Clinical characteristics and response to prophylactic fluconazole of preterm VLBW neonates with baseline and acquired fungal colonisation in NICU: data from a multicentre RCT.

BACKGROUND: Fungal colonisation by Candida spp. affects a high proportion of VLBW neonates in NICU. However, few data are available on the clinical characteristics of colonisation in preterm infants who are colonised at baseline via vertical transmission, compared to preterms who become colonised during their stay in NICU via horizontal transmission. MATERIAL AND METHODS: We reviewed the database of a multicentre, randomised trial of prophylactic fluconazole in VLBW neonates conducted in 8 Italian NICUs in the years 2004 and 2005 (Manzoni et al., NEJM 2007;356(24):2483-95). Per the protocol, all enrolled infants underwent weekly surveillance cultures from birth till discharge. We investigated the frequency of the two different modalities of Candida colonisation in this population, as well as the clinical and outcome characteristics possibly related to them. RESULTS: Overall, Candida colonisation affected 54 of 336 infants (16.1%). Baseline (i.e., detected <3(rd) day of life) colonisation affected 16 (4.7%), and acquired 38 (11.4%), of the 54 colonised preterms. Infants with baseline colonisation had significantly higher birth weight (1229 ± 28 g vs. 1047 g ± 29, p = 0.01) and gestational age (30.2 wks ± 2.7 vs. 28.5 wks ± 2.6, p = 0.01), and were significantly more likely to limit progression from colonisation to invasive Candida infection when fluconazole prophylaxis was instituted (21.6% vs. 42.7%, p = 0.009). Isolation of C. parapsilosis was significantly more frequent in infants with acquired colonisation. CONCLUSIONS: Infants with baseline and acquired colonisation differ for demographics characteristics and for their response to fluconazole prophylaxis. This information may be useful for targeting more accurate management strategies for these two different groups of colonised preterms in NICU.

Mode of delivery and threshold retinopathy of prematurity in pre-term ELBW neonates.

BACKGROUND: Retinopathy of prematurity (ROP) is a multifactorial disease, but little is known about its relationship with perinatal risk factors. We tested the hypothesis that the mode of delivery may be associated with threshold ROP as defined by CRYO-ROP. METHODS: We conducted a prospective, cohort analysis of a database of all extremely low birth weight (ELBW) neonates (= birth weight < 1000 g) admitted over a 8-year period from 1997 to 2004 to a large tertiary neonatal intensive care unit in a urban area of northern Italy and screened for ROP. Incidence of threshold ROP was calculated for the whole studied population. The definition of threshold ROP was as defined by the CRYO-ROP study. Univariate analysis was performed to look for significant associations between threshold ROP and several possible associated factors, and among them, the mode of delivery (vaginal delivery or caesarean section). When an association was indicated by p < 0.05, multiple logistic regression was used to determine the factors significantly associated with ROP. RESULTS: Enrolled ELBW neonates were 174, and 46 of them (26.4%) displayed threshold ROP. Threshold ROP occurred in 40.9% (27 of 66) of the neonates vaginally delivered and in 17.5% (19 of 108) of those born via caesarean section (R.R. 3.35; 95% CI 1.230-4.855; p = 0.008 at univariate analysis, and = 0.04 at multivariate logistic regression after controlling for birth weight, gestational age, intraventricular haemorrhage grade 2 or more, days on supplemental oxygen, systemic fungal infection). Birth by vaginal delivery was not significantly associated with other major sequelae of prematurity (intraventricular haemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis). CONCLUSIONS: In our Institution birth by vaginal delivery is a significant and independent predictor of threshold ROP in ELBW infants. We suggest to consider closely ophthalmological surveillance for pre-term ELBW infants born this mode.