The Pediatric Infectious Disease Journal Issue: Volume 17(2), February 1998, pp 146-148 Copyright: (C) Williams & Wilkins 1998. All Rights Reserved. Publication Type: [Original Studies] ISSN: 0891-3668 Accession: 00006454-199802000-00013 Keywords: Fungal infection, liposomal amphotericin B, newborn infant [Original Studies] Liposomal amphotericin B treatment for neonatal fungal infections SCARCELLA, ALDA MD; PASQUARIELLO, MARIA B. MD; GIUGLIANO, BRUNELLA MD; VENDEMMIA, MARIA MD; DE LUCIA, AMALIA MD Author Information From the Department of Pediatrics, University of Naples"Federico II," Naples, Italy. Accepted for publication Nov. 19, 1997. Address for reprints: Dr. Alda Scarcella, Department of Pediatrics, University of Naples"Federico II," Via Pansini 5, 80131 Naples, Italy. Fax +39 81 7463268/5451278. ---------------------------------------------- Outline Abstract INTRODUCTION METHODS RESULTS DISCUSSION ACKNOWLEDGMENTS REFERENCES Abstract Background. Disseminated fungal infections are a major problem in high risk neonates. Conventional antifungal agents are often unsatisfactory and have a high incidence of severe adverse effects. Methods. We administered liposomal encapsulated amphotericin B (AmBisome(R)), which is an alternative to conventional amphotericin B, to 40 preterm (mean birth weight, 1090 +/- 313.6 g; mean gestational age, 28.35 +/- 2.13 weeks) and 4 full term (mean birth weight, 3080 +/- 118 g; mean gestational age, 39 +/- 0.7 weeks) newborn infants with a severe fungal infection. Results. Candida albicans was the most frequent fungus isolated (70%). The duration of intravenous AmBisome(R) therapy ranged from 7 to 49 days; the cumulative dose ranged from 7 to 138.8 mg/kg (median, 45.2 mg/kg). Administration of AmBisome(R) was effective in 72.7% of patients; 5 of 6 cases of meningitis also recovered; 63.6% of 33 very low birth weight infants survived. No side effects were observed. Conclusions. To our knowledge this is the largest study of the treatment of neonates with liposomal amphotericin B, and the results confirm its effectiveness and safety. However, randomized clinical trials are required to establish the most effective administration protocol for AmBisome(R), i.e. the starting dosage, the maximum effective dosage and the cumulative dosage, and to verify whether the preparation should be associated with another antifungal agent. ---------------------------------------------- INTRODUCTION Systemic fungal infections are a major problem in neonatal intensive care units, both because of the increased survival of very low birth weight infants and because of the increasingly widespread use of invasive therapeutic and diagnostic techniques.1-4 Prolonged antibiotic therapy has been associated with an increased risk of these hospital infections, which are a major cause of morbidity and mortality in newborn infants, despite antifungal therapy.4 Amphotericin B, also combined with other antifungal agents, is the treatment of choice for disseminated fungal infections, but the patients must be carefully monitored because more than 40% develop side effects. In some cases premedication or decreasing the dosage or the frequency of antifungal administration allow continued effective treatment. However, treatment must be temporarily discontinued in most cases of nephrotoxicity and hepatic function abnormalities, and thus the infection may not be adequately treated.1, 4, 5 Clinical studies have shown that amphotericin B incorporated in unilamellar liposomes is effective in the treatment of severe systemic fungal infections in children 6 and in adults.7, 8 Liposomal preparations of amphotericin B are now being used to treat disseminated fungal infection in high risk neonates,9-14 thus far, without severe adverse effects. We report our experience in 44 newborn infants with severe fungal infection, treated with AmBisome(R) (NeX-star Pharmaceuticals Italia), a preparation of liposomal amphotericin B now commercially available in Italy. METHODS Of 2143 patients (726 very low birth weight infants) hospitalized from January, 1992, through December, 1996, 40 preterm and 4 full term newborn infants with severe fungal infections were treated with liposomal amphotericin B after obtaining informed consent from the parents. All patients studied met one of the following criteria: (1) one positive cerebrospinal fluid culture and/or blood culture obtained from peripheral sites with at least two manifestations of infection, e.g. apnea, bradycardia, temperature fluctuations, shock, diffuse maculopapular rash, hypoglycemia, glycosuria, acidosis, thrombocytopenia, leukopenia; (2) positive joint aspirate with clinical signs of arthritis. We excluded from this study infants with only positive urine cultures. Fungi were isolated on blood agar plates and identified using the ID 32 C Strip(R)(bioMerieux Italia, Rome, Italy), and the API 20 C Strip(R) (bioMerieux). In the case of fungal infection the indwelling vascular catheter was removed or replaced before beginning treatment, and a new blood culture was performed. In positive cases cultures were then examined 48 to 72 h after the treatment was started and then weekly thereafter or earlier if there was a frank clinical improvement. We used AmBisome(R), a preparation of amphotericin B in lyophilized powder, incorporated in unilamellar liposomes with a diameter of 50 to 100 nm after rehydration, instead of conventional amphotericin B. The initial daily dosage was 1 mg/kg of body weight; this was increased stepwise by 1 mg/kg to a maximal dosage of 5 mg/kg according to the patients' clinical conditions. The infusion time was 30 to 60 min. Before the treatment and twice a week during treatment, we measured blood urea nitrogen, serum creatinine, total and direct bilirubin, serum aspartate transaminase, serum alanine transaminase, alkaline phosphatase, serum electrolytes and blood cell count to detect the onset of adverse effects. AmBisome(R) was discontinued if the infant had a complete resolution of signs and symptoms of infection and the culture taken 1 week earlier was negative. Weekly blood cultures were examined for 2 weeks after discontinuation of therapy. Data are expressed as mean +/- SD. The least squares method was used to examine the relationship between duration of therapy and gestation. RESULTS The 40 preterm newborn infants enrolled in our study had a mean gestational age of 28.35+/- 2.13 weeks (range, 25 to 33 weeks) and a mean birth weight of 1090 +/- 313.6 g (range, 680 to 1840 g). Severe fungal sepsis associated with meningitis occurred in 6 cases, with peritonitis in one case and polyarticular infection and osteomyelitis in another case. Three of the four full term infants had systemic infection; joint infection was diagnosed in the other infant. All preterm newborn infants had been exposed to several well-known risk factors of infection (e.g. intubation, vessel incannulation, transfusion, nasogastric feeding tube and lipid infusion). All babies received broad spectrum antibiotics for 19 +/- 10 days before diagnosis of fungal infection. Two full term newborn infants were also exposed to at least 2 risk factors; one had congenital candidiasis with positive blood culture on the first day of life associated with maternal fungal vaginitis diagnosed after delivery; no risk factor of infection was identified in the other infant, who had a positive joint aspirate and clinical symptoms of arthritis. The mean age at diagnosis was 22 +/- 12 days. Thirty-one Candida albicans (70%), 4 Pichia carsonii, 4 Candida parapsilosis, 2 Candida sake, 2 Candida humicola, and 1 Candida guilliermondii were isolated. Six babies received the minimal daily dosage of 1 mg/kg of AmBisome(R) throughout the treatment. The daily dosage was increased to a maximum of 3 mg/kg in 22 cases, 4 mg/kg in 14 cases and 5 mg/kg in 2 cases (a preterm infant with osteomyelitis and polyarticular infection and a full term infant with osteoarthritis). The cumulative dosage ranged from 7 to 138.8 mg/kg (median, 45.2 mg/kg). We were not able to measure serum concentrations of liposomal amphotericin B. The mean duration of the therapy was 22 +/- 8 days(range, 7 to 49 days). Fungal culture follow-up and clinical course confirmed that therapy with liposomal amphotericin B was effective in the treatment of fungal infections in all full term and in 28 preterm newborn infants including 5 of the 6 babies affected by meningitis. A negative culture was obtained after means of 4+/- 1 days of therapy in the full term infants and 12 +/- 8 days in the preterm infants. There was a significant correlation between gestational age and duration of therapy in the newborn infants who recovered (r = -0.27;P = 0.001). Twelve of the 33 very low birth weight infants succumbed to the fungal infection; these babies had a mean gestational age of 27.8 +/- 2.1 weeks (range, 25 to 32 weeks) and a mean birth weight of 989 +/- 287.5 g(range, 680 to 1490 g). The mean duration of therapy was 14 +/- 6 days. Four infants died after only 7 days of therapy. In the unsuccessfully treated infants diagnosis was later than in surviving infants (24 +/- 13 vs 20 +/- 11 days of life). The postmortem blood culture revealed C. albicans in 8 cases,P. carsonii, C. humicola, C. parapsilosis and C. guilliermondii in the other 4 cases. Liposomal amphotericin B administration was not associated with fever, chills or phlebitis at infusion sites. Blood pressure, hepatic, renal or hematologic indices were within normal range, except for hypokalemia (serum potassium DISCUSSION To our knowledge the present study of 44 neonates is the largest thus far reported on the treatment with AmBisome(R) of newborn infants with severe and prolonged fungal infections. This study confirms the effectiveness and safety of this treatment; 32(72.7%) of the 44 infants treated were cured including 21 (63.6%) of the 33 very low birth weight infants. No severe side effects were detected during treatment. In addition the good outcome obtained in 5 of our 6 cases of meningitis and in the cases reported by Sievers et al.12 and by Jarlov et al.13 demonstrates that AmBisome(R) crosses the blood-brain barrier; this is particularly relevant in neonates given the high incidence of central nervous system involvement in infants in intensive care units.15 The nonresponse to treatment in 12 of our cases might be the result of a late diagnosis caused in turn by nonspecific signs of fungal infection. In fact in 6 of these infants, symptoms were attributed to recurrent prolonged apneic episodes nonresponsive to therapy. A late diagnosis resulted in a longer exposure to fungal infection risk factors, e.g. indwelling vascular catheter and antibiotic treatment, that are frequently necessary in very low birth weight infants. In addition an effective dosage was probably not reached in these cases of late diagnosis. In our infants the mean treatment duration was 22 +/- 8 days. Similarly Lackner et al.9 and Sievers et al.12 successfully treated their preterm infants with proved systemic candidiasis for 26 and 40 days, respectively. The mean duration of therapy in our infants who died was only 14 +/- 6 days. Moreover the mean cumulative dose was lower in the infants who succumbed than in the successfully treated infants(33.7 +/- 22.5 mg/kg vs. 51.19 +/- 34.9). It is conceivable that had the starting dosage been higher, an effective cumulative concentration of AmBisome(R) would have been reached in these infants. Our starting dosage was 1 mg/kg/day, which eradicated the fungal infection in only 2 infants (5%). We used 5 mg/kg/day only in the full term infant with osteoarthritis and in the preterm newborn infant with osteomyelitis and severe polyarticular infection. Although our study lacks a control, in other studies infants with severe fungal-induced diseases have responded to liposomal amphotericin B after conventional amphotericin B was ineffectual.9, 10, 13, 14 In two instances AmBisome(R) was used alone,9, 11, 14 as in our study, whereas in other cases it was administered associated with other antifungal agents.10, 13 In all cases the preparation was effective and no severe side effects were reported. Because of the good clinical outcome of liposomal amphotericin B treatment and its lack of severe adverse effects in our study and in others, the question arises: is it ethical to conduct controlled clinical trials with conventional vs. liposomal amphotericin B in very high risk patients such as preterm neonates with severe disseminated fungal infections? Rather, trials should be conducted to establish the most effective administration protocol for AmBisome(R), i.e. the starting dosage, the maximum effective dosage and the cumulative dosage, and to verify whether the preparation should be associated with another antifungal agent. ACKNOWLEDGMENTS We are grateful to Dr. Lucio Di Martino for having first brought AmBisome(R) as an antifungal agent to our attention. We are indebted to Jean Gilder for the editorial revision. REFERENCES 1. Baley JM, Meyers C, Kliegman RM, Jacobs MR, Blumer JL. Pharmacokinetics, outcome of treatment, and toxic effects of amphotericin-B and 5-flurocytosine in neonates. J Pediatr 1990;116:791-7. Full text via Find It Bibliographic Links 2. Johnson DE, Thompson TR, Green TP, Ferrieri P. Systemic candidiasis in very low-birth-weight infants ( 3. Weese-Majer DE, Wheeler Fondriest D, Brouillette RT, Shulman ST. Risk factors associated with candidemia in the neonatal intensive care unit: a case-control study. Pediatr Infect Dis J 1987;6:190-6. Ovid Full Text Full text via Find It Bibliographic Links 4. Ng PC. Systemic fungal infections in neonates. Arch Dis Child 1994; 71:F130-5. Full text via Find It Bibliographic Links 5. Emminger W, Lang HRM, Emminger-Schmidmeier W, Peters C, Gadner H. Amphotericin B serum levels in pediatric bone marrow transplant recipients. Bone Marrow Transplant 1991;7:95-9. Full text via Find It Bibliographic Links 6. Zoubeck A, Emminger W, Emminger-Schmidmeier W, et al. Conventional vs liposomal amphotericin B in immunosuppressed children. Pediatr Hematol Oncol 1992;9:187-90. 7. Katz NM, Pierce PF, Anzeck RA, et al. Liposomal amphotericin B for treatment of pulmonary aspergillosis in a heart transplant patient. J Heart Transplant 1990;9:14-7. Full text via Find It Bibliographic Links 8. Meunier F, Prentice H, Ringden O. Liposomal amphotericin B (AmBisome): safety data from a phase II/III clinical trial. J Antimicrob Chemother 1991;28(Suppl B):83-91. Full text via Find It Bibliographic Links 9. Lackner H, Schwinger W, Urban C, et al. Liposomal amphotericin B (AmBisome) for treatment of disseminated fungal infections in two infants of very low-birth-weight. Pediatrics 1992;89:1259-61. Full text via Find It Bibliographic Links 10. Vincent M, Webster MH, Pether JVS. Liposomal amphotericin B. Lancet 1992;339:374-5. 11. da Silva LP, Amaral JMV, Ferreira NC. Which is the most appropriate dosage of liposomal amphotericin B (AmBisome) for the treatment of fungal infections in infants of very low birth weight? Pediatrics 1993;91:1217-8. Full text via Find It Bibliographic Links 12. Sievers R, Neubauer AP, Natzschka J. Liposomal amphotericin B for treatment of a disseminated Candida infection with encephalitis and osteoarthritis in a preterm neonate. Monatsschr Kinderheilkd 1994;142:266-8. Full text via Find It 13. Jarlov JO, Born P, Bruun B. Candida albicans meningitis in a 27 weeks premature infant treated with liposomal amphotericin B (AmBisome). Scand J Infect Dis 1995;27:419-20. Full text via Find It Bibliographic Links 14. Evdoridou J, Roilides E, Bibashi E, Kremenopoulos G. Multifocal osteoarthritis due to Candida albicans in a neonate: serum level monitoring of liposomal amphotericin B and literature review. Infection 1997;25:112-6. Full text via Find It Bibliographic Links 15. Faix RG. Systemic Candida infections in infants in intensive care nurseries: high incidence of central nervous system involvement. J Pediatr 1984;105:616-22. Full text via Find It Bibliographic Links Key words: Fungal infection; liposomal amphotericin B; newborn infant