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Meta-Analysis
. 2015 Oct 24;2015(10):CD003850.
doi: 10.1002/14651858.CD003850.pub5.

Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants

Jemma Cleminson  1 , Nicola Austin, William McGuire
Affiliations
Meta-Analysis

Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants

Jemma Cleminson et al. Cochrane Database Syst Rev. .

Abstract

Background: Invasive fungal infection is an important cause of mortality and morbidity in very preterm and very low birth weight infants. Early diagnosis is difficult and treatment is often delayed. Systemically absorbed antifungal agents (usually azoles) are increasingly used as prophylaxis against invasive fungal infection in this population.

Objectives: To assess the effect of prophylactic systemic antifungal therapy on mortality and morbidity in very preterm or very low birth weight infants.

Search methods: We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 8), MEDLINE, EMBASE, and CINAHL (to May 2015), conference proceedings, and previous reviews.

Selection criteria: Randomised controlled trials or quasi-randomised controlled trials that compared the effect of prophylactic systemic antifungal therapy versus placebo or no drug or another antifungal agent or dose regimen in very low birth weight infants.

Data collection and analysis: We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors.

Main results: We identified 15 eligible trials enrolling a total of 1690 infants. Ten trials (1371 infants) compared systemic antifungal prophylaxis versus placebo or no drug. These trials were generally of good methodological quality. Meta-analysis found a statistically significant reduction in the incidence of invasive fungal infection (typical risk ratio (RR) 0.43, 95% confidence interval (CI) 0.31 to 0.59; risk difference (RD) -0.09, 95% CI -0.12 to -0.06). The average incidence of invasive fungal infection in the control groups of the trials (16%) was much higher than that generally reported from large cohort studies. Meta-analysis did not find a statistically significant difference in the risk of death prior to hospital discharge (typical RR 0.79, 95% CI 0.61 to 1.02; typical RD -0.04, 95% CI -0.07 to 0.00). Very limited data on long-term neurodevelopmental outcomes were available. Three trials that compared systemic versus oral or topical non-absorbed antifungal prophylaxis did not detect any statistically significant effects on invasive fungal infection or mortality. Two trials that compared different dose regimens of prophylactic intravenous fluconazole did not detect any significant differences in infection rates or mortality.

Authors' conclusions: Prophylactic systemic antifungal therapy reduces the incidence of invasive fungal infection in very preterm or very low birth weight infants. This finding should be interpreted and applied cautiously since the incidence of invasive fungal infection was very high in the control groups of many of the included trials. Meta-analysis does not demonstrate a statistically significant effect on mortality. There are currently only limited data on the long-term neurodevelopmental consequences for infants exposed to this intervention. In addition, there is a need for further data on the effect of the intervention on the emergence of organisms with antifungal resistance.

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Conflict of interest statement

None

Figures

1
1
Forest plot of comparison: 1 Systemic antifungal agent versus placebo or no drug, outcome: 1.1 Invasive fungal infection.
2
2
Funnel plot of comparison: 1 Systemic antifungal agent versus placebo or no drug, outcome: 1.1 Invasive fungal infection.
3
3
Forest plot of comparison: 1 Systemic antifungal agent versus placebo or no drug, outcome: 1.2 Death prior to hospital discharge.
4
4
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 1 Invasive fungal infection.
1.2
1.2. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 2 Death prior to hospital discharge.
1.3
1.3. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 3 VABS‐II Domain Scores.
1.4
1.4. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 4 Self esteem scores.
1.5
1.5. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 5 Neurodevelopmental impairment (composite).
1.6
1.6. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 6 Bayley‐III cognition composite score < 70.
1.7
1.7. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 7 Cerebral Palsy.
1.8
1.8. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 8 Deafness.
1.9
1.9. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 9 Blindness.
1.10
1.10. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 10 Retinopathy of prematurity.
1.11
1.11. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 11 Necrotising enterocolitis.
1.12
1.12. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 12 Chronic lung disease.
1.13
1.13. Analysis
Comparison 1 Systemic antifungal agent versus placebo or no drug, Outcome 13 Length of hospital stay.
2.1
2.1. Analysis
Comparison 2 Systemic antifungal agent versus oral or topical antifungal prophylaxis, Outcome 1 Invasive fungal infection.
2.2
2.2. Analysis
Comparison 2 Systemic antifungal agent versus oral or topical antifungal prophylaxis, Outcome 2 Death prior to hospital discharge.
2.3
2.3. Analysis
Comparison 2 Systemic antifungal agent versus oral or topical antifungal prophylaxis, Outcome 3 Bronchopulmonary dysplasia.
2.4
2.4. Analysis
Comparison 2 Systemic antifungal agent versus oral or topical antifungal prophylaxis, Outcome 4 Necrotizing enterocolitis.
2.5
2.5. Analysis
Comparison 2 Systemic antifungal agent versus oral or topical antifungal prophylaxis, Outcome 5 Retinopathy of prematurity.
2.6
2.6. Analysis
Comparison 2 Systemic antifungal agent versus oral or topical antifungal prophylaxis, Outcome 6 Duration of intensive care unit stay.
3.1
3.1. Analysis
Comparison 3 One systemic antifungal agent versus another agent or dose regimen, Outcome 1 Invasive fungal infection.
3.2
3.2. Analysis
Comparison 3 One systemic antifungal agent versus another agent or dose regimen, Outcome 2 Death prior to hospital discharge.
3.3
3.3. Analysis
Comparison 3 One systemic antifungal agent versus another agent or dose regimen, Outcome 3 Retinopathy of prematurity.
3.4
3.4. Analysis
Comparison 3 One systemic antifungal agent versus another agent or dose regimen, Outcome 4 Necrotising enterocolitis.
3.5
3.5. Analysis
Comparison 3 One systemic antifungal agent versus another agent or dose regimen, Outcome 5 Chronic lung disease.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Arrieta 2010 {published data only}
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Aghai 2006 {published data only}
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References to other published versions of this review

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