Controversies about the management of invasive fungal infections in very low birth weight infants

Objetivo: Rever as mais recentes publica????es sobre infec????o f??ngica no rec??m-nascido de muito baixo peso ao nascer, com objetivo de fornecer aos profissionais de sa??de atualiza????o sobre um crescente problema nas unidades neonatais. A revis??o se dirige especificamente ??s quest??es relacionadas a incid??ncia, manuseio cl??nico, tratamento e profilaxia. Fontes de dados: Artigos originais e de revis??o, publicados nos ??ltimos 15 anos no MEDLINE e Lilacs, foram identificados usando como palavras-chave: rec??m-nascido, prematuro, baixo peso ao nascer,infec????o f??ngica, sepse, c??ndida, anfotericina e fluconazol. S??ntese dos dados: A incid??ncia de sepse f??ngica vem aumentando nas unidades de terapia intensiva neonatal. Embora novas drogas venham se tornando dispon??veis (echinocandinas), a anfotericina B continua sendo a droga de escolha para o tratamento inicial. Atualmente, existem quatro classes de drogas dispon??veis para o tratamento: os polienos macrol??deos (anfotericina B e formula????es lip??dicas), os azoles(fluconazol e voriconazol), as pirimidinas fluorinadas (flucitosina) e asechinocandinas (micafungin e caspofungin). Duas drogas v??m sendo descritas na preven????o da doen??a invasiva: nistatina e fluconazol. Fluconazol ?? a droga sobre a qual mais se conhece da farmacocin??ticano per??odo neonatal, e a sua administra????o profil??tica em rec??m nascidos com menos de 1.000 g por 6 semanas est?? associada a menor incid??ncia de infec????o f??ngica. Conclus??es: Um melhor entendimento sobre a incid??ncia da sepsef??ngica, diagn??stico, manuseio cl??nico, tratamento e profilaxia ?? uma importante arma na morbidade e mortalidade. A identifica????o de rec??m-nascidos prematuros de alto risco para o desenvolvimento da doen??a e a institui????o de medidas profil??ticas e tratamento precoce podem diminuir a morbimortalidade.OBJECTIVE: This review encompasses the most recent publications about fungal infection in very low birth weight infants, keeping health professionals updated about this growing problem observed in neonatal units. SOURCES OF DATA: Original and review articles published over the past 15 years were searched in MEDLINE and Lilacs, using the following keywords: preterm infant, very low birth weight infants, sepsis, fungal infection, antifungal, Candida, amphotericin and fluconazole. SUMMARY OF THE FINDINGS: Invasive fungal infections affect especially preterm infants. Although new drugs (echinocandins) to treat fungal infection are available, amphotericin is the most widely used drug for the treatment of systemic candidiasis at this stage of life. Currently, there are four types of antifungal agents used in the treatment of fungal infections in neonates: polyene macrolides (amphotericin B deoxycholate and lipid preparations), azoles (triazoles), fluorinated pyrimidines (flucytosine) and echinocandins (caspofungin and micafungin). Two drugs capable of preventing invasive fungal infection are described: nystatin and fluconazole. The pharmacokinetics of fluconazole in the neonatal period is widely known and its prophylactic administration during the first six weeks of life has been associated with less invasive fungal infection in infants weighing less than 1,000 g at birth. CONCLUSIONS: Fungal infections constitute an important problem in the neonatal intensive care unit and a better understanding of the incidence, diagnosis, clinical management, treatment, and prophylaxis is important in order to reduce morbidity and mortality. The identification of high-risk preterm infants and the implementation of prophylactic measures and early treatment may improve the outcome of these patients