Fungal Facts & TPN

Advances in neonatal management have led to considerable improvement in newborn survival. However, bacterial and fungal infections are still a devastating complication and an important cause of morbidity in babies in the NICU. A large number of neonatal fungal infections are due to Candida Albicans, and are more common in neonates receiving lipids via TPN (Total Parental Nutrition). M. furfur, a lipid dependent fungus, is also seen frequently in babies receiving lipids through central venous catheters.  Nurses can greatly reduce infections rates by adhering to strict aseptic technique when working with TPN, and by close observation of the neonate for early signs of sepsis.

Research has shown that the administration of contaminated intravenous solutions, especially total parental nutrition solutions (with intralipids), has been linked to the development of systemic fungal infections. Other risk factors for the development of systemic fungal infections in neonates include prematurity, use of broad spectrum antibiotics, prolonged duration of endotracheal intubation, presence of central venous catheters, surgical procedures and the use of corticosteroids.
Amphotericin B is the drug of choice for systemic fungal infections. The cumulative dose required for adequate treatment of systemic candidiasis in neonates is estimated to be 20-30 mg/kg. Although resistance to amphotericin B is not a major problem, it does have serious side effects including the risk of nephrotoxicity and hepatotoxicity. Other side effects include thrombocytopenia, hypokalemia and hypomagnesemia. Thus, the monitoring of serum potassium and magnesium is imperative during the therapy.

Newer formulations of Amphotericin B are now available and have been reported to have lesser toxicity.  The drug Liposomal Amphotericin B derived from neutral lipids (L-AMP-LRC-1) is the most effective drug at lower dosage and is a less expensive drug for the treatment of neonatal candidiasis.

Remember to safeguard your practice by always double checking TPN orders with another RN, closely monitoring vitals and labs during therapy and being meticulous with hand washing and aseptic techniques.

Rao S, Ali U. Systemic fungal infections in neonates. J Postgrad Med 2005;51:27-9