Stewardship and Challenges: Antifungal Use in NICUs

Rising empirical antifungal use in NICUs—driven by diagnostic gaps and inconsistent neonatal dosing—has accelerated resistant Candida emergence and exposed vulnerable neonates to avoidable toxicity.

Empirical antifungal starts are now more common than in prior NICU practice because diagnostics often fail to identify invasive fungal disease quickly and neonatal dosing guidance is inconsistent. Clinicians increasingly start treatment at the bedside for non-specific sepsis signs when tests are imperfect, lowering the threshold for empirical therapy and increasing antifungal exposure without a matching rise in confirmed cases.

Key drivers include low blood-culture sensitivity (often ≤50% in neonatal series), non-specific clinical presentations—apnea, feeding intolerance, temperature instability—prophylactic habits that extend drug exposure beyond strictly defined high-risk groups, and gaps in neonatal pharmacokinetic evidence that produce wide dosing variation. Together, these limitations increase unnecessary empirical antifungal use.

Antifungal stewardship programs that are multidisciplinary, aligned to local Candida epidemiology, and include clear protocols for agent selection, dosing, and duration serve as the primary corrective measure. These frameworks standardize neonatal dosing where evidence exists, set predefined start/stop criteria, and use audit-and-feedback to reduce unnecessary empirical therapy—lowering resistance pressure and treatment-related toxicity.

Implementation barriers are compact but consequential: lack of rapid bedside diagnostics, limited NICU-specific pharmacokinetic data, clinician training gaps, and logistical hurdles for routine multidisciplinary review and timely audit. Addressing these requires parallel investments in diagnostic access, targeted dosing studies, and operational pathways that embed stewardship review into NICU workflows.

Key Takeaways:

• Diagnostic limits and dosing uncertainty have lowered empirical-treatment thresholds, increasing antifungal exposure.
• Multidisciplinary, locally tailored stewardship optimizes agent selection, dosing, and duration to limit resistance and toxicity.
• Combined stewardship, diagnostics, and dosing research defines the operational path to safer antifungal use in neonatal care.