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NICU fluconazole prophylaxis may lead to Malassezia colonisation and fungaemia

October 17 2019

IDSA recommends fluconazole prophylaxis for the first six weeks in premature neonates weighing <1kg in units with high rates (>10%) of invasive candidiasis (read the guidelines; point 51). Dr I-Ting Chen and colleagues in Taiwan describe their experiences following the introduction of fluconazole prophylaxis to a NICU unit in 2014.

  • On average, 781 neonates were admitted per year. Before fluconazole prophylaxis was introduced, there were 1-2 cases of candidaemia most years. No cases were seen in the 3 years following introduction.
  • Before introduction, no cases of Malassezia furfur colonisation were seen. Since introduction, they identified 19 cases where the pCVC tip was colonised with M. furfur, in which case it was removed immediately. Some colonised infants received amphotericin B or an increased dose of fluconazole. There was 1 case of Malassezia fungaemia, which was treated with amphotericin B (the infant survived).
  • The authors speculate that fluconazole prophylaxis may create selection pressure that leads to Malassezia colonisation. Indeed, another study reported an increase in Malassezia pachydermatis infections following introduction of fluconazole prophylaxis.
  • Lipid infusions containing olive oil and LED phototherapy were thought to also be contributing factors.
  • In a different Malassezia outbreak, infection control measures also included banning staff from using lipid-rich hand moisturiser.

Culture of most Malassezia species requires specialist growth media such as SDA overlaid with olive oil, or Malassezia-specific CHROMagar.

Read the paper: Chen et al (2019) Advances in Neonatal Care