Unveiling the emerging of fluconazole-resistant Candida albicans in preterm with acute kidney injury: a growing challenge at Vajira hospital

doi:10.15406/jpnc.2024.14.00541

Journal of

eISSN: 2373-4426

Pediatrics & Neonatal Care

Clinical Case Volume 14 Issue 1

Unveiling the emerging of fluconazole-resistant Candida albicans in preterm with acute kidney injury: a growing challenge at Vajira hospital

Pichada Saengrat,¹

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Ornatcha Sirimongkolchaiyakul,² Thiraporn Kanjanaphan³

¹Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Thailand
²Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Thailand
³Division of Pediatric Infectious Disease, Department of Pediatrics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Thailand

Correspondence: Thiraporn Kanjanaphan, Division of Pediatric Infectious Disease, Department of Pediatrics, Faculty of Medicine, 681, Vajira Hospital, Navamindradhiraj University, Samsen Road, Dusit District, Bangkok, 10300 Thailand, Tel +66955192942

Received: March 04, 2024 | Published: March 18, 2024

Citation: Saengrat P, Sirimongkolchaiyakul O, Kanjanaphan T. Unveiling the emerging of fluconazole-resistant Candida albicans in preterm with acute kidney injury: a growing challenge at Vajira hospital. J Pediatr Neonatal Care. 2024;14(1):60-61. DOI: 10.15406/jpnc.2024.14.00541

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Abstract

This case presents a challenging scenario in a preterm female newborn born at 25 weeks gestation,who developed respiratory distress syndrome, followed by pneumonia, sepsis, subsequent renal complications, and candida albicans infection. Despite initial susceptibility to fluconazole, the emergence of fluconazole-resistant candida albicans led to a shift in antifungal treatment to amphotericin B in an acute kidney injury neonate. This case underscores the growing concern of drug-resistant candida albicans in neonates, highlighting the importance of judicious selection of empirical antifungal therapy and comprehensive management strategies, especially in the context of acute kidney injury.

Keywords: fungus, drug-resistant, neonate, fluconazole, candida, albicans

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A preterm female newborn with a gestational age of 25 weeks. Her birth weight was 650 grams. She was diagnosed with respiratory distress syndrome. On the 30th day of life, the patient developed pneumonia with sepsis. Subsequent sputum analysis identified the carbapenem-resistant acinetobacter baumannii and stenotrophomonas maltophilia. Treatment was initiated with meropenem, colistin, and levofloxacin. After one week, the patient's creatinine levels began to rise, accompanied by oliguria, likely due to ischemic acute tubular necrosis and the nephrotoxic effects of multiple medications. Peritoneal dialysis was performed. Simultaneously, she still had fever and thrombocytopenia, and a urine culture revealed a count of >10⁵candida albicans. Considering that C. albicans had previously shown full susceptibility to fluconazole, intravenous fluconazole was initiated as an antifungal treatment. Despite receiving fluconazole treatment for one week, subsequent urine cultures continued to show the presence of C. albicans. The patient underwent abdominal, head ultrasonography, echocardiography, and retinal examinations, all of which showed no evidence of candida infection. Consequently, fluconazole-resistant C. albicans was considered the primary differential diagnosis, and the treatment was switched to intravenous amphotericin B. After three days, urine cultures no longer detected any organisms. Subsequently, the drug susceptibility test for C. albicans revealed a minimum inhibitory concentration (MIC) of 4 μg/mL for fluconazole and 0.5 μg/mL for amphotericin B. In this case, intravenous amphotericin B was continued for 14 days after the absence of any growth in the urine culture. Additionally, the patient underwent peritoneal dialysis for one month (Figure 1).

Figure 1 The timeline of clinical course.

Candida infections are common in neonates, infants, and children, with invasive candidiasis posing a significant challenge, and candiduria in newborns must be investigated and treated.¹ This is especially true for extremely low birth weight infants, where the incidence is approximately 5.5%,² and the all-cause mortality rate during the neonatal period ranges from 14.4%.³ Candida albicans remains the most prevalent species in neonates and children.¹ Notably, C. albicans has shown susceptibility to fluconazole, with a reported susceptibility rate of 86-99% minimum inhibitory concentration (MIC) testing.^4,5 However, we have encountered a concerning issue of fluconazole resistance in C. albicans within the neonatal intensive care unit. Therefore, when dealing with severe invasive candidiasis, it is essential to carefully consider the choice of empirical antifungal treatment in the future. This case highlights the emergence of drug-resistant Candida albicans. Accurate microbial susceptibility testing and a multidisciplinary approach are important.