Nationwide survey of neonatal invasive fungal infection in Japan

Nationwide survey of neonatal invasive fungal infection in Japan Abstract Invasive fungal infection (IFI) is a life-threating infectious disease in high-risk neonates. Strategies for the treatment and prevention of IFI in neonates in Japan remain unclear. We conducted a nationwide retrospective survey to determine IFI incidence between January 2014 and October 2015. Primary survey questionnaires were submitted to 309 medical facilities that regularly treat high-risk neonates. The questionnaire assessed IFI incidence during the study period, methods for preventing fungal infection in early delivery neonates, and methods for preventing mother-to-child fungal transmission. The secondary questionnaire was for facilities that had IFI cases and replied to the primary questionnaire. In total, 128 medical facilities (41.4%) completed the primary questionnaire, 17/128 facilities recorded 23 proven or probable IFI cases. Estimated annual IFI incidence was 0.33/1000 live births of hospitalized neonates. Patient data at IFI onset were available for all 23 patients. Birth weight was < 1000 g in 18 patients. Causative microorganisms were identified in 22 patients. Candida species (n = 21) were the most common pathogens, and one patient had mucormycosis. The mortality rate was 17.4%. Regarding neonatal fungal prophylaxis, 55/128 facilities (43.0%) reported administering therapy. The most frequently used prophylactic drugs were fluconazole, then micafungin. Fungal prophylaxis for mothers who showed fungal colonization was performed in 30/128 facilities (23.4%). Oxiconazole vaginal tablets were most commonly used as prophylaxis for high-risk mothers. In Japan, the diagnosis, treatment, and prevention of neonatal IFI varied. Continuous surveillance and treatment regimen for neonatal IFI are required to improve outcomes in high-risk neonates. invasive fungal infection, neonatal, epidemiology, Japan Introduction Invasive fungal infection (IFI) is a life-threating infectious disease that occurs in immunocompromised patients. In pediatric medicine, most cases of immunodeficiency are congenital or secondary to diseases such as hematomalignancies and rheumatic disease with immunosuppressive therapy, and also in high-risk neonates. The burden of disease attributed to neonatal IFI varies by geographic region and maternal and neonatal risk factors.1 Approximately, one million neonates are born every year in Japan. Japan has one of the lowest neonatal mortality rates in the world.2 Contrastingly, the preterm birth rate is approximately 5% in Japan.3 IFI is a notable cause of mortality and morbidity in very preterm or very low birth weight (VLBW) infants (birth weight < 1500 g). Other risk factors for IFI include the use of central venous lines, intubation, parenteral nutrition, broad-spectrum antibiotics administration, prolonged hospitalization, abdominal surgery, exposure to an H2 blocker, and colonization with Candida spp.4 In a nationwide survey on pediatric IFI in Japan conducted between 2005 and 2009, only six cases of neonatal IFI were reported.5 However, the main targets of this retrospective survey were medical facilities that had pediatric wards. Therefore, appropriate guidelines for the prevention and treatment of IFI in neonatal medicine in Japan were not developed. The purpose of this study was to assess the incidence of IFI in neonates through a nationwide survey of medical facilities with neonatal intensive care units (NICU) and to formulate effective guidelines for the prevention and treatment of neonatal IFI. This study is important for improving the prognosis of high-risk neonates. Methods We conducted a nationwide retrospective survey in November 2015, in order to determine the incidence of IFI between January 2014 and October 2015. This survey was performed with the regular annual nationwide survey of neonatal bacterial infectious diseases by the committee for infection and vaccine promotion of the Japan Society for Neonatal Health and Development. The chief medical officer of each medical facility filled the questionnaire based on information from the patients’ charts. The primary survey questionnaire was sent to 309 medical facilities that regularly treat high-risk neonates. The primary questionnaire assessment canvassed the incidence of IFI during the study period, the method for preventing fungal infection in high-risk neonates soon after birth. High-risk neonates were defined as very preterm neonates (gestational age ≤28 weeks), those with very low birth weight (≤1000 g), and infants receiving broad-spectrum antibiotic therapy excluding the initial therapy with ampicillin and gentamicin.6 The primary questionnaire also assessed the method of maternal antifungal prophylaxis for preventing mother with fungal colonization to high-risk neonate transmission. The definition of IFI in the primary questionnaire was based on each clinician's diagnosis according to the laboratory data and clinical course. The secondary questionnaire assessment was for facilities that reported cases of IFI from their reply to the primary questionnaire. The secondary questionnaire included the patient's gestation age, birth weight, sex, underlying condition, postnatal age at onset, clinical symptoms, diagnostic modality for infection, pathogenic fungus, choice of antifungal agents, and the method of prevention and outcome (see supplementary file). Early-onset infection was defined as an infection occurring within 6 days after birth. Finally, the patients with proven or provable IFI, defined according to the revised criteria of the European Organization for Research and Treatment of Cancer/Infectious Diseases Mycoses Study Group (EORTC/MSG) were enrolled in this study. Briefly, proven IFI required mycological confirmation from a normally sterile site, whereas probable IFI required host factor, clinical and mycological evidence.7 Variables were summarized as frequencies, percentages, and medians. The analysis compared the incidence of neonatal IFI in two groups, using a χ2 test with the P value set at .05. All statistical calculations were performed using JMP Pro Ver.12 (SAS Institute Inc., Cary, NC, USA). This study was approved by the Ethical Committee of Chiba University Graduate School of Medicine (No. 2116) and Medical Mycology Research Center, Chiba University (No. 6). Results Results from the primary questionnaire The questionnaires were sent to 309 medical facilities in the Neonatal Research Network Japan and other related medical facilities that also had NICU or treated neonates. In total, 128 facilities replied to the primary questionnaire and the response rate was 41.4%. Notably, 24/128 facilities reported having managed 34 IFI cases including possible IFI, and 55/128 (43.0%) medical facilities offered neonatal fugal prophylaxis. The most frequently used prophylactic drug was fluconazole (n = 35), followed by micafungin (n = 16) (Table 1). Fungal prophylaxis was offered to mothers with fungal colonization in 30 of 128 facilities (23.4%). The majority of high-risk mothers received prophylaxis with oxiconazole vaginal tablets (Table 2). Table 1. Antifungal prophylaxis for neonates (number of facilities = 55). Antifungal agents Number of facilities, n (%) Fosfluconazole 15 (27.3) Fluconazole 14 (25.5) Micafungin 11 (20.0) Micafungin or fluconazole 2 (3.6) Micafungin or fosfluconazole 2 (3.6) Fosfluconazole+miconazole 2 (3.6) Liposomal amphotericin B 2 (3.6) Caspofungin 1 (1.8) Micafungin+miconazole 1 (1.8) Amphotericin B or miconazole 1 (1.8) Miconazole 1 (1.8) Not described 3 (5.4) Antifungal agents Number of facilities, n (%) Fosfluconazole 15 (27.3) Fluconazole 14 (25.5) Micafungin 11 (20.0) Micafungin or fluconazole 2 (3.6) Micafungin or fosfluconazole 2 (3.6) Fosfluconazole+miconazole 2 (3.6) Liposomal amphotericin B 2 (3.6) Caspofungin 1 (1.8) Micafungin+miconazole 1 (1.8) Amphotericin B or miconazole 1 (1.8) Miconazole 1 (1.8) Not described 3 (5.4) View Large Table 1. Antifungal prophylaxis for neonates (number of facilities = 55). Antifungal agents Number of facilities, n (%) Fosfluconazole 15 (27.3) Fluconazole 14 (25.5) Micafungin 11 (20.0) Micafungin or fluconazole 2 (3.6) Micafungin or fosfluconazole 2 (3.6) Fosfluconazole+miconazole 2 (3.6) Liposomal amphotericin B 2 (3.6) Caspofungin 1 (1.8) Micafungin+miconazole 1 (1.8) Amphotericin B or miconazole 1 (1.8) Miconazole 1 (1.8) Not described 3 (5.4) Antifungal agents Number of facilities, n (%) Fosfluconazole 15 (27.3) Fluconazole 14 (25.5) Micafungin 11 (20.0) Micafungin or fluconazole 2 (3.6) Micafungin or fosfluconazole 2 (3.6) Fosfluconazole+miconazole 2 (3.6) Liposomal amphotericin B 2 (3.6) Caspofungin 1 (1.8) Micafungin+miconazole 1 (1.8) Amphotericin B or miconazole 1 (1.8) Miconazole 1 (1.8) Not described 3 (5.4) View Large Table 2. Antifungal prophylaxis for mothers (number of facilities = 30). Antifungal agents Number of facilities, n (%) Vaginal tablet Oxiconazole 10 (33.3) Isoconazole 3 (10.0) Miconazole 1 (3.3) Not described 8 (26.7) Systemic administration Micafungin 1 (3.3) Not described 7 (23.3) Antifungal agents Number of facilities, n (%) Vaginal tablet Oxiconazole 10 (33.3) Isoconazole 3 (10.0) Miconazole 1 (3.3) Not described 8 (26.7) Systemic administration Micafungin 1 (3.3) Not described 7 (23.3) View Large Table 2. Antifungal prophylaxis for mothers (number of facilities = 30). Antifungal agents Number of facilities, n (%) Vaginal tablet Oxiconazole 10 (33.3) Isoconazole 3 (10.0) Miconazole 1 (3.3) Not described 8 (26.7) Systemic administration Micafungin 1 (3.3) Not described 7 (23.3) Antifungal agents Number of facilities, n (%) Vaginal tablet Oxiconazole 10 (33.3) Isoconazole 3 (10.0) Miconazole 1 (3.3) Not described 8 (26.7) Systemic administration Micafungin 1 (3.3) Not described 7 (23.3) View Large Results from the secondary questionnaire All medical facilities that reported having recorded cases of IFI in the primary questionnaire replied to the secondary questionnaire. Among the 34 cases, there were 16 cases of proven IFI, 7 cases of probable IFI, and the remaining 11 were clinically suspected cases base on the patients’ reactions to antibiotics. Finally, 17/128 facilities reported 23 proven or probable cases of IFI (Table 3). Eleven cases of IFI were reported in 2014 (January–December 2014), and 12 in 2015 (January–October 2015). The annual number of hospitalized patients in these 128 medical facilities was 37,457. The estimated annual incidence of IFI was 0.33 per 1000 live births of hospitalized neonates. Patient data on the onset of IFI was available for all 23 patients. The median gestational age at birth was 26 weeks (range: 22–33 weeks), the median birth weight was 891 g (range: 394–2,040 g), and 13 patients were male. The birth weight was < 1000 g in 18 patients and > 1500 g in four patients, two of whom had underlying diseases. The median age at onset of IFI was 18 days (range: 0–161 days). Early-onset infection occurred in 10 cases, and 20/23 cases presented with IFI within 30 days after birth. The rates of occurrence of the associated risk factors are presented in Table 4. The most frequent laboratory finding of patients with IFI at initial diagnosis was a low platelet count. The clinical diagnoses of the gross number of fungal infection revealed that 15 cases were sepsis; six were pneumonia; five were dermatitis; three were septic shock; two were intestinal candida infection; and one exhibited meningitis/ventriculitis, peritonitis, liver abscess, and disseminated infection. The causative microorganisms were identified in 22 patients. Candida species (n = 21) were the most commonly isolated pathogen, and one patient was reported to have mucormycosis. In 13/21 patients, IFI due to candida was caused by C. albicans, five by C. parapsilosis, two by C. glabrata, and one by C. albicans and C. glabrata. The causative microorganism was not identified for the remaining one probable case of IFI. As a first-line antifungal treatment, 11 patients received micafungin, eight received fosfluconazole, three received fluconazole, one received liposomal amphotericin B. In nine cases, the first-line antifungal treatment had to be changed (Table 3). Liposomal amphotericin B was finally prescribed for five patients. The median duration of treatment in survivors was 34 days (range: 3–110 days). Four patients died during the antifungal therapy, all of whom had extremely low birth weights. The median postnatal age at death was 80 days (range: 11–225 days). Among the deceased patients, two were infected with C. parapsilosis and one each with C. albicans and Mucorales. Notably, 2/4 (50%) of those who died had been treated with micafungin, one with liposomal amphotericin B, and one with fluconazole. The median duration of treatment for those who died was 33 days (range: 4–64 days). Involvement of other organs apart from the primary site of infection was also noted in those who died. Two patients died within 1 week of the onset of IFI. IFI directly contributed to the death of these two patients. One patient who survived exhibited sequelae and was treated at home on oxygen therapy. Of 17 medical facilities that reported cases of IFI, 12 (70.6%) routinely provided antifungal prophylaxis to high-risk neonates. The incidence of IFI in the facilities that provided antifungal prophylaxis to neonates (2.3 per 1000 live births of hospitalized neonates) was lower than the incidence of IFI in those that did not provide antifungal prophylaxis to neonates (4.0 per 1000 live births of hospitalized neonates), but this difference was not statistically significant. Also, of the 17 medical facilities that reported cases of IFI, six (35.3%) routinely provided antifungal prophylaxis to high-risk mothers. The incidence of IFI in the facilities that provided antifungal prophylaxis to mothers (2.8 per 1000 live births of hospitalized neonates) was higher than the incidence of IFI in those that did not provide antifungal prophylaxis to mothers (2.6 per 1000 live births of hospitalized neonates), but this difference was not statistically significant. Again, of 17 medical facilities that reported cases of IFI, 14 (82.4%) routinely provided antifungal prophylaxis to high-risk neonates and/or high-risk mothers. The incidence of IFI in the facilities that provided antifungal prophylaxis (2.6 per 1000 live births of hospitalized neonates) was lower than the incidence of IFI in those that did not provide antifungal prophylaxis (3.7 per 1000 live births of hospitalized neonates), but this difference was not statistically significant. Thus, the provision of antifungal prophylaxis did not statistically make a difference regarding the incidence of IFI in our study. Table 3. Clinical characteristics of patients with proven/probable invasive fungal infections. Case number Proven /Probable IFI Birth weight (g) Gestational age at birth (weeks) Postnatal age at onset (days) Antifungal prophylaxis for infant Clinical diagnoses Supporting laboratory result Pathogen Initial treatment Final treatment Outcome 1 Proven 430 22 6 Yes Septic shock dermatitis LPlt/HG Candida parapsilosis MCFG MCFG Death (5 days after onset) 2 Proven 470 22 7 No Sepsis dermatitis none Candida albicans F-FLCZ MCFG Cured 3 Proven 452 22 7 Yes Disseminated infection HG Mucorales MCFG MCFG Death (4 days after onset) 4 Proven 550 23 0 No Sepsis none Candida albicans FLCZ FLCZ Cured with sequelae 5 Proven 588 24 16 No Sepsis LPlt/HG /BDG Candida parapsilosis F-FLCZ MCFG Cured 6 Proven 470 24 10 No Sepsis LPlt/HG Candida glabrata F-FLCZ F-FLCZ Cured 7 Proven 782 24 0 No Sepsis BDG Candida albicans F-FLCZ F-FLCZ Cured 8. Proven 808 25 45 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG FLCZ +L-AMB Cured 9 Proven 783 26 5 Yes Sepsis dermatitis none Candida albicans FLCZ MCFG Cured 10 Proven 658 26 10 Yes Sepsis liver abscess LPlt Candida PCR(+) Candida albicans MCFG MCFG Cured 11 Proven 394 26 161 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG L-AMB Death (64 days after onset) 12 Proven 1009 26 0 No Septic shock dermatitis pneumonia LPlt Candida albicans F-FLCZ F-FLCZ Cured 13 Proven 816 29 88 No Sepsis LPlt Candida parapsilosis F-FLCZ F-FLCZ Cured 14 Proven 1884 30 11 No Sepsis LPlt Candida albicans MCFG MCFG Cured 15 Proven 1872 31 0 No Sepsis pneumonia BDG Candida albicans MCFG MCFG Cured 16 Proven 2040 33 1 No Sepsis none Candida albicans + Candida glabrata MCFG MCFG Cured 17 Probable 582 23 7 Yes Septic shock BDG Candida albicans F-FLCZ L-AMB Cured 18 Probable 916 25 0 No Sepsis pneumonia abnormal OE Candida albicans F-FLCZ F-FLCZ Cured 19 Probable 530 25 18 No Intestinal Candida infection peritonitis LPlt/HG /BDG Candida albicans L-AMB L-AMB +MCFG Cured 20 Probable 924 26 0 No Meningitis venticulitis dermatitis pneumonia LPlt /BDG Candida albicans MCFG F-FLCZ +L-AMB Cured 21 Probable 948 27 17 No Intestinal Candida infection peritonitis pneumonia HG/LPlt /BDG Candida albicans FLCZ FLCZ Death (57 days after onset) 22 Probable 1591 29 0 No Pneumonia LPlt/BDG Candida glabrata MCFG F-FLCZ Cured 23 Probable 998 29 10 No Sepsis HG/BDG Unidentified MCFG MCFG Cured Case number Proven /Probable IFI Birth weight (g) Gestational age at birth (weeks) Postnatal age at onset (days) Antifungal prophylaxis for infant Clinical diagnoses Supporting laboratory result Pathogen Initial treatment Final treatment Outcome 1 Proven 430 22 6 Yes Septic shock dermatitis LPlt/HG Candida parapsilosis MCFG MCFG Death (5 days after onset) 2 Proven 470 22 7 No Sepsis dermatitis none Candida albicans F-FLCZ MCFG Cured 3 Proven 452 22 7 Yes Disseminated infection HG Mucorales MCFG MCFG Death (4 days after onset) 4 Proven 550 23 0 No Sepsis none Candida albicans FLCZ FLCZ Cured with sequelae 5 Proven 588 24 16 No Sepsis LPlt/HG /BDG Candida parapsilosis F-FLCZ MCFG Cured 6 Proven 470 24 10 No Sepsis LPlt/HG Candida glabrata F-FLCZ F-FLCZ Cured 7 Proven 782 24 0 No Sepsis BDG Candida albicans F-FLCZ F-FLCZ Cured 8. Proven 808 25 45 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG FLCZ +L-AMB Cured 9 Proven 783 26 5 Yes Sepsis dermatitis none Candida albicans FLCZ MCFG Cured 10 Proven 658 26 10 Yes Sepsis liver abscess LPlt Candida PCR(+) Candida albicans MCFG MCFG Cured 11 Proven 394 26 161 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG L-AMB Death (64 days after onset) 12 Proven 1009 26 0 No Septic shock dermatitis pneumonia LPlt Candida albicans F-FLCZ F-FLCZ Cured 13 Proven 816 29 88 No Sepsis LPlt Candida parapsilosis F-FLCZ F-FLCZ Cured 14 Proven 1884 30 11 No Sepsis LPlt Candida albicans MCFG MCFG Cured 15 Proven 1872 31 0 No Sepsis pneumonia BDG Candida albicans MCFG MCFG Cured 16 Proven 2040 33 1 No Sepsis none Candida albicans + Candida glabrata MCFG MCFG Cured 17 Probable 582 23 7 Yes Septic shock BDG Candida albicans F-FLCZ L-AMB Cured 18 Probable 916 25 0 No Sepsis pneumonia abnormal OE Candida albicans F-FLCZ F-FLCZ Cured 19 Probable 530 25 18 No Intestinal Candida infection peritonitis LPlt/HG /BDG Candida albicans L-AMB L-AMB +MCFG Cured 20 Probable 924 26 0 No Meningitis venticulitis dermatitis pneumonia LPlt /BDG Candida albicans MCFG F-FLCZ +L-AMB Cured 21 Probable 948 27 17 No Intestinal Candida infection peritonitis pneumonia HG/LPlt /BDG Candida albicans FLCZ FLCZ Death (57 days after onset) 22 Probable 1591 29 0 No Pneumonia LPlt/BDG Candida glabrata MCFG F-FLCZ Cured 23 Probable 998 29 10 No Sepsis HG/BDG Unidentified MCFG MCFG Cured BDG, Elevation of (1→3)- β-D-glucan (BDG > 11 pg/ml); F-FLCZ, Fosfluconazole; FLCZ, Fluconazole; HG, Hyper glycemia (blood glucose > 150 mg/dl); L-AMB, Liposomal amphotericin B; LPlt, Low platelet count (platelet < 10 × 104/mm3); MCFG, Micafungin; ND, Not done; OE, Ophthalmologic examination; PCR, Polymerase chain reaction. View Large Table 3. Clinical characteristics of patients with proven/probable invasive fungal infections. Case number Proven /Probable IFI Birth weight (g) Gestational age at birth (weeks) Postnatal age at onset (days) Antifungal prophylaxis for infant Clinical diagnoses Supporting laboratory result Pathogen Initial treatment Final treatment Outcome 1 Proven 430 22 6 Yes Septic shock dermatitis LPlt/HG Candida parapsilosis MCFG MCFG Death (5 days after onset) 2 Proven 470 22 7 No Sepsis dermatitis none Candida albicans F-FLCZ MCFG Cured 3 Proven 452 22 7 Yes Disseminated infection HG Mucorales MCFG MCFG Death (4 days after onset) 4 Proven 550 23 0 No Sepsis none Candida albicans FLCZ FLCZ Cured with sequelae 5 Proven 588 24 16 No Sepsis LPlt/HG /BDG Candida parapsilosis F-FLCZ MCFG Cured 6 Proven 470 24 10 No Sepsis LPlt/HG Candida glabrata F-FLCZ F-FLCZ Cured 7 Proven 782 24 0 No Sepsis BDG Candida albicans F-FLCZ F-FLCZ Cured 8. Proven 808 25 45 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG FLCZ +L-AMB Cured 9 Proven 783 26 5 Yes Sepsis dermatitis none Candida albicans FLCZ MCFG Cured 10 Proven 658 26 10 Yes Sepsis liver abscess LPlt Candida PCR(+) Candida albicans MCFG MCFG Cured 11 Proven 394 26 161 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG L-AMB Death (64 days after onset) 12 Proven 1009 26 0 No Septic shock dermatitis pneumonia LPlt Candida albicans F-FLCZ F-FLCZ Cured 13 Proven 816 29 88 No Sepsis LPlt Candida parapsilosis F-FLCZ F-FLCZ Cured 14 Proven 1884 30 11 No Sepsis LPlt Candida albicans MCFG MCFG Cured 15 Proven 1872 31 0 No Sepsis pneumonia BDG Candida albicans MCFG MCFG Cured 16 Proven 2040 33 1 No Sepsis none Candida albicans + Candida glabrata MCFG MCFG Cured 17 Probable 582 23 7 Yes Septic shock BDG Candida albicans F-FLCZ L-AMB Cured 18 Probable 916 25 0 No Sepsis pneumonia abnormal OE Candida albicans F-FLCZ F-FLCZ Cured 19 Probable 530 25 18 No Intestinal Candida infection peritonitis LPlt/HG /BDG Candida albicans L-AMB L-AMB +MCFG Cured 20 Probable 924 26 0 No Meningitis venticulitis dermatitis pneumonia LPlt /BDG Candida albicans MCFG F-FLCZ +L-AMB Cured 21 Probable 948 27 17 No Intestinal Candida infection peritonitis pneumonia HG/LPlt /BDG Candida albicans FLCZ FLCZ Death (57 days after onset) 22 Probable 1591 29 0 No Pneumonia LPlt/BDG Candida glabrata MCFG F-FLCZ Cured 23 Probable 998 29 10 No Sepsis HG/BDG Unidentified MCFG MCFG Cured Case number Proven /Probable IFI Birth weight (g) Gestational age at birth (weeks) Postnatal age at onset (days) Antifungal prophylaxis for infant Clinical diagnoses Supporting laboratory result Pathogen Initial treatment Final treatment Outcome 1 Proven 430 22 6 Yes Septic shock dermatitis LPlt/HG Candida parapsilosis MCFG MCFG Death (5 days after onset) 2 Proven 470 22 7 No Sepsis dermatitis none Candida albicans F-FLCZ MCFG Cured 3 Proven 452 22 7 Yes Disseminated infection HG Mucorales MCFG MCFG Death (4 days after onset) 4 Proven 550 23 0 No Sepsis none Candida albicans FLCZ FLCZ Cured with sequelae 5 Proven 588 24 16 No Sepsis LPlt/HG /BDG Candida parapsilosis F-FLCZ MCFG Cured 6 Proven 470 24 10 No Sepsis LPlt/HG Candida glabrata F-FLCZ F-FLCZ Cured 7 Proven 782 24 0 No Sepsis BDG Candida albicans F-FLCZ F-FLCZ Cured 8. Proven 808 25 45 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG FLCZ +L-AMB Cured 9 Proven 783 26 5 Yes Sepsis dermatitis none Candida albicans FLCZ MCFG Cured 10 Proven 658 26 10 Yes Sepsis liver abscess LPlt Candida PCR(+) Candida albicans MCFG MCFG Cured 11 Proven 394 26 161 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG L-AMB Death (64 days after onset) 12 Proven 1009 26 0 No Septic shock dermatitis pneumonia LPlt Candida albicans F-FLCZ F-FLCZ Cured 13 Proven 816 29 88 No Sepsis LPlt Candida parapsilosis F-FLCZ F-FLCZ Cured 14 Proven 1884 30 11 No Sepsis LPlt Candida albicans MCFG MCFG Cured 15 Proven 1872 31 0 No Sepsis pneumonia BDG Candida albicans MCFG MCFG Cured 16 Proven 2040 33 1 No Sepsis none Candida albicans + Candida glabrata MCFG MCFG Cured 17 Probable 582 23 7 Yes Septic shock BDG Candida albicans F-FLCZ L-AMB Cured 18 Probable 916 25 0 No Sepsis pneumonia abnormal OE Candida albicans F-FLCZ F-FLCZ Cured 19 Probable 530 25 18 No Intestinal Candida infection peritonitis LPlt/HG /BDG Candida albicans L-AMB L-AMB +MCFG Cured 20 Probable 924 26 0 No Meningitis venticulitis dermatitis pneumonia LPlt /BDG Candida albicans MCFG F-FLCZ +L-AMB Cured 21 Probable 948 27 17 No Intestinal Candida infection peritonitis pneumonia HG/LPlt /BDG Candida albicans FLCZ FLCZ Death (57 days after onset) 22 Probable 1591 29 0 No Pneumonia LPlt/BDG Candida glabrata MCFG F-FLCZ Cured 23 Probable 998 29 10 No Sepsis HG/BDG Unidentified MCFG MCFG Cured BDG, Elevation of (1→3)- β-D-glucan (BDG > 11 pg/ml); F-FLCZ, Fosfluconazole; FLCZ, Fluconazole; HG, Hyper glycemia (blood glucose > 150 mg/dl); L-AMB, Liposomal amphotericin B; LPlt, Low platelet count (platelet < 10 × 104/mm3); MCFG, Micafungin; ND, Not done; OE, Ophthalmologic examination; PCR, Polymerase chain reaction. View Large Table 4. Risk factors of associated with neonatal invasive fungal infection (n = 23). Risk factor Number of IFI cases, n (%) Birth weight < 1000 g 18 (78.3) Gestation age ≤28 weeks 17 (73.9) Small for date 3 (13.0) Underlying disease without ELBW 11 (47.8) Systemic corticosteroid therapy for baby 10 (43.5) Central venous catheter 22 (95.7) Fungal colonization at multiple sites 10 (43.5) No antifungal prophylaxis 16 (69.6) Systemic corticosteroid therapy for mother 11 (47.8) Premature rupture of membranes 9 (39.1) Vaginal delivery 9 (39.1) Vaginal Candida colonization of mother 10 (43.5) Risk factor Number of IFI cases, n (%) Birth weight < 1000 g 18 (78.3) Gestation age ≤28 weeks 17 (73.9) Small for date 3 (13.0) Underlying disease without ELBW 11 (47.8) Systemic corticosteroid therapy for baby 10 (43.5) Central venous catheter 22 (95.7) Fungal colonization at multiple sites 10 (43.5) No antifungal prophylaxis 16 (69.6) Systemic corticosteroid therapy for mother 11 (47.8) Premature rupture of membranes 9 (39.1) Vaginal delivery 9 (39.1) Vaginal Candida colonization of mother 10 (43.5) ELBW, Extremely low birth weight. View Large Table 4. Risk factors of associated with neonatal invasive fungal infection (n = 23). Risk factor Number of IFI cases, n (%) Birth weight < 1000 g 18 (78.3) Gestation age ≤28 weeks 17 (73.9) Small for date 3 (13.0) Underlying disease without ELBW 11 (47.8) Systemic corticosteroid therapy for baby 10 (43.5) Central venous catheter 22 (95.7) Fungal colonization at multiple sites 10 (43.5) No antifungal prophylaxis 16 (69.6) Systemic corticosteroid therapy for mother 11 (47.8) Premature rupture of membranes 9 (39.1) Vaginal delivery 9 (39.1) Vaginal Candida colonization of mother 10 (43.5) Risk factor Number of IFI cases, n (%) Birth weight < 1000 g 18 (78.3) Gestation age ≤28 weeks 17 (73.9) Small for date 3 (13.0) Underlying disease without ELBW 11 (47.8) Systemic corticosteroid therapy for baby 10 (43.5) Central venous catheter 22 (95.7) Fungal colonization at multiple sites 10 (43.5) No antifungal prophylaxis 16 (69.6) Systemic corticosteroid therapy for mother 11 (47.8) Premature rupture of membranes 9 (39.1) Vaginal delivery 9 (39.1) Vaginal Candida colonization of mother 10 (43.5) ELBW, Extremely low birth weight. View Large Discussion To the best of our knowledge, this is the first report on the nationwide surveillance of neonatal IFI in Japan. This study clarified the incidence of neonatal IFI and the actual state of prophylaxis against IFI for mothers and babies in Japan. The estimated annual IFI incidence in the present study was 0.33 per 1000 live births of hospitalized neonates. According to the reports from other countries, Xia et al. reported that the incidence of invasive candidiasis was 0.74 cases per 1000 preterm discharges from NICU in China.8 Nguyen et al. also reported the incidence of invasive candida infection was one case per 1000 patients below 32 weeks gestational age per year in France.9 Oeser et al. reported the incidence of neonatal IFI in England between 2004 and 2010 as 2.4 per 1000 neonatal unit admissions.10 The incidence of our study was similar to the above studies. Notably, several studies showed higher incidence rate (7%) than our study.11,12 Possible explanations for these discrepancies include differences in patient demographics, medical practices, and surveillance systems. Regarding the methods for the prevention neonatal IFI, the systematic review of randomized control trials on the use of antifungal chemotherapy to prevent neonatal IFI in VLBW infants reported that prophylactic fluconazole and oral nystatin were both highly effective. Both agents were safe without significant toxicities.13 In our study, only 43% of medical facilities prescribed antifungal prophylaxis for high-risk neonates; 16/55 facilities (29.1%) chose micafungin as the prophylactic agent. Therefore, the antifungal prophylaxis for high-risk neonates was not widely performed, and the prophylactic agents administered were varied in Japan. Pregnancy increases the frequency of vaginal Candida colonization.14 Concerning maternal antifungal prophylaxis, there were two eligible randomized controlled trials in which pregnant women were treated for vulvovaginal candidiasis and where preterm birth was reported as an outcome. There was a significant in the number of spontaneous preterm births in treated compared with untreated women.15,16 In our study, fungal prophylaxis for mothers who showed fungal colonization was administered in 23.4% of the medical facilities. Antifungal vaginal tablets were the most common prophylactic agents prescribed. Further studies are required to clarify the efficacy of antifungal prophylaxis for mothers in Japan. In our study, 23 cases of IFI were reported. The most common pathogenic fungus was Candida spp, of which C. albicans was the predominant species. Notably, non–albicans Candida spp. were also isolated in our study. Although C. albicans has historically been the most prominent species involved in IFI, C. parapsilosis is increasing in frequency, and neonates are disproportionately affected. In a Tunisian study, C. albicans was the predominant species up to 2006, and a shift in the species spectrum was observed with an increase in non-albicans species, predominantly C. parapsilosis.17 Another study revealed that C. parapsilosis was the leading causative pathogen of IFI and was isolated in 33.3% of the patients.18 Regarding the treatment of C. parapsilosis infection, echinocandin-resistant strains, which may be associated with acquired mutations of the gene encoding (1→3)- β-D-glucan (BDG) synthase have been involved.19 Practically, 60% of cases of IFI caused by C. parapsilosis required a change of the initial fungal treatment in our study. In our study, one patient with mucormycosis was reported, who developed a disseminated infection and died. The pathogenic diagnosis was made by autopsy. IFI caused by Mucorales is rare in children, and data on mucormycosis in neonates are lacking. Mucormycosis is a life-threatening infection in neonates, and amphotericin B is the recommended antifungal agent.20 IFI is associated with high morbidity and mortality in preterm neonates. The main risk factors of IFI are multiple antibiotics including third-generation cephalosporins, central venous catheters, parenteral nutrition, immunosuppression, and VLBW.21,22 Colonization with Candida spp. in neonates is also an important risk factor of IFI. Neonates acquire Candida spp. either via maternal-vertical transmission or nosocomial acquisition in the nursery. Multiple sites may become colonized, and a direct correlation between fungal colonization and subsequent progression to invasive candidemia was determined.4 Vaginal delivery, low birth weight, and low gestational age may also be considered risk factors for candida colonization.23 We studied the frequency of the established risk factors for IFIs in the literature.4 In our study, majority of the neonates with IFI had central venous catheterization (22/23), birth weight < 1000 g (18/23), gestation age ≤28 weeks (17/23), and no antifungal agent prophylaxis (16/23). Contrastingly, an underlying disease without ELBW (11/23), systematic corticosteroid therapy for neonates (11/23) and vaginal Candida colonization of the mother (10/23) were noted in < 50% of the IFI cases in our study. Invasive candidiasis is uncommon in infants with a birth weight > 1500 g. Infants at greatest risk are those exposed to broad-spectrum antibiotics and with platelet counts of < 50,000/mm.3,24 In our study, birth weight was > 1,500 g in four patients, two of whom had underlying diseases. The definitive diagnosis of IFI relies on the growth of fungi in blood culture from otherwise sterile sites, but our study identified 70% of the cases via this method. Goudjil et al. reported that the changes in the serum BDG levels might be of value in evaluating the efficacy of antifungal therapy.25 Zhao et al. also reported the usefulness of BDG for identifying the diagnostic and prognostic markers of IFI in preterm infants. The sensitivity in diagnosing IFI by a BDG cutoff > 10 pg/ml was 68.3% and specificity was 75.6%.26 In our study, 6/23 cases were serologically diagnosed with IFI (a BDG value of > 11 pg/ml was considered as positive). Trovato et al. recently reported the usefulness of fungal DNA detection in blood culture for the diagnosis of invasive candidiasis in neonates.27 In our study, one patient was diagnosed with IFI based on the detection of fungal DNA. Regarding the treatment, according to the European Society of Clinical Microbiology and Infectious Diseases guidelines for the diagnosis and management of Candida disease in neonates and children, amphotericin B deoxy cholate, liposomal amphotericin B, amphotericin B lipid complex, fluconazole, micafungin, and caspofungin can all potentially be used for the treatment of invasive candidiasis in neonates.28 Over the past decade, the number of antifungal agents in development has increased, but the majority are not labeled for use in neonates.29 In our study, micafungin was most commonly used as the initial antifungal treatment, followed by fosfluconazole. However, the treatment of eight cases was changed from the initial treatment during the clinical course. The duration of treatment in survivors was variable (range: 3–110 days). It is important that a treatment regimen for neonatal IFI is established. The mortality rate in our study was 17.4% (4/23), which is similar to a study from China (19.3%) but lower than a report from England (31%).8,10 All deceased patients were ELBW infants. The causative fungi of the deceased cases were Candida spp. (n = 3) and mucormycosis (n = 1). A report on the virulent factors of Candida spp. described that individual isolates of Candida spp. were varied in their virulent properties such as adhesion and cytotoxicity. However, highly virulent Candida strains are associated with clinical outcomes.30 It is also important that the isolated strain from IFI was stocked and its virulence analyzed precisely. There are several limitations to our study. The first was the low response rate to the primary questionnaire (41.4%), which could have led to an underestimation of the incidence of IFI. However, the responding medical facilities included 33 qualified main training hospitals with NICU (units for level III intensive care), which are evenly distributed throughout Japan. The annual numbers of VLBW infants delivered in Japan and in these medical facilities were 7500 and 4000, respectively.31 The annual number of VLBW infants in this survey was calculated based on the data from the medical facilities. We think that the present results are representative of the current Japanese situation because approximately half of VLBW infants were covered in this survey. Second, our study identified only 23 cases of proven or probable IFI. Improved diagnostics for fungi are required to guide the initiation of prompt antifungal therapy in premature infants.32 Finally, we did not collect any data on the antifungal susceptibility of the isolated fungi, and the dosage of antifungal agent used. To clarify the efficacy of the antifungal treatment, these data are important.33 Further surveillance studies are required to investigate these points. In conclusion, our nationwide survey identified 23 IFI cases during the 22-month study period. The majority of IFI cases were caused by Candida infection, and the mortality rate was 17.4%. According to a large cohort study in the United States, the incidence of invasive candidiasis in the NICU decreased over the 14-year study period. Increased use of fluconazole prophylaxis, empirical antifungal therapy, and decreased use of broad-spectrum antibiotics may have contributed to this observation.34 In Japan, the diagnosis, treatment, and prevention of neonatal IFI varied. Continuous surveillance and the establishment of a treatment regimen against neonatal IFI, including regulation of the use of broad-spectrum antibiotics, are required to improve outcomes in high-risk neonates. Supplementary material Supplementary data are available at MMYCOL online. Acknowledgements The authors thank the members of the committee for infection and vaccine promotion of the Japan Society for Neonatal Health and Development for their support during this surveillance study. Source of Funding This study was funded by the Project for the development of prevention, diagnosis and treatment against elderly and neonatal aspergillosis, Chiba University. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of the paper. References 1. Shane AL , Stoll BJ . Neonatal sepsis: progress towards improved outcomes . J Infect . 2014 ; 68 : S24 – 32 . Google Scholar CrossRef Search ADS PubMed 2. Kim do H , Jeon J , Park CG , Sriram S , Lee KS . Neonatal and infant mortality in Korea, Japan, and the US: Effect of birth weight distribution and birth weight-specific mortality rates . J Korean Med Sci . 2016 ; 31 : 1450 – 1454 . Google Scholar CrossRef Search ADS PubMed 3. Blencowe H , Cousens S , Oestergaard MZ et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications . Lancet . 2012 ; 379 : 2162 – 2172 . Google Scholar CrossRef Search ADS PubMed 4. Leibovitz E. Strategies for the prevention of neonatal candidiasis . Pediatr Neonatol . 2012 ; 53 : 83 – 89 . Google Scholar CrossRef Search ADS PubMed 5. Mori M . Nationwide survey of treatment for pediatric patients with invasive fungal infections in Japan . J Infect Chemother . 2013 ; 19 : 946 – 950 . Google Scholar CrossRef Search ADS PubMed 6. Rolnitsky A , Levy I , Sirota L , Shalit I , Klinger G . Targeted fluconazole prophylaxis for high-risk very low birth weight infants . Eur J Pediatr . 2012 ; 171 : 1481 – 1487 . Google Scholar CrossRef Search ADS PubMed 7. De Pauw B , Walsh TJ , Donnelly JP et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis . 2008 ; 46 : 1813 – 1821 . Google Scholar CrossRef Search ADS PubMed 8. Xia H , Wu H , Xia S et al. Invasive candidiasis in preterm neonates in China: a retrospective study from 11 NICUs during 2009–2011. Pediatr Infect Dis J . 2014 ; 33 : 106 – 109 . Google Scholar CrossRef Search ADS PubMed 9. Nguyen K , Zmeter G , Claris O , Kassai B . Epidemiology of invasive Candida infection in a neonatal intensive care unit in France . Acta Paediatrica . 2012 ; 101 : e137 – e139 . Google Scholar CrossRef Search ADS PubMed 10. Oeser C , Vergnano S , Naidoo R et al. Neonatal invasive fungal infection in England 2004–2010. Clin Microbiol Infect . 2014 ; 20 : 936 – 941 . Google Scholar CrossRef Search ADS PubMed 11. Benjamin DK Jr. , BJ Stoll , AA Fanaroff et al. Neonatal candidiasis among extremely low birth weight infants: risk factors, mortality rates, and neurodevelopmental outcomes at 18 to 22 months . Pediatrics . 2006 ; 117 : 84 – 92 . Google Scholar CrossRef Search ADS PubMed 12. Cotten CM , McDonald S , Stoll B , Goldberg RN , Poole K , Jr Benjamin DK . The association of third-generation cephalosporin use and invasive candidiasis in extremely low birth-weight infants . Pediatrics . 2006 ; 118 : 717 – 722 . Google Scholar CrossRef Search ADS PubMed 13. 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 : 846 – 851 . Google Scholar CrossRef Search ADS PubMed 14. Sobel JD. Vulvovaginal candidosis . Lancet . 2007 ; 369 : 1961 – 1971 . Google Scholar CrossRef Search ADS PubMed 15. Kiss H , Petricevic L , Husslein P . Prospective randomised controlled trial of an infection screening programme to reduce the rate of preterm delivery . BMJ . 2004 ; 329 : 371 . Google Scholar CrossRef Search ADS PubMed 16. Roberts CL , Rickard K , Kotsiou G , Morris JM . Treatment of asymptomatic vaginal candidiasis in pregnancy to prevent preterm birth: an open-label pilot randomized controlled trial . BMC Pregnancy and Childbirth . 2011 ; 11 : 18 . Google Scholar CrossRef Search ADS PubMed 17. Ben Abdeljelil J , Saghrouni F , Nouri S et al. Neonatal invasive candidiasis in Tunisian hospital: incidence, risk factors, distribution of species and antifungal susceptibility . Mycoses . 2012 ; 55 : 493 – 500 . Google Scholar CrossRef Search ADS PubMed 18. Yu Y , Du L , Yuan T et al. Risk factors and clinical analysis for invasive fungal infection in neonatal intensive care unit patients . Am J Perinatol . 2013 ; 30 : 589 – 594 . Google Scholar CrossRef Search ADS PubMed 19. Chow BD , Linden JR , Bliss JM . Candida parapsilosis and the neonate: epidemiology, virulence and host defense in a unique patient setting . Expert Rev Anti Infect Ther . 2012 ; 10 : 935 – 946 . Google Scholar CrossRef Search ADS PubMed 20. Zaoutis TE , Roilides E , Chiou CC et al. Zygomycosis in children: a systematic review and analysis of reported cases . Pediatric Infect Dis J . 2007 ; 26 : 723 – 727 . Google Scholar CrossRef Search ADS 21. Tezer H , Canpolat FE , Dilmen U . Invasive fungal infections during the neonatal period: diagnosis, treatment and prophylaxis . Expert Opin Pharmacother . 2012 ; 13 : 193 – 205 . Google Scholar CrossRef Search ADS PubMed 22. Hsieh E , Smith PB , Benjamin DK Jr . Neonatal fungal infections: when to treat? Early Hum Dev . 2012 ; 88 : S6 – S10 . Google Scholar CrossRef Search ADS PubMed 23. Ali GY , Algohary EH , Rashed KA , Almoghanum M , Khalifa AA . Prevalence of Candida colonization in preterm newborns and VLBW in neonatal intensive care unit: role of maternal colonization as a risk factor in transmission of disease . J Matern Fetal Neonatal Med . 2012 ; 25 : 789 – 795 . Google Scholar CrossRef Search ADS PubMed 24. Lee JH , Hornik CP , Benjamin DK Jr. et al. Risk factors for invasive candidiasis in infants > 1500 g birth weight . Pediatr Infect Dis J . 2013 ; 32 : 222 – 226 . Google Scholar CrossRef Search ADS PubMed 25. Goudjil S , Kongolo G , Dusol L et al. (1-3)- β‐D‐glucan levels in candidiasis infections in the critically ill neonate. J Matern Fetal Neonatal Med . 2013 ; 26 : 44 – 48 . CrossRef Search ADS PubMed 26. Zhao D , Qiu G , Luo Z , Zhang Y . Platelet parameters and (1,3)-β‐D-glucan as a diagnostic and prognostic marker of invasive fungal disease in preterm infants . PLOS One . 2015 ; 10 : e0123907 . Google Scholar CrossRef Search ADS PubMed 27. Trovato L , Betta P , Romeo MG , Oliveri S . Detection of fungal DNA in lysis-centrifugation blood culture for the diagnosis of invasive candidiasis in neonatal patients . Clin Microbial Infect . 2012 ; 18 : E63 – E65 . Google Scholar CrossRef Search ADS 28. Hope WW , Castagnola E , Groll AH et al. ESCMID guideline for the diagnosis and management of Candida diseases 2012: prevention and management of invasive infections in neonates and children caused by Candida spp . Clin Microbiol Infect . 2012 ; 18 : 38 – 52 . Google Scholar CrossRef Search ADS PubMed 29. Testoni D , Smith PB , Benjamin DK Jr . The use of antifungal therapy in neonatal intensive care . Clin Perinatol . 2012 ; 39 : 83 – 98 . Google Scholar CrossRef Search ADS PubMed 30. Bliss JM , Wong AY , Bhak G et al. Candida virulence properties and adverse clinical outcomes in neonatal candidiasis . J Pediatr . 2012 ; 161 : 441 – 447 . Google Scholar CrossRef Search ADS PubMed 31. Ministry of Health, Labour and Welfare in Japan . Annual numbers of live births in Japan in 2015 . http://home.b05.itscom.net/kisoh/boshihokentop.html (In Japanese, Accessed: 27th June 2017) 32. Kelly MS , Benjamin DK , Smith PB . The epidemiology and diagnosis of invasive candidiasis among premature infants . Clin Perinatol . 2015 ; 42 : 105 – 117 . Google Scholar CrossRef Search ADS PubMed 33. Regazzi M , Billaud EM , Lefeuvre S , Stronati M . Pharmacokinetics of antifungal agents in neonates and young infants . Curr Med Chem . 2012 ; 19 : 4621 – 4632 . Google Scholar CrossRef Search ADS PubMed 34. Aliaga S , Clark RH , Laughon M et al. Changes in the incidence of candidiasis in neonatal intensive care units . Pediatrics . 2014 ; 133 : 236 – 242 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Medical Mycology Oxford University Press

Nationwide survey of neonatal invasive fungal infection in Japan

Medical Mycology , Volume 56 (6) – Aug 1, 2018

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Taylor & Francis
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© The Author(s) 2017. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology.
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1369-3786
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Abstract

Abstract Invasive fungal infection (IFI) is a life-threating infectious disease in high-risk neonates. Strategies for the treatment and prevention of IFI in neonates in Japan remain unclear. We conducted a nationwide retrospective survey to determine IFI incidence between January 2014 and October 2015. Primary survey questionnaires were submitted to 309 medical facilities that regularly treat high-risk neonates. The questionnaire assessed IFI incidence during the study period, methods for preventing fungal infection in early delivery neonates, and methods for preventing mother-to-child fungal transmission. The secondary questionnaire was for facilities that had IFI cases and replied to the primary questionnaire. In total, 128 medical facilities (41.4%) completed the primary questionnaire, 17/128 facilities recorded 23 proven or probable IFI cases. Estimated annual IFI incidence was 0.33/1000 live births of hospitalized neonates. Patient data at IFI onset were available for all 23 patients. Birth weight was < 1000 g in 18 patients. Causative microorganisms were identified in 22 patients. Candida species (n = 21) were the most common pathogens, and one patient had mucormycosis. The mortality rate was 17.4%. Regarding neonatal fungal prophylaxis, 55/128 facilities (43.0%) reported administering therapy. The most frequently used prophylactic drugs were fluconazole, then micafungin. Fungal prophylaxis for mothers who showed fungal colonization was performed in 30/128 facilities (23.4%). Oxiconazole vaginal tablets were most commonly used as prophylaxis for high-risk mothers. In Japan, the diagnosis, treatment, and prevention of neonatal IFI varied. Continuous surveillance and treatment regimen for neonatal IFI are required to improve outcomes in high-risk neonates. invasive fungal infection, neonatal, epidemiology, Japan Introduction Invasive fungal infection (IFI) is a life-threating infectious disease that occurs in immunocompromised patients. In pediatric medicine, most cases of immunodeficiency are congenital or secondary to diseases such as hematomalignancies and rheumatic disease with immunosuppressive therapy, and also in high-risk neonates. The burden of disease attributed to neonatal IFI varies by geographic region and maternal and neonatal risk factors.1 Approximately, one million neonates are born every year in Japan. Japan has one of the lowest neonatal mortality rates in the world.2 Contrastingly, the preterm birth rate is approximately 5% in Japan.3 IFI is a notable cause of mortality and morbidity in very preterm or very low birth weight (VLBW) infants (birth weight < 1500 g). Other risk factors for IFI include the use of central venous lines, intubation, parenteral nutrition, broad-spectrum antibiotics administration, prolonged hospitalization, abdominal surgery, exposure to an H2 blocker, and colonization with Candida spp.4 In a nationwide survey on pediatric IFI in Japan conducted between 2005 and 2009, only six cases of neonatal IFI were reported.5 However, the main targets of this retrospective survey were medical facilities that had pediatric wards. Therefore, appropriate guidelines for the prevention and treatment of IFI in neonatal medicine in Japan were not developed. The purpose of this study was to assess the incidence of IFI in neonates through a nationwide survey of medical facilities with neonatal intensive care units (NICU) and to formulate effective guidelines for the prevention and treatment of neonatal IFI. This study is important for improving the prognosis of high-risk neonates. Methods We conducted a nationwide retrospective survey in November 2015, in order to determine the incidence of IFI between January 2014 and October 2015. This survey was performed with the regular annual nationwide survey of neonatal bacterial infectious diseases by the committee for infection and vaccine promotion of the Japan Society for Neonatal Health and Development. The chief medical officer of each medical facility filled the questionnaire based on information from the patients’ charts. The primary survey questionnaire was sent to 309 medical facilities that regularly treat high-risk neonates. The primary questionnaire assessment canvassed the incidence of IFI during the study period, the method for preventing fungal infection in high-risk neonates soon after birth. High-risk neonates were defined as very preterm neonates (gestational age ≤28 weeks), those with very low birth weight (≤1000 g), and infants receiving broad-spectrum antibiotic therapy excluding the initial therapy with ampicillin and gentamicin.6 The primary questionnaire also assessed the method of maternal antifungal prophylaxis for preventing mother with fungal colonization to high-risk neonate transmission. The definition of IFI in the primary questionnaire was based on each clinician's diagnosis according to the laboratory data and clinical course. The secondary questionnaire assessment was for facilities that reported cases of IFI from their reply to the primary questionnaire. The secondary questionnaire included the patient's gestation age, birth weight, sex, underlying condition, postnatal age at onset, clinical symptoms, diagnostic modality for infection, pathogenic fungus, choice of antifungal agents, and the method of prevention and outcome (see supplementary file). Early-onset infection was defined as an infection occurring within 6 days after birth. Finally, the patients with proven or provable IFI, defined according to the revised criteria of the European Organization for Research and Treatment of Cancer/Infectious Diseases Mycoses Study Group (EORTC/MSG) were enrolled in this study. Briefly, proven IFI required mycological confirmation from a normally sterile site, whereas probable IFI required host factor, clinical and mycological evidence.7 Variables were summarized as frequencies, percentages, and medians. The analysis compared the incidence of neonatal IFI in two groups, using a χ2 test with the P value set at .05. All statistical calculations were performed using JMP Pro Ver.12 (SAS Institute Inc., Cary, NC, USA). This study was approved by the Ethical Committee of Chiba University Graduate School of Medicine (No. 2116) and Medical Mycology Research Center, Chiba University (No. 6). Results Results from the primary questionnaire The questionnaires were sent to 309 medical facilities in the Neonatal Research Network Japan and other related medical facilities that also had NICU or treated neonates. In total, 128 facilities replied to the primary questionnaire and the response rate was 41.4%. Notably, 24/128 facilities reported having managed 34 IFI cases including possible IFI, and 55/128 (43.0%) medical facilities offered neonatal fugal prophylaxis. The most frequently used prophylactic drug was fluconazole (n = 35), followed by micafungin (n = 16) (Table 1). Fungal prophylaxis was offered to mothers with fungal colonization in 30 of 128 facilities (23.4%). The majority of high-risk mothers received prophylaxis with oxiconazole vaginal tablets (Table 2). Table 1. Antifungal prophylaxis for neonates (number of facilities = 55). Antifungal agents Number of facilities, n (%) Fosfluconazole 15 (27.3) Fluconazole 14 (25.5) Micafungin 11 (20.0) Micafungin or fluconazole 2 (3.6) Micafungin or fosfluconazole 2 (3.6) Fosfluconazole+miconazole 2 (3.6) Liposomal amphotericin B 2 (3.6) Caspofungin 1 (1.8) Micafungin+miconazole 1 (1.8) Amphotericin B or miconazole 1 (1.8) Miconazole 1 (1.8) Not described 3 (5.4) Antifungal agents Number of facilities, n (%) Fosfluconazole 15 (27.3) Fluconazole 14 (25.5) Micafungin 11 (20.0) Micafungin or fluconazole 2 (3.6) Micafungin or fosfluconazole 2 (3.6) Fosfluconazole+miconazole 2 (3.6) Liposomal amphotericin B 2 (3.6) Caspofungin 1 (1.8) Micafungin+miconazole 1 (1.8) Amphotericin B or miconazole 1 (1.8) Miconazole 1 (1.8) Not described 3 (5.4) View Large Table 1. Antifungal prophylaxis for neonates (number of facilities = 55). Antifungal agents Number of facilities, n (%) Fosfluconazole 15 (27.3) Fluconazole 14 (25.5) Micafungin 11 (20.0) Micafungin or fluconazole 2 (3.6) Micafungin or fosfluconazole 2 (3.6) Fosfluconazole+miconazole 2 (3.6) Liposomal amphotericin B 2 (3.6) Caspofungin 1 (1.8) Micafungin+miconazole 1 (1.8) Amphotericin B or miconazole 1 (1.8) Miconazole 1 (1.8) Not described 3 (5.4) Antifungal agents Number of facilities, n (%) Fosfluconazole 15 (27.3) Fluconazole 14 (25.5) Micafungin 11 (20.0) Micafungin or fluconazole 2 (3.6) Micafungin or fosfluconazole 2 (3.6) Fosfluconazole+miconazole 2 (3.6) Liposomal amphotericin B 2 (3.6) Caspofungin 1 (1.8) Micafungin+miconazole 1 (1.8) Amphotericin B or miconazole 1 (1.8) Miconazole 1 (1.8) Not described 3 (5.4) View Large Table 2. Antifungal prophylaxis for mothers (number of facilities = 30). Antifungal agents Number of facilities, n (%) Vaginal tablet Oxiconazole 10 (33.3) Isoconazole 3 (10.0) Miconazole 1 (3.3) Not described 8 (26.7) Systemic administration Micafungin 1 (3.3) Not described 7 (23.3) Antifungal agents Number of facilities, n (%) Vaginal tablet Oxiconazole 10 (33.3) Isoconazole 3 (10.0) Miconazole 1 (3.3) Not described 8 (26.7) Systemic administration Micafungin 1 (3.3) Not described 7 (23.3) View Large Table 2. Antifungal prophylaxis for mothers (number of facilities = 30). Antifungal agents Number of facilities, n (%) Vaginal tablet Oxiconazole 10 (33.3) Isoconazole 3 (10.0) Miconazole 1 (3.3) Not described 8 (26.7) Systemic administration Micafungin 1 (3.3) Not described 7 (23.3) Antifungal agents Number of facilities, n (%) Vaginal tablet Oxiconazole 10 (33.3) Isoconazole 3 (10.0) Miconazole 1 (3.3) Not described 8 (26.7) Systemic administration Micafungin 1 (3.3) Not described 7 (23.3) View Large Results from the secondary questionnaire All medical facilities that reported having recorded cases of IFI in the primary questionnaire replied to the secondary questionnaire. Among the 34 cases, there were 16 cases of proven IFI, 7 cases of probable IFI, and the remaining 11 were clinically suspected cases base on the patients’ reactions to antibiotics. Finally, 17/128 facilities reported 23 proven or probable cases of IFI (Table 3). Eleven cases of IFI were reported in 2014 (January–December 2014), and 12 in 2015 (January–October 2015). The annual number of hospitalized patients in these 128 medical facilities was 37,457. The estimated annual incidence of IFI was 0.33 per 1000 live births of hospitalized neonates. Patient data on the onset of IFI was available for all 23 patients. The median gestational age at birth was 26 weeks (range: 22–33 weeks), the median birth weight was 891 g (range: 394–2,040 g), and 13 patients were male. The birth weight was < 1000 g in 18 patients and > 1500 g in four patients, two of whom had underlying diseases. The median age at onset of IFI was 18 days (range: 0–161 days). Early-onset infection occurred in 10 cases, and 20/23 cases presented with IFI within 30 days after birth. The rates of occurrence of the associated risk factors are presented in Table 4. The most frequent laboratory finding of patients with IFI at initial diagnosis was a low platelet count. The clinical diagnoses of the gross number of fungal infection revealed that 15 cases were sepsis; six were pneumonia; five were dermatitis; three were septic shock; two were intestinal candida infection; and one exhibited meningitis/ventriculitis, peritonitis, liver abscess, and disseminated infection. The causative microorganisms were identified in 22 patients. Candida species (n = 21) were the most commonly isolated pathogen, and one patient was reported to have mucormycosis. In 13/21 patients, IFI due to candida was caused by C. albicans, five by C. parapsilosis, two by C. glabrata, and one by C. albicans and C. glabrata. The causative microorganism was not identified for the remaining one probable case of IFI. As a first-line antifungal treatment, 11 patients received micafungin, eight received fosfluconazole, three received fluconazole, one received liposomal amphotericin B. In nine cases, the first-line antifungal treatment had to be changed (Table 3). Liposomal amphotericin B was finally prescribed for five patients. The median duration of treatment in survivors was 34 days (range: 3–110 days). Four patients died during the antifungal therapy, all of whom had extremely low birth weights. The median postnatal age at death was 80 days (range: 11–225 days). Among the deceased patients, two were infected with C. parapsilosis and one each with C. albicans and Mucorales. Notably, 2/4 (50%) of those who died had been treated with micafungin, one with liposomal amphotericin B, and one with fluconazole. The median duration of treatment for those who died was 33 days (range: 4–64 days). Involvement of other organs apart from the primary site of infection was also noted in those who died. Two patients died within 1 week of the onset of IFI. IFI directly contributed to the death of these two patients. One patient who survived exhibited sequelae and was treated at home on oxygen therapy. Of 17 medical facilities that reported cases of IFI, 12 (70.6%) routinely provided antifungal prophylaxis to high-risk neonates. The incidence of IFI in the facilities that provided antifungal prophylaxis to neonates (2.3 per 1000 live births of hospitalized neonates) was lower than the incidence of IFI in those that did not provide antifungal prophylaxis to neonates (4.0 per 1000 live births of hospitalized neonates), but this difference was not statistically significant. Also, of the 17 medical facilities that reported cases of IFI, six (35.3%) routinely provided antifungal prophylaxis to high-risk mothers. The incidence of IFI in the facilities that provided antifungal prophylaxis to mothers (2.8 per 1000 live births of hospitalized neonates) was higher than the incidence of IFI in those that did not provide antifungal prophylaxis to mothers (2.6 per 1000 live births of hospitalized neonates), but this difference was not statistically significant. Again, of 17 medical facilities that reported cases of IFI, 14 (82.4%) routinely provided antifungal prophylaxis to high-risk neonates and/or high-risk mothers. The incidence of IFI in the facilities that provided antifungal prophylaxis (2.6 per 1000 live births of hospitalized neonates) was lower than the incidence of IFI in those that did not provide antifungal prophylaxis (3.7 per 1000 live births of hospitalized neonates), but this difference was not statistically significant. Thus, the provision of antifungal prophylaxis did not statistically make a difference regarding the incidence of IFI in our study. Table 3. Clinical characteristics of patients with proven/probable invasive fungal infections. Case number Proven /Probable IFI Birth weight (g) Gestational age at birth (weeks) Postnatal age at onset (days) Antifungal prophylaxis for infant Clinical diagnoses Supporting laboratory result Pathogen Initial treatment Final treatment Outcome 1 Proven 430 22 6 Yes Septic shock dermatitis LPlt/HG Candida parapsilosis MCFG MCFG Death (5 days after onset) 2 Proven 470 22 7 No Sepsis dermatitis none Candida albicans F-FLCZ MCFG Cured 3 Proven 452 22 7 Yes Disseminated infection HG Mucorales MCFG MCFG Death (4 days after onset) 4 Proven 550 23 0 No Sepsis none Candida albicans FLCZ FLCZ Cured with sequelae 5 Proven 588 24 16 No Sepsis LPlt/HG /BDG Candida parapsilosis F-FLCZ MCFG Cured 6 Proven 470 24 10 No Sepsis LPlt/HG Candida glabrata F-FLCZ F-FLCZ Cured 7 Proven 782 24 0 No Sepsis BDG Candida albicans F-FLCZ F-FLCZ Cured 8. Proven 808 25 45 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG FLCZ +L-AMB Cured 9 Proven 783 26 5 Yes Sepsis dermatitis none Candida albicans FLCZ MCFG Cured 10 Proven 658 26 10 Yes Sepsis liver abscess LPlt Candida PCR(+) Candida albicans MCFG MCFG Cured 11 Proven 394 26 161 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG L-AMB Death (64 days after onset) 12 Proven 1009 26 0 No Septic shock dermatitis pneumonia LPlt Candida albicans F-FLCZ F-FLCZ Cured 13 Proven 816 29 88 No Sepsis LPlt Candida parapsilosis F-FLCZ F-FLCZ Cured 14 Proven 1884 30 11 No Sepsis LPlt Candida albicans MCFG MCFG Cured 15 Proven 1872 31 0 No Sepsis pneumonia BDG Candida albicans MCFG MCFG Cured 16 Proven 2040 33 1 No Sepsis none Candida albicans + Candida glabrata MCFG MCFG Cured 17 Probable 582 23 7 Yes Septic shock BDG Candida albicans F-FLCZ L-AMB Cured 18 Probable 916 25 0 No Sepsis pneumonia abnormal OE Candida albicans F-FLCZ F-FLCZ Cured 19 Probable 530 25 18 No Intestinal Candida infection peritonitis LPlt/HG /BDG Candida albicans L-AMB L-AMB +MCFG Cured 20 Probable 924 26 0 No Meningitis venticulitis dermatitis pneumonia LPlt /BDG Candida albicans MCFG F-FLCZ +L-AMB Cured 21 Probable 948 27 17 No Intestinal Candida infection peritonitis pneumonia HG/LPlt /BDG Candida albicans FLCZ FLCZ Death (57 days after onset) 22 Probable 1591 29 0 No Pneumonia LPlt/BDG Candida glabrata MCFG F-FLCZ Cured 23 Probable 998 29 10 No Sepsis HG/BDG Unidentified MCFG MCFG Cured Case number Proven /Probable IFI Birth weight (g) Gestational age at birth (weeks) Postnatal age at onset (days) Antifungal prophylaxis for infant Clinical diagnoses Supporting laboratory result Pathogen Initial treatment Final treatment Outcome 1 Proven 430 22 6 Yes Septic shock dermatitis LPlt/HG Candida parapsilosis MCFG MCFG Death (5 days after onset) 2 Proven 470 22 7 No Sepsis dermatitis none Candida albicans F-FLCZ MCFG Cured 3 Proven 452 22 7 Yes Disseminated infection HG Mucorales MCFG MCFG Death (4 days after onset) 4 Proven 550 23 0 No Sepsis none Candida albicans FLCZ FLCZ Cured with sequelae 5 Proven 588 24 16 No Sepsis LPlt/HG /BDG Candida parapsilosis F-FLCZ MCFG Cured 6 Proven 470 24 10 No Sepsis LPlt/HG Candida glabrata F-FLCZ F-FLCZ Cured 7 Proven 782 24 0 No Sepsis BDG Candida albicans F-FLCZ F-FLCZ Cured 8. Proven 808 25 45 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG FLCZ +L-AMB Cured 9 Proven 783 26 5 Yes Sepsis dermatitis none Candida albicans FLCZ MCFG Cured 10 Proven 658 26 10 Yes Sepsis liver abscess LPlt Candida PCR(+) Candida albicans MCFG MCFG Cured 11 Proven 394 26 161 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG L-AMB Death (64 days after onset) 12 Proven 1009 26 0 No Septic shock dermatitis pneumonia LPlt Candida albicans F-FLCZ F-FLCZ Cured 13 Proven 816 29 88 No Sepsis LPlt Candida parapsilosis F-FLCZ F-FLCZ Cured 14 Proven 1884 30 11 No Sepsis LPlt Candida albicans MCFG MCFG Cured 15 Proven 1872 31 0 No Sepsis pneumonia BDG Candida albicans MCFG MCFG Cured 16 Proven 2040 33 1 No Sepsis none Candida albicans + Candida glabrata MCFG MCFG Cured 17 Probable 582 23 7 Yes Septic shock BDG Candida albicans F-FLCZ L-AMB Cured 18 Probable 916 25 0 No Sepsis pneumonia abnormal OE Candida albicans F-FLCZ F-FLCZ Cured 19 Probable 530 25 18 No Intestinal Candida infection peritonitis LPlt/HG /BDG Candida albicans L-AMB L-AMB +MCFG Cured 20 Probable 924 26 0 No Meningitis venticulitis dermatitis pneumonia LPlt /BDG Candida albicans MCFG F-FLCZ +L-AMB Cured 21 Probable 948 27 17 No Intestinal Candida infection peritonitis pneumonia HG/LPlt /BDG Candida albicans FLCZ FLCZ Death (57 days after onset) 22 Probable 1591 29 0 No Pneumonia LPlt/BDG Candida glabrata MCFG F-FLCZ Cured 23 Probable 998 29 10 No Sepsis HG/BDG Unidentified MCFG MCFG Cured BDG, Elevation of (1→3)- β-D-glucan (BDG > 11 pg/ml); F-FLCZ, Fosfluconazole; FLCZ, Fluconazole; HG, Hyper glycemia (blood glucose > 150 mg/dl); L-AMB, Liposomal amphotericin B; LPlt, Low platelet count (platelet < 10 × 104/mm3); MCFG, Micafungin; ND, Not done; OE, Ophthalmologic examination; PCR, Polymerase chain reaction. View Large Table 3. Clinical characteristics of patients with proven/probable invasive fungal infections. Case number Proven /Probable IFI Birth weight (g) Gestational age at birth (weeks) Postnatal age at onset (days) Antifungal prophylaxis for infant Clinical diagnoses Supporting laboratory result Pathogen Initial treatment Final treatment Outcome 1 Proven 430 22 6 Yes Septic shock dermatitis LPlt/HG Candida parapsilosis MCFG MCFG Death (5 days after onset) 2 Proven 470 22 7 No Sepsis dermatitis none Candida albicans F-FLCZ MCFG Cured 3 Proven 452 22 7 Yes Disseminated infection HG Mucorales MCFG MCFG Death (4 days after onset) 4 Proven 550 23 0 No Sepsis none Candida albicans FLCZ FLCZ Cured with sequelae 5 Proven 588 24 16 No Sepsis LPlt/HG /BDG Candida parapsilosis F-FLCZ MCFG Cured 6 Proven 470 24 10 No Sepsis LPlt/HG Candida glabrata F-FLCZ F-FLCZ Cured 7 Proven 782 24 0 No Sepsis BDG Candida albicans F-FLCZ F-FLCZ Cured 8. Proven 808 25 45 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG FLCZ +L-AMB Cured 9 Proven 783 26 5 Yes Sepsis dermatitis none Candida albicans FLCZ MCFG Cured 10 Proven 658 26 10 Yes Sepsis liver abscess LPlt Candida PCR(+) Candida albicans MCFG MCFG Cured 11 Proven 394 26 161 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG L-AMB Death (64 days after onset) 12 Proven 1009 26 0 No Septic shock dermatitis pneumonia LPlt Candida albicans F-FLCZ F-FLCZ Cured 13 Proven 816 29 88 No Sepsis LPlt Candida parapsilosis F-FLCZ F-FLCZ Cured 14 Proven 1884 30 11 No Sepsis LPlt Candida albicans MCFG MCFG Cured 15 Proven 1872 31 0 No Sepsis pneumonia BDG Candida albicans MCFG MCFG Cured 16 Proven 2040 33 1 No Sepsis none Candida albicans + Candida glabrata MCFG MCFG Cured 17 Probable 582 23 7 Yes Septic shock BDG Candida albicans F-FLCZ L-AMB Cured 18 Probable 916 25 0 No Sepsis pneumonia abnormal OE Candida albicans F-FLCZ F-FLCZ Cured 19 Probable 530 25 18 No Intestinal Candida infection peritonitis LPlt/HG /BDG Candida albicans L-AMB L-AMB +MCFG Cured 20 Probable 924 26 0 No Meningitis venticulitis dermatitis pneumonia LPlt /BDG Candida albicans MCFG F-FLCZ +L-AMB Cured 21 Probable 948 27 17 No Intestinal Candida infection peritonitis pneumonia HG/LPlt /BDG Candida albicans FLCZ FLCZ Death (57 days after onset) 22 Probable 1591 29 0 No Pneumonia LPlt/BDG Candida glabrata MCFG F-FLCZ Cured 23 Probable 998 29 10 No Sepsis HG/BDG Unidentified MCFG MCFG Cured Case number Proven /Probable IFI Birth weight (g) Gestational age at birth (weeks) Postnatal age at onset (days) Antifungal prophylaxis for infant Clinical diagnoses Supporting laboratory result Pathogen Initial treatment Final treatment Outcome 1 Proven 430 22 6 Yes Septic shock dermatitis LPlt/HG Candida parapsilosis MCFG MCFG Death (5 days after onset) 2 Proven 470 22 7 No Sepsis dermatitis none Candida albicans F-FLCZ MCFG Cured 3 Proven 452 22 7 Yes Disseminated infection HG Mucorales MCFG MCFG Death (4 days after onset) 4 Proven 550 23 0 No Sepsis none Candida albicans FLCZ FLCZ Cured with sequelae 5 Proven 588 24 16 No Sepsis LPlt/HG /BDG Candida parapsilosis F-FLCZ MCFG Cured 6 Proven 470 24 10 No Sepsis LPlt/HG Candida glabrata F-FLCZ F-FLCZ Cured 7 Proven 782 24 0 No Sepsis BDG Candida albicans F-FLCZ F-FLCZ Cured 8. Proven 808 25 45 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG FLCZ +L-AMB Cured 9 Proven 783 26 5 Yes Sepsis dermatitis none Candida albicans FLCZ MCFG Cured 10 Proven 658 26 10 Yes Sepsis liver abscess LPlt Candida PCR(+) Candida albicans MCFG MCFG Cured 11 Proven 394 26 161 Yes Sepsis LPlt/BDG Candida parapsilosis MCFG L-AMB Death (64 days after onset) 12 Proven 1009 26 0 No Septic shock dermatitis pneumonia LPlt Candida albicans F-FLCZ F-FLCZ Cured 13 Proven 816 29 88 No Sepsis LPlt Candida parapsilosis F-FLCZ F-FLCZ Cured 14 Proven 1884 30 11 No Sepsis LPlt Candida albicans MCFG MCFG Cured 15 Proven 1872 31 0 No Sepsis pneumonia BDG Candida albicans MCFG MCFG Cured 16 Proven 2040 33 1 No Sepsis none Candida albicans + Candida glabrata MCFG MCFG Cured 17 Probable 582 23 7 Yes Septic shock BDG Candida albicans F-FLCZ L-AMB Cured 18 Probable 916 25 0 No Sepsis pneumonia abnormal OE Candida albicans F-FLCZ F-FLCZ Cured 19 Probable 530 25 18 No Intestinal Candida infection peritonitis LPlt/HG /BDG Candida albicans L-AMB L-AMB +MCFG Cured 20 Probable 924 26 0 No Meningitis venticulitis dermatitis pneumonia LPlt /BDG Candida albicans MCFG F-FLCZ +L-AMB Cured 21 Probable 948 27 17 No Intestinal Candida infection peritonitis pneumonia HG/LPlt /BDG Candida albicans FLCZ FLCZ Death (57 days after onset) 22 Probable 1591 29 0 No Pneumonia LPlt/BDG Candida glabrata MCFG F-FLCZ Cured 23 Probable 998 29 10 No Sepsis HG/BDG Unidentified MCFG MCFG Cured BDG, Elevation of (1→3)- β-D-glucan (BDG > 11 pg/ml); F-FLCZ, Fosfluconazole; FLCZ, Fluconazole; HG, Hyper glycemia (blood glucose > 150 mg/dl); L-AMB, Liposomal amphotericin B; LPlt, Low platelet count (platelet < 10 × 104/mm3); MCFG, Micafungin; ND, Not done; OE, Ophthalmologic examination; PCR, Polymerase chain reaction. View Large Table 4. Risk factors of associated with neonatal invasive fungal infection (n = 23). Risk factor Number of IFI cases, n (%) Birth weight < 1000 g 18 (78.3) Gestation age ≤28 weeks 17 (73.9) Small for date 3 (13.0) Underlying disease without ELBW 11 (47.8) Systemic corticosteroid therapy for baby 10 (43.5) Central venous catheter 22 (95.7) Fungal colonization at multiple sites 10 (43.5) No antifungal prophylaxis 16 (69.6) Systemic corticosteroid therapy for mother 11 (47.8) Premature rupture of membranes 9 (39.1) Vaginal delivery 9 (39.1) Vaginal Candida colonization of mother 10 (43.5) Risk factor Number of IFI cases, n (%) Birth weight < 1000 g 18 (78.3) Gestation age ≤28 weeks 17 (73.9) Small for date 3 (13.0) Underlying disease without ELBW 11 (47.8) Systemic corticosteroid therapy for baby 10 (43.5) Central venous catheter 22 (95.7) Fungal colonization at multiple sites 10 (43.5) No antifungal prophylaxis 16 (69.6) Systemic corticosteroid therapy for mother 11 (47.8) Premature rupture of membranes 9 (39.1) Vaginal delivery 9 (39.1) Vaginal Candida colonization of mother 10 (43.5) ELBW, Extremely low birth weight. View Large Table 4. Risk factors of associated with neonatal invasive fungal infection (n = 23). Risk factor Number of IFI cases, n (%) Birth weight < 1000 g 18 (78.3) Gestation age ≤28 weeks 17 (73.9) Small for date 3 (13.0) Underlying disease without ELBW 11 (47.8) Systemic corticosteroid therapy for baby 10 (43.5) Central venous catheter 22 (95.7) Fungal colonization at multiple sites 10 (43.5) No antifungal prophylaxis 16 (69.6) Systemic corticosteroid therapy for mother 11 (47.8) Premature rupture of membranes 9 (39.1) Vaginal delivery 9 (39.1) Vaginal Candida colonization of mother 10 (43.5) Risk factor Number of IFI cases, n (%) Birth weight < 1000 g 18 (78.3) Gestation age ≤28 weeks 17 (73.9) Small for date 3 (13.0) Underlying disease without ELBW 11 (47.8) Systemic corticosteroid therapy for baby 10 (43.5) Central venous catheter 22 (95.7) Fungal colonization at multiple sites 10 (43.5) No antifungal prophylaxis 16 (69.6) Systemic corticosteroid therapy for mother 11 (47.8) Premature rupture of membranes 9 (39.1) Vaginal delivery 9 (39.1) Vaginal Candida colonization of mother 10 (43.5) ELBW, Extremely low birth weight. View Large Discussion To the best of our knowledge, this is the first report on the nationwide surveillance of neonatal IFI in Japan. This study clarified the incidence of neonatal IFI and the actual state of prophylaxis against IFI for mothers and babies in Japan. The estimated annual IFI incidence in the present study was 0.33 per 1000 live births of hospitalized neonates. According to the reports from other countries, Xia et al. reported that the incidence of invasive candidiasis was 0.74 cases per 1000 preterm discharges from NICU in China.8 Nguyen et al. also reported the incidence of invasive candida infection was one case per 1000 patients below 32 weeks gestational age per year in France.9 Oeser et al. reported the incidence of neonatal IFI in England between 2004 and 2010 as 2.4 per 1000 neonatal unit admissions.10 The incidence of our study was similar to the above studies. Notably, several studies showed higher incidence rate (7%) than our study.11,12 Possible explanations for these discrepancies include differences in patient demographics, medical practices, and surveillance systems. Regarding the methods for the prevention neonatal IFI, the systematic review of randomized control trials on the use of antifungal chemotherapy to prevent neonatal IFI in VLBW infants reported that prophylactic fluconazole and oral nystatin were both highly effective. Both agents were safe without significant toxicities.13 In our study, only 43% of medical facilities prescribed antifungal prophylaxis for high-risk neonates; 16/55 facilities (29.1%) chose micafungin as the prophylactic agent. Therefore, the antifungal prophylaxis for high-risk neonates was not widely performed, and the prophylactic agents administered were varied in Japan. Pregnancy increases the frequency of vaginal Candida colonization.14 Concerning maternal antifungal prophylaxis, there were two eligible randomized controlled trials in which pregnant women were treated for vulvovaginal candidiasis and where preterm birth was reported as an outcome. There was a significant in the number of spontaneous preterm births in treated compared with untreated women.15,16 In our study, fungal prophylaxis for mothers who showed fungal colonization was administered in 23.4% of the medical facilities. Antifungal vaginal tablets were the most common prophylactic agents prescribed. Further studies are required to clarify the efficacy of antifungal prophylaxis for mothers in Japan. In our study, 23 cases of IFI were reported. The most common pathogenic fungus was Candida spp, of which C. albicans was the predominant species. Notably, non–albicans Candida spp. were also isolated in our study. Although C. albicans has historically been the most prominent species involved in IFI, C. parapsilosis is increasing in frequency, and neonates are disproportionately affected. In a Tunisian study, C. albicans was the predominant species up to 2006, and a shift in the species spectrum was observed with an increase in non-albicans species, predominantly C. parapsilosis.17 Another study revealed that C. parapsilosis was the leading causative pathogen of IFI and was isolated in 33.3% of the patients.18 Regarding the treatment of C. parapsilosis infection, echinocandin-resistant strains, which may be associated with acquired mutations of the gene encoding (1→3)- β-D-glucan (BDG) synthase have been involved.19 Practically, 60% of cases of IFI caused by C. parapsilosis required a change of the initial fungal treatment in our study. In our study, one patient with mucormycosis was reported, who developed a disseminated infection and died. The pathogenic diagnosis was made by autopsy. IFI caused by Mucorales is rare in children, and data on mucormycosis in neonates are lacking. Mucormycosis is a life-threatening infection in neonates, and amphotericin B is the recommended antifungal agent.20 IFI is associated with high morbidity and mortality in preterm neonates. The main risk factors of IFI are multiple antibiotics including third-generation cephalosporins, central venous catheters, parenteral nutrition, immunosuppression, and VLBW.21,22 Colonization with Candida spp. in neonates is also an important risk factor of IFI. Neonates acquire Candida spp. either via maternal-vertical transmission or nosocomial acquisition in the nursery. Multiple sites may become colonized, and a direct correlation between fungal colonization and subsequent progression to invasive candidemia was determined.4 Vaginal delivery, low birth weight, and low gestational age may also be considered risk factors for candida colonization.23 We studied the frequency of the established risk factors for IFIs in the literature.4 In our study, majority of the neonates with IFI had central venous catheterization (22/23), birth weight < 1000 g (18/23), gestation age ≤28 weeks (17/23), and no antifungal agent prophylaxis (16/23). Contrastingly, an underlying disease without ELBW (11/23), systematic corticosteroid therapy for neonates (11/23) and vaginal Candida colonization of the mother (10/23) were noted in < 50% of the IFI cases in our study. Invasive candidiasis is uncommon in infants with a birth weight > 1500 g. Infants at greatest risk are those exposed to broad-spectrum antibiotics and with platelet counts of < 50,000/mm.3,24 In our study, birth weight was > 1,500 g in four patients, two of whom had underlying diseases. The definitive diagnosis of IFI relies on the growth of fungi in blood culture from otherwise sterile sites, but our study identified 70% of the cases via this method. Goudjil et al. reported that the changes in the serum BDG levels might be of value in evaluating the efficacy of antifungal therapy.25 Zhao et al. also reported the usefulness of BDG for identifying the diagnostic and prognostic markers of IFI in preterm infants. The sensitivity in diagnosing IFI by a BDG cutoff > 10 pg/ml was 68.3% and specificity was 75.6%.26 In our study, 6/23 cases were serologically diagnosed with IFI (a BDG value of > 11 pg/ml was considered as positive). Trovato et al. recently reported the usefulness of fungal DNA detection in blood culture for the diagnosis of invasive candidiasis in neonates.27 In our study, one patient was diagnosed with IFI based on the detection of fungal DNA. Regarding the treatment, according to the European Society of Clinical Microbiology and Infectious Diseases guidelines for the diagnosis and management of Candida disease in neonates and children, amphotericin B deoxy cholate, liposomal amphotericin B, amphotericin B lipid complex, fluconazole, micafungin, and caspofungin can all potentially be used for the treatment of invasive candidiasis in neonates.28 Over the past decade, the number of antifungal agents in development has increased, but the majority are not labeled for use in neonates.29 In our study, micafungin was most commonly used as the initial antifungal treatment, followed by fosfluconazole. However, the treatment of eight cases was changed from the initial treatment during the clinical course. The duration of treatment in survivors was variable (range: 3–110 days). It is important that a treatment regimen for neonatal IFI is established. The mortality rate in our study was 17.4% (4/23), which is similar to a study from China (19.3%) but lower than a report from England (31%).8,10 All deceased patients were ELBW infants. The causative fungi of the deceased cases were Candida spp. (n = 3) and mucormycosis (n = 1). A report on the virulent factors of Candida spp. described that individual isolates of Candida spp. were varied in their virulent properties such as adhesion and cytotoxicity. However, highly virulent Candida strains are associated with clinical outcomes.30 It is also important that the isolated strain from IFI was stocked and its virulence analyzed precisely. There are several limitations to our study. The first was the low response rate to the primary questionnaire (41.4%), which could have led to an underestimation of the incidence of IFI. However, the responding medical facilities included 33 qualified main training hospitals with NICU (units for level III intensive care), which are evenly distributed throughout Japan. The annual numbers of VLBW infants delivered in Japan and in these medical facilities were 7500 and 4000, respectively.31 The annual number of VLBW infants in this survey was calculated based on the data from the medical facilities. We think that the present results are representative of the current Japanese situation because approximately half of VLBW infants were covered in this survey. Second, our study identified only 23 cases of proven or probable IFI. Improved diagnostics for fungi are required to guide the initiation of prompt antifungal therapy in premature infants.32 Finally, we did not collect any data on the antifungal susceptibility of the isolated fungi, and the dosage of antifungal agent used. To clarify the efficacy of the antifungal treatment, these data are important.33 Further surveillance studies are required to investigate these points. In conclusion, our nationwide survey identified 23 IFI cases during the 22-month study period. The majority of IFI cases were caused by Candida infection, and the mortality rate was 17.4%. According to a large cohort study in the United States, the incidence of invasive candidiasis in the NICU decreased over the 14-year study period. Increased use of fluconazole prophylaxis, empirical antifungal therapy, and decreased use of broad-spectrum antibiotics may have contributed to this observation.34 In Japan, the diagnosis, treatment, and prevention of neonatal IFI varied. Continuous surveillance and the establishment of a treatment regimen against neonatal IFI, including regulation of the use of broad-spectrum antibiotics, are required to improve outcomes in high-risk neonates. Supplementary material Supplementary data are available at MMYCOL online. Acknowledgements The authors thank the members of the committee for infection and vaccine promotion of the Japan Society for Neonatal Health and Development for their support during this surveillance study. Source of Funding This study was funded by the Project for the development of prevention, diagnosis and treatment against elderly and neonatal aspergillosis, Chiba University. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and the writing of the paper. References 1. Shane AL , Stoll BJ . Neonatal sepsis: progress towards improved outcomes . J Infect . 2014 ; 68 : S24 – 32 . Google Scholar CrossRef Search ADS PubMed 2. Kim do H , Jeon J , Park CG , Sriram S , Lee KS . Neonatal and infant mortality in Korea, Japan, and the US: Effect of birth weight distribution and birth weight-specific mortality rates . J Korean Med Sci . 2016 ; 31 : 1450 – 1454 . Google Scholar CrossRef Search ADS PubMed 3. Blencowe H , Cousens S , Oestergaard MZ et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications . Lancet . 2012 ; 379 : 2162 – 2172 . Google Scholar CrossRef Search ADS PubMed 4. Leibovitz E. Strategies for the prevention of neonatal candidiasis . Pediatr Neonatol . 2012 ; 53 : 83 – 89 . Google Scholar CrossRef Search ADS PubMed 5. Mori M . Nationwide survey of treatment for pediatric patients with invasive fungal infections in Japan . J Infect Chemother . 2013 ; 19 : 946 – 950 . Google Scholar CrossRef Search ADS PubMed 6. Rolnitsky A , Levy I , Sirota L , Shalit I , Klinger G . Targeted fluconazole prophylaxis for high-risk very low birth weight infants . Eur J Pediatr . 2012 ; 171 : 1481 – 1487 . Google Scholar CrossRef Search ADS PubMed 7. De Pauw B , Walsh TJ , Donnelly JP et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis . 2008 ; 46 : 1813 – 1821 . Google Scholar CrossRef Search ADS PubMed 8. Xia H , Wu H , Xia S et al. Invasive candidiasis in preterm neonates in China: a retrospective study from 11 NICUs during 2009–2011. Pediatr Infect Dis J . 2014 ; 33 : 106 – 109 . Google Scholar CrossRef Search ADS PubMed 9. Nguyen K , Zmeter G , Claris O , Kassai B . Epidemiology of invasive Candida infection in a neonatal intensive care unit in France . Acta Paediatrica . 2012 ; 101 : e137 – e139 . Google Scholar CrossRef Search ADS PubMed 10. Oeser C , Vergnano S , Naidoo R et al. Neonatal invasive fungal infection in England 2004–2010. Clin Microbiol Infect . 2014 ; 20 : 936 – 941 . Google Scholar CrossRef Search ADS PubMed 11. Benjamin DK Jr. , BJ Stoll , AA Fanaroff et al. Neonatal candidiasis among extremely low birth weight infants: risk factors, mortality rates, and neurodevelopmental outcomes at 18 to 22 months . Pediatrics . 2006 ; 117 : 84 – 92 . Google Scholar CrossRef Search ADS PubMed 12. Cotten CM , McDonald S , Stoll B , Goldberg RN , Poole K , Jr Benjamin DK . The association of third-generation cephalosporin use and invasive candidiasis in extremely low birth-weight infants . Pediatrics . 2006 ; 118 : 717 – 722 . Google Scholar CrossRef Search ADS PubMed 13. 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 : 846 – 851 . Google Scholar CrossRef Search ADS PubMed 14. Sobel JD. Vulvovaginal candidosis . Lancet . 2007 ; 369 : 1961 – 1971 . Google Scholar CrossRef Search ADS PubMed 15. Kiss H , Petricevic L , Husslein P . Prospective randomised controlled trial of an infection screening programme to reduce the rate of preterm delivery . BMJ . 2004 ; 329 : 371 . Google Scholar CrossRef Search ADS PubMed 16. Roberts CL , Rickard K , Kotsiou G , Morris JM . Treatment of asymptomatic vaginal candidiasis in pregnancy to prevent preterm birth: an open-label pilot randomized controlled trial . BMC Pregnancy and Childbirth . 2011 ; 11 : 18 . Google Scholar CrossRef Search ADS PubMed 17. Ben Abdeljelil J , Saghrouni F , Nouri S et al. Neonatal invasive candidiasis in Tunisian hospital: incidence, risk factors, distribution of species and antifungal susceptibility . Mycoses . 2012 ; 55 : 493 – 500 . Google Scholar CrossRef Search ADS PubMed 18. Yu Y , Du L , Yuan T et al. Risk factors and clinical analysis for invasive fungal infection in neonatal intensive care unit patients . Am J Perinatol . 2013 ; 30 : 589 – 594 . Google Scholar CrossRef Search ADS PubMed 19. Chow BD , Linden JR , Bliss JM . Candida parapsilosis and the neonate: epidemiology, virulence and host defense in a unique patient setting . Expert Rev Anti Infect Ther . 2012 ; 10 : 935 – 946 . Google Scholar CrossRef Search ADS PubMed 20. Zaoutis TE , Roilides E , Chiou CC et al. Zygomycosis in children: a systematic review and analysis of reported cases . Pediatric Infect Dis J . 2007 ; 26 : 723 – 727 . Google Scholar CrossRef Search ADS 21. Tezer H , Canpolat FE , Dilmen U . Invasive fungal infections during the neonatal period: diagnosis, treatment and prophylaxis . Expert Opin Pharmacother . 2012 ; 13 : 193 – 205 . Google Scholar CrossRef Search ADS PubMed 22. Hsieh E , Smith PB , Benjamin DK Jr . Neonatal fungal infections: when to treat? Early Hum Dev . 2012 ; 88 : S6 – S10 . Google Scholar CrossRef Search ADS PubMed 23. Ali GY , Algohary EH , Rashed KA , Almoghanum M , Khalifa AA . Prevalence of Candida colonization in preterm newborns and VLBW in neonatal intensive care unit: role of maternal colonization as a risk factor in transmission of disease . J Matern Fetal Neonatal Med . 2012 ; 25 : 789 – 795 . Google Scholar CrossRef Search ADS PubMed 24. Lee JH , Hornik CP , Benjamin DK Jr. et al. Risk factors for invasive candidiasis in infants > 1500 g birth weight . Pediatr Infect Dis J . 2013 ; 32 : 222 – 226 . Google Scholar CrossRef Search ADS PubMed 25. Goudjil S , Kongolo G , Dusol L et al. (1-3)- β‐D‐glucan levels in candidiasis infections in the critically ill neonate. J Matern Fetal Neonatal Med . 2013 ; 26 : 44 – 48 . CrossRef Search ADS PubMed 26. Zhao D , Qiu G , Luo Z , Zhang Y . Platelet parameters and (1,3)-β‐D-glucan as a diagnostic and prognostic marker of invasive fungal disease in preterm infants . PLOS One . 2015 ; 10 : e0123907 . Google Scholar CrossRef Search ADS PubMed 27. Trovato L , Betta P , Romeo MG , Oliveri S . Detection of fungal DNA in lysis-centrifugation blood culture for the diagnosis of invasive candidiasis in neonatal patients . Clin Microbial Infect . 2012 ; 18 : E63 – E65 . Google Scholar CrossRef Search ADS 28. Hope WW , Castagnola E , Groll AH et al. ESCMID guideline for the diagnosis and management of Candida diseases 2012: prevention and management of invasive infections in neonates and children caused by Candida spp . Clin Microbiol Infect . 2012 ; 18 : 38 – 52 . Google Scholar CrossRef Search ADS PubMed 29. Testoni D , Smith PB , Benjamin DK Jr . The use of antifungal therapy in neonatal intensive care . Clin Perinatol . 2012 ; 39 : 83 – 98 . Google Scholar CrossRef Search ADS PubMed 30. Bliss JM , Wong AY , Bhak G et al. Candida virulence properties and adverse clinical outcomes in neonatal candidiasis . J Pediatr . 2012 ; 161 : 441 – 447 . Google Scholar CrossRef Search ADS PubMed 31. Ministry of Health, Labour and Welfare in Japan . Annual numbers of live births in Japan in 2015 . http://home.b05.itscom.net/kisoh/boshihokentop.html (In Japanese, Accessed: 27th June 2017) 32. Kelly MS , Benjamin DK , Smith PB . The epidemiology and diagnosis of invasive candidiasis among premature infants . Clin Perinatol . 2015 ; 42 : 105 – 117 . Google Scholar CrossRef Search ADS PubMed 33. Regazzi M , Billaud EM , Lefeuvre S , Stronati M . Pharmacokinetics of antifungal agents in neonates and young infants . Curr Med Chem . 2012 ; 19 : 4621 – 4632 . Google Scholar CrossRef Search ADS PubMed 34. Aliaga S , Clark RH , Laughon M et al. Changes in the incidence of candidiasis in neonatal intensive care units . Pediatrics . 2014 ; 133 : 236 – 242 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Medical MycologyOxford University Press

Published: Aug 1, 2018

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