distribution of Candida species causing candidemia has been noted in several institutions with increasing isolation of non-Albicans species in neonates  . C. parapsilosis is the second most commonly isolated Candida species, accounting for a quarter to a third of systemic neonatal Candida infections [3,7] . In a review of neonatal C. parapsilosis infections, it comprised a third of all Candida infections with an associated mortality of approximately 10%  . C. parapsilosis predominantly presents as a bloodstream infection, mostly in association with a central venous catheter. Although the use of prophylactic fluconazole has not resulted in an increase in the incidence of C. glabrata in neonates, it is important to monitor the relative incidences of the different Candida species as fluconazole use increases in NICU patients  . Increased caspofungin use has also been associated with increased incidence of C. parapsilosis fungemia  .
Fungal infections other than those caused by Candida species, are uncommon in neonates. Nonetheless, non-Candida fungal infections occur in neonates resulting in significant mortality and morbidity. Similar to Candida infections, the incidence of non-Candida fungal infections in neonates appears to be increasing, particularly in premature infants  . Table 1 reviews invasive fungal infections in neonates including the uncommon fungal infections [1,11-33] .
The most common neonatal presentation of Candida infections is invasive bloodstream infection and may be viewed as primary or secondary to other sites of primary infection. Infection can originate from the urinary tract, GI tract, skin and...