Caspofungin for Refractory Candidemia in Neonates

This is in reference to the recent report showing the effectiveness of caspofungin in treating persistent and progressive candidiasis.¹ We would like to share another case of refractory fungemia in an extreme premature infant that responded to caspofungin.

A 660-g baby girl was delivered vaginally at 23 weeks of gestation at a regional hospital. Before delivery, the mother received 1 dose of antenatal steroids with magnesium sulfate and penicillin. Soon after delivery, the baby was intubated. Surfactant was given at ~45 minutes of life, and baby was ventilated with pressures of 20/5, rate of 60 and 100% oxygen. Umbilical catheters were placed, and the infant required pressor support with dopamine, dobutamine and hydrocortisone. Ampicillin and cefatoxime were given after obtaining the blood culture. On day 4, a percutaneous central venous catheter (PCVC) was inserted, and fluconazole prophylaxis was started. On day 6, the platelet count was 40,000, for which a platelet transfusion was given. A blood culture was obtained, and amphotericin B was added. The blood culture was reported to be positive for Candida glabrata. The chest radiograph was suggestive of bilateral pneumonia.

The infant's respiratory status continued to deteriorate and she was treated with high frequency ventilation. After the mother's consent, dexamethasone was started, in expectance of weaning from the ventilator. Respiratory status improved slightly; however, 3 consecutive blood cultures were reported to be positive despite 18 days of amphotericin B therapy with a cumulative dose of 18 mg/kg. The cardiac echocardiogram showed no vegetation, and renal ultrasound was normal with no bezoars. The infant had persistent thrombocytopenia requiring multiple platelet transfusions. The PCVC was removed after 2 positive blood cultures. The C. glabrata sensitivity pattern showed that the minimal inhibitory concentration (MIC) for amphotericin was 1.00, whereas for caspofungin it was 0.25 (isolates with MIC >1 are likely to be resistant). On day 28, after consulting with pediatric infectious disease and obtaining consent from the mother caspofungin was added as used earlier.¹ The platelet counts (on days 3, 4, 5 and 6 after therapy) were stabilized, and a repeat blood culture (72 hours after therapy) was sterile. The baby was extubated on day 5 of caspofungin therapy. There were no adverse events related to caspofungin administration. The liver function and renal function test were monitored regularly and remained normal during and after the caspofungin therapy.

Presently the infant is tolerating full feedings and is receiving nasal cannula oxygen. Her head ultrasound showed no bleeding, and eye examination is due in 2 weeks.

Shabih Manzar, MD

Medha Kamat, MD

Suma Pyati, MD

Division of Neonatology

John Stroger Hospital of Cook County

Chicago, IL