**Author details**

by neonates who do not exhibit many of the toxicities seen in older children and adults. However, liposomal amphotericin B has been found to be safe and efficacious in newborns with renal impairment. Another polyene agent, nystatin suspension, is administered orally to infants with gestational age ≤ 27 weeks or birth weight less than 750 g until removal of central venous catheters; this is shown to reduce colonization of the gastrointestinal tract

Among the azoles, fluconazole is more frequently used in NICUs for the treatment of oropharyngeal and systemic candidiasis, but has no inherent activity against the genus *Aspergillus*, which is rare pathogen in neonates. This antifungal agent is commonly recommended as prophylactic therapy in NICU with a high incidence in fungal infections. Fluconazole prophylaxis is effective in reducing the rate of colonization and progression to systemic infection in nursery; on the other hand, some studies have revealed that prophylactic or empiric therapy with antifungal agents may be associated with changes in *Candida* ecology and antifungal agent susceptibility. Actually, the fluconazole dose recommended for neonates is 6 mg/kg/ day, and maintenance doses currently used in NICUs in Europe is often higher, between 6

New azoles such as voriconazole, posaconazole and ravuconazole have limited utility in the nursery and are rarely used to treat neonatal infections. Voriconazole is a second-generation triazole that has excellent activity against *Candida* and *Aspergillus* spp.; however, data on its use in neonates are limited. Posaconazole and ravuconazole are the newest agents of the triazole family with added action against zygomycetes, however there are scarces of survey involving these antifungal agents in infants and the use of ravuconazole is not already

The echinocandins (micafungin, caspofungin and anidulafungin) are increasingly used for treatment of *Candida* sp. infections. Their role in the nursery is not so clear, although accruing evidence suggests they may be safe and effective, especially for the treatment of invasive infections caused by *Candida* spp. Some point have to be taken under consideration before the use of echinocandins in NICUs: first, limited clinical data also suggest that these agents may be effective for the treatment of central nervous system infections. Second, a high incidence of *C. parapsilosis* in NICUs is usually reported and this species is related to higher minimum

Among the three representatives of the group, micafungin is the most recommended and its use is approved for adults, children and newborns, being considered the one with better description for neonatal population. The use of caspofungin is approved by the FDA, but only for adults and children over 3 months of age. There were no relevant clinical trials that sup-

Invasive fungal infections are devastating pathologies that still result in death or serious longterm morbidity in neonates; however, the management of this mycosis has progressed greatly, with the azole agents playing a significant role. Effective prophylactic strategies have recently become available; therefore, the choice and use of appropriate antifungal drugs need careful assessment of neonatal characteristics, the epidemiology and drug pharmacokinetics [53].

port the administration of anidulafungin among neonates and children [56, 57].

approved by the Food and Drug Administration (FDA) [59, 60].

inhibitory concentration (MIC) front of echinocandins [56, 57].

and the rate of invasive candidiasis [55].

and 12 mg/kg [53, 56–58].

116 Selected Topics in Neonatal Care

Rejane P. Neves1 \*, Ana Maria R. de Carvalho Parahym2 , Carolina M. da Silva1 , Danielle P.C. Macêdo2 , André F.G. Leal1 , Henrique J. Neves1 and Reginaldo G. Lima-Neto3

\*Address all correspondence to: rejadel@yahoo.com.br

1 Department of Mycology, Centre of Biosciences, Federal University of Pernambuco (UFPE), Recife, Brazil

2 Department of Pharmaceutical Sciences, Center for Health Sciences, UFPE, Recife, Brazil

3 Department of Tropical Medicine, Center for Health Sciences, UFPE, Recife, Brazil
