Nystatatin drops dosages

[frenchalice]

Hi there,
I am looking for some evidence based information supporting giving Nystatin drops at a dosage of 50,000IU every 3 hours instead of giving it at 100.000IU every 6 hours. I work in an NICU so I am dealing with a premature and medically ill infant group.
Thanks

[frenchalice]

oops spelling error in title...."Nystatin"

[admin]

Frenchalice:

This is a difficult subject to approach briefly. Below is a good review of the use of fluconazole and nystatin to prophylactically prevent candida infections in premature infants.

Pull up a copy of this paper, its quite good.

Tom Hale



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Clin Perinatol. 2010 Sep;37(3):611-28. doi: 10.1016/j.clp.2010.06.003.

Strategies to prevent invasive candidal infection in extremely preterm infants.

Kaufman DA, Manzoni P.


Abstract
The highest incidence of invasive candidal infection (ICI) occurs in extremely preterm infants (<1000 g birth weight and <or=27 weeks' gestation). In this population, ICI has high mortality, leads to significant neurodevelopmental impairment, and results in increased length of hospital stay and costs. Randomized clinical trials in infants of less than 1000 g birth weight have demonstrated that ICI is decreased 88% by antifungal prophylaxis with fluconazole compared to 54% by nystatin prophylaxis from retrospective studies. Fluconazole is more efficacious than nystatin prophylaxis in infants weighing less than 1000 g, is less expense, requires less frequent dosing (twice weekly intravenous [IV] dosing), and can be given when infants are not feeding. While antifungal prophylaxis is inexpensive, cost-effective, and easy to administer, yet has not been instituted universally despite A-1 evidence from single and multicenter studies demonstrating efficacy and safety. Debate is ongoing over whether empiric therapy or improved infection control practices are superior to prophylaxis, whether prophylaxis should be instituted only in neonatal intensive care units (NICUs) with a relatively high ICI rate, and whether fluconazole prophylaxis is safe or risks emergence of resistance. To date, azole resistance has not emerged with targeted treatment of high-risk infants for the duration of IV catheter use. Empiric therapy for suspected ICI and standardized therapy for candidemia, including central venous catheter removal, may decrease mortality; however, these approaches still risk neurodevelopmental impairment in ICI survivors. Infection control practices have not been subjected to prospective or randomized trials to demonstrate efficacy in reducing fungal infections. Evidence is presented in this article from clinical trials demonstrating efficacy and safety of antifungal prophylaxis in preventing ICI in preterm infants. The greatest impact of antifungal prophylaxis preventing ICI and decreasing Candida-related mortality and neurodevelopmental impairment would be achieved with a universal approach in all NICUs.
(c) 2010 Elsevier Inc. All rights reserved.
PMID: 20813274 [PubMed - indexed for MEDLINE]

------another good paper -----------------------


Early Hum Dev. 2012 May;88 Suppl 2:S45-9. doi: 10.1016/S0378-3782(12)70014-2.
"Getting to Zero": preventing invasive Candida infections and eliminating infection-related mortality and morbidity in extremely preterm infants.
Kaufman DA.

Abstract
Prevention of invasive Candida infections (ICI) is an achievable goal for every NICU and supported by A-1 evidence. Due to the incidence of ICI, high infection-associated mortality and neurodevelopmental impairment, antifungal prophylaxis should be targeted to infants <1000 g or ≤ 27 weeks gestation. There is A-1 evidence for both fluconazole and nystatin prophylaxis for the prevention of ICI. Evidence currently would favour fluconazole prophylaxis in high-risk preterm infants since intravenous fluconazole prophylaxis has greater efficacy compared to enteral nystatin prophylaxis, efficacy in the most immature patients in whom mortality is the highest, requires less dosing, and can be given to infants with gastrointestinal disease or haemodynamic instability. All NICUs caring for extremely preterm infants should use antifungal prophylaxis. Even in NICUs with low rates of ICI, antifungal prophylaxis is crucial to improving survival and neurodevelopmental outcomes for this vulnerable population. For infants 1000-1500 g if there is concern for ICI in the NICU, either drug could be chosen for prophylaxis. Fluconazole prophylaxis administered at 3 mg/kg twice a week, while intravenous access is required, appears to be the safest and most effective schedule in preventing ICI while attenuating the emergence of fungal resistance. Invasive Candida infections are one group of infections we can prevent.
Copyright ? 2012 Elsevier Ireland Ltd. All rights reserved.
PMID: 22633513 [PubMed - indexed for MEDLINE]

[admin]

Franchalice:

I just spoke with our NICU nurse. We use for premature infants with THRUSH, 100,000 IU every 6 hours. I don't know if this is evidence-based, but it probably is.

Tom Hale