Expert Commentary & Five-year Review
The emphasis in the next 5 years will be on the prevention of invasive fungal infection by targeting risk factors for colonization and invasive infection. Simple but significant measures for prevention of fungal infection should include early enteral feeding with human milk, avoidance of formula feeds, decreasing dependence on catheters and parenteral nutrition. Avoidance of broad-spectrum antibiotics, steroids, gastric acid reducing agents (e.g., H2 blockers and proton pump inhibitors) is strongly recommended. Careful prevention of horizontal transmission in the NICU is paramount for C. parapsilosis infections. In addition, better molecular diagnostic techniques such as PCR, DNA sequencing and hybridization techniques will allow rapid detection even after antimicrobial treatment is started. Investigators are examining the role of biomarkers to diagnose and evaluate responses to antifungal therapy. These markers include β-glucan of the cell wall, anti-Candida antibodies, D-arabinitol (candidal metabolite) and fungal chitin synthase (assessed with PCR).[149–151] Microarray technology and gene chips are being studied to rapidly determine susceptibility and resistance patterns at the time of diagnosis which will facilitate early initiation of therapy with the appropriate antifungal agent.[152,153] Empiric antifungal therapy in the presence of risk factors and clinical illness has been debated, but careful modeling may indicate high-risk patients that may benefit before fungal cultures become positive. Use of prebiotics such as lactoferrin and probiotics optimized for the type of organisms and dosage have a great potential in altering the gastrointestinal microbiome of neonates, decreasing fungal colonization and hence invasive fungal infections. Antifungal prophylaxis with fluconazole or other agents such as nystatin or miconazole would be beneficial in high-risk patients such as ELBW infants or in units with high baseline fungal infection rates.
Expert Rev Anti Infect Ther. 2013;11(7):709-721. © 2013 Expert Reviews Ltd.