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Neonatal Peritoneal Candidiasis Successfully Treated with Anidulafungin Add-On Therapy

Pediatric Critical Care Fellow, Division of Pediatric Critical Care, University of Alabama at Birmingham

Kimberley W Benner, PharmD BCPS FASHP

Associate Professor, McWhorter School of Pharmacy, Samford University, Birmingham, AL

Priya Prabhakaran, MD

Assistant Professor, Division of Pediatric Critical Care, University of Alabama at Birmingham

Reprints: Dr. Varisco, Division of Pediatric Critical Care, University of Alabama at Birmingham, 1600 7th Ave. South, Pediatric Critical Care Office, ACC Ste. 504, Birmingham, AL 35226, fax 205/975-6505, bvarisco{at}peds.uab.edu

OBJECTIVE: To report the first successful use of anidulafungin and liposomal amphotericin B in an infant with peritoneal candidiasis.

CASE SUMMARY: An 11-day-old term female infant with Hirschsprung enterocolitis and bowel perforation was transferred to our institution on day 4 of hospitalization with septic shock and abdominal compartment syndrome. Initial peritoneal culture at time of colectomy did not grow yeast; however, Candida albicans grew from cultures obtained on abdominal washout 2 days later even while the patient was on treatment with liposomal amphotericin B 5 mg/kg/day. Anidulafungin 1.5 mg/kg/day intravenous therapy was instituted, and within 4 days peritoneal cultures were negative. The patient slowly recovered and, after a prolonged hospitalization, she was discharged home on hospital day 68 on partial parenteral nutrition.

DISCUSSION: Despite the rising incidence of fluconazole-resistant Candida spp., pediatric dosing guidelines, and an adult indication for echinocandin use in candidal peritonitis, there are no reports of echinocandin use for fungal peritonitis in pediatric patients. The echinocandins are rational choices when fluconazole resistance is a concern. Furthermore, the unique clearance profile of anidulafungin makes it an attractive choice in critically ill patients with hepatic and renal dysfunction; the Infectious Diseases Society of America has recommended that an echinocandin be first-line antifungal therapy for moderately or severely ill pediatric or adult patients.

CONCLUSIONS: Peritoneal candidiasis is a common complication of bowel perforation in neonates. Anidulafungin's pharmacokinetic and antifungal properties make it a viable therapeutic option in the treatment of this disease in critically ill infants and children.

Key Words: amphotericin B, anidulafungin, echinocandins, intestinal perforation, neonate, peritonitis

Published Online, October 13, 2009. www.theannals.com, DOI 10.1345/aph.1M350

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