Pediatric Resident MGMCRI Pondicherry

1. FUNGAL INFECTION
IN NEONATES
DR.RAVI KUMAR
2ND
YEARPG
DEPT OF PEDIATRICS
MGMCRI

2. Discussion
• Introduction
• Etiology
• Epidemiology
• RiskFactors
• Clinical Manifestations
• Diagnosis
• Treatment
• Prevention

3. Introduction
• Among the fungal infections Candida has emerged as
an important cause of neonatal infections with
significant morbidity and mortality, especially in
LBW& ELBWinfants.
• Clinical presentations vary fromlocalized skin
infections to life-threatening systemic infection

4. Etiology
• Candida Infection
• Non – Candida Infections - Uncommon
Candida
• C. Albicans (60%)- most common among Candida
spp
• C. Parapsilosis.
OtherCandida Spp:
• C. Tropicalis
• C. Lusitaniae
• C. Glabrata
• C. Krusei

5. Non-candida Spp
• Aspergillosis
• Zygomycosis
• Malassezia Sepsis
• Trichosporonosis
• Cryptococcosis
• Coccidioidomycosis
• Blastomycosis
• Dermatophytosis.

6. Epidemiology
• Candida species are important hospital-acquired
pathogens in infants admitted to the NICU.
• In VLBWinfants Candida albicans is the third most
common cause of LONS.
Transmission
• Vertical transmission from the motheror
• Horizontal transmission from health care workers/
the hospital environment.

7. RiskFactors
• Immaturity of host defenses and
colonization with Candida before
complete establishment of normal
intestinal flora probably contribute to
the pathogenicity of Candida in the
neonate.

8. Clinical Manifestations
Various presentations of Candida infections:
1.Mucocutaneous candidiasis
2.Systemic candidiasis
3.Catheter-related infections
4.Focal infection

9. MUCOCUTANEOUS
CANDIDIASIS
1) Oral Candidiasis (Thrush)
• Irregularwhite plaques
• +/- erythematous base on the buccal/lingual mucosa
• In breastfed infants - ductal candidiasis in the
mother's breast.
• Concurrent treatment of both is necessary
• Such mother’s are advised to withhold expressed
milkuntil treatment has been instituted.

10. white plaques on
the innerlip,
tongue & Buccal
mucosa

11. TREATMENT
• Nystatin - oral suspension 1 ml (1 Lakh U/ml) is
applied to each side of the mouth Q6Hfor10 to 14
days.
• Fluconazole - 6 mg/kg IV/PO once followed by 3
mg/kg IV/PO each day can be used forsevere oral
candidiasis if nystatin oral therapy is not effective.
• Systemic fluconazole is highly effective in treating
chronic mucocutaneous candidiasis in the
immunocompromised host.

12. MUCOCUTANEOUS
CANDIDIASIS
2) Candida DiaperDermatitis
Discrete erythematous papules and plaques over
inguinal region with superficial scales, and satellite
lesions

13. TREATMENT
Effectively treated with Topical agents :
•2% nystatin ointment
•2% miconazole ointment,
•1% clotrimazole cream.
•Concomitant treatment with oral nystatin to eliminate
intestinal colonization is often recommended
•It is reasonable to use simultaneous oral and topical
therapy forrefractory candidal diaperdermatitis.

14. MUCOCUTANEOUS
CANDIDIASIS
3) Congenital Candidiasis
• Generalized eruptions appearon first day of life
• 2 to 4 mm erythematous macules /papules that rest
upon a 5 to 10 mm erythematous base.
• These lesions evolve into pustules, vesicles, oreven
bullae.
• Riskfactors : Prolonged ROM/Vaginal Candidiasis

16. SEBORRHEIC DERMATITIS
• Greasy, yellow plaques on the scalp with some
degree of hairloss.
• Cause : Presence of Malassezia spp in the oil
secretion on the skin
• Such lesions are highly prevalent during the first 4
weeks of life
Treatment :
• Gentle scrubbing of scalp
• Vaseline application
• Removal of scales using a soft brush
• Forextensive cases, topical mild corticosteroid or
antifungal is indicated.

17. Cradle Cap

18. Systemic Candidiasis
• Serious formof nosocomial infection in VLBW
• Primarily caused by C. albicans and C. parapsilosis
• Common presentation is similarto that of bacterial
sepsis.
The most significant Epidemiologic factors were
 Birth Weight <1000g,
 Presence of central catheter,
 Delay in enteral feeding, and broadspectrum
antibiotic exposure
 The use of H2 blockers orsystemic steroids

19. CLINICAL FEATURES
• Lethargy
• Feeding intolerance
• Hyperbilirubinemia
• Apnea
• Persistent Hyperglycemia & Thrombocytopenia
• Cardiovascularinstability
• Respiratory distress
• Multi-organ Failure

20. DIAGNOSIS
 Blood Culture
• Cultures should be obtained through both the central
line catheterand a peripheral vessel - to distinguish
between disseminated infection and catheter-related
candidiasis.
 Urine Culture
• Both fungal culture and fungal staining (KOH
preparation) of urine must be obtained by USG
guided Suprapubic Aspiration (SPA)
• GramStain - VesicularContents /by KOH
Preparations Of Skin Scrapings

21. Candida albicans on a
culture plate
Pseudohyphae of
Candida albicans on
potassiumhydroxide
(KOH) preparation with
light microscopy

22. DIAGNOSIS
• Before the initiation of antifungal therapy, CSF
should be obtained forcell count and fungal culture.
Furtherevaluation
• USG abdomen and Brain - Fungal abscess
• Ophthal Assessment- Endophthalmitis
• ECHO - Endocarditis

23. TREATMENT
Amphotericin B
A polyene, which binds to ergosterol in the fungal cell
membrane leading to cell leakage and death.
Dosage :
•Invasive Candidiasis
Lipid Complex Preparation - 5mg/kg/dose iv infusion
over2 hours O.D
•CNS & Urinary tract Infection
Non-Liposomal Preparation - 0.5 to 1.5 mg/kg/day iv
infusion over2 to 6 hrs.

24. Contd,..
Duration :
•7-14days fora Negative Blood culture/Catheter
Associated Infection
•Upto 3 weeks if specific end-organ infection is present
Renal Dose Adjustment :
•Alternate day dosing
•Hold the dose for2 to 5days - If Serum creatinine
>0.4 mg/dl from the baseline

25. Contd,..
Sensitivity :
All common strains except C. lusitaniae, C. glabrata,
and C. Krusei
Adverse Effects :
•Phlebitis at the site of infusion
•Renal toxicity
•Hypokalemia & Hypomagnesemia
•Dose-dependent toxicities -bone marrow suppression
with anemia, thrombocytopenia, and elevated liver
enzymes

26. Second Line Agent:
Fluconazole
1st
generation Triazole
MOA:
•Inhibits the enzyme 14-alpha-sterol demethylase,
which is necessary forthe production of ergosterol, a
majorcomponent of the fungal cell membrane.
•Added only if initial therapy with amphotericin is not
effective
•Dosage : 12 mg/kg/day Q24H/Q48Hfor2 weeks
•Prophylaxis : 6 mg/kg/day twice weekly for6 weeks
•C. krusei and C. glabrata are frequently resistant

27. Contd,..
Voriconazole
2nd
generation Triazole
•Broaderspectrum& Increased potency
•Effective in fluconazole-resistant species, but there
are no comparable studies in neonates.
Flucytosine
Nucleoside analogue
•Used in combination with amphotericin B
•Excellent CNS penetration
•Dosage : 50 to 150 mg/kg/day POQ6H
•Only available in enteral form

28. PREVENTION
• Minimizing use of broad-spectrumantibiotics & H2
Blockers
• Parenteral nutrition and lipid mixtures should be
changed every 24 hours.
• Removal of central catheters when candidemia is
identified
• Prophylactic fluconazole is reserved forELBW
infants in centers with a high incidence of fungal
infection, Routine use is not recommended.

29. INVASIVE FOCAL INFECTIONS
Focal infection is generally due to seeding of the
individual organ systemfromhematogenous
dissemination.
Involves:
A)UTI
B)CNS INFECTION
C)PERITONITIS
D)ENDOPHTHALMITIS
E)OSTEOARTICULARINFECTIONS
F)ENDOCARDITIS

30. Candida UTI
Incidence : 0.5 %
Riskfactors : Congenital anomalies of the kidney and
urinary tract, obstruction, urinary stasis, and presence
of an indwelling bladdercatheter
Clinical features : Apnea, bradycardia, glucose
intolerance, & decreased urine output
Diagnosis :
1) Urine Culture –Positive
• > 1000 CFU/mL fora specimen collected by USG
guidance SPA
•> 10,000 CFU/mL in a specimen collected by
catheterization
2) USG KUB

31. CNS INFECTION
• Incidence : 10%
• Cause : Hematogenous spread of Candida presenting
as meningitis.
• Uncommon Presentation : brain abscesses,
ventriculitis
• Clinical features : Temperature instability,
irritability, poorfeeding, vomiting, respiratory
distress, and apnea
• Complications : Obstructive hydrocephalus
• Diagnosis : CSF analysis/Brain imaging

32. PERITONITIS
Studies reported to have Spontaneous intestinal
perforation (SIP) is associated with disseminated
candidal infection.
Riskfactors :
•VLBWNeonates
•NEC
Diagnosis :
•Blood/Peritoneal fluid Culture
•USG Abdomen

33. ENDOPHTHALMITIS
Cause :
•Hematogenous spread of Candida to the eye,
Presenting as Occularcandidiasis.
•Affected neonate is mostly Asymptomatic
•Increased riskof developing ROP
Diagnosis :
Indirect ophthalmoscopy examination
Treatment :
Surgical Intervention – Severe ROP

34. Focal, glistening, white, infiltrative, often mound-like
lesions on the retinavitreal haziness/snowballs
appearance within the vitreous

35. OSTEOARTICULAR
INFECTION
Rarely occurs as an isolated event ,
typically occurs because of
disseminated infection
Clinical features :
•Localized erythema/swelling & pain
•Lackof spontaneous movement of the extremity
Diagnosis :
•Depends upon isolating Candida fromeithercultures
of the synovial fluid orbone aspirate

36. ENDOCARDITIS
It’s the most common complication of candidemia
Riskfactors :
•Central vein catheter
•Cyanotic congenital heart disease
•Prematurity
Diagnosis :
•ECHOto detect thrombi orvegetations

37. TAKE HOME MESSAGE
• Candida has emerged as a common cause of
infections in infants admitted to the neonatal
intensive care unit (NICU), particularly in VLBW
infants.
• Catheter-related infection is a majorcause of
disseminated systemic infection
• Avoid extensive use of H2 blockers orsystemic
steroids among neonates
• Prophylactic fluconazole is reserved forELBW
infants, not recommended forroutine use.

38. THANK YOU