CHALLENGES AND OPPORTUNITIES FOR PREVENTING VARICELLA OUTBREAKS IN THIS SETTING

and ethanol to increase LT effectiveness, micafungin stability test in ethanol 70% was performed by serial dosages carried out at the beginning of the test and then after 2, 6, 12 and 24 hours. Drug concentration, analyzed by high-performance liquid cromatography, was unchanged at all these timepoints. Therefore, a combined LT of 0.3 mL, containing a 1:1 mixture of 70% ethanol and micafungin sodium 5 mg/L, was instilled. The catheter was subsequently closed for 12 hours. Thereafter, the catheter was flushed with saline. Blood culture drawn from the catheter immediately before treatment beginning became positive after 48 hours. Therefore, systemic therapy with micafungin (Mycamine, 10 mg/kg; Astellas Pharma, Northbrook, IL) was also begun and a second LT was performed with the same dosages and modalities. Blood sterilization was finally obtained and catheter removal was avoided. Systemic antifungal therapy with liposomal amphotericin-B and micafungin was continued for 21 days. DISCUSSION Several authors believe that the prolonged use of intravascular devices is closely responsible for the increased infection rates observed in patients hospitalized in Neonatal Intensive Care Unit. In neonates, the delay in removing vascular catheters when a fungal infection arises seems to be associated with significantly increased mortality, 10 although most of the studies involved infants during the first 2–4 months of life. Furthermore, neonates with delayed CVC removal (>1 day after initiation of antifungal therapy) more frequently show neurodevelopmental delays compared with infants in which CVC was promptly removed at the onset of infection. 2 The timing of catheter removal has also been associated with candidemia duration: time to clear candida from the blood was 5 days in neonates who underwent prompt CVC removal versus 7.3 days in those in which the removal had occurred late. 2 Taking these data as a whole, catheter removal is highly recommended as soon as systemic candidiasis is diagnosed, either in adults or in children. 10 If the patient needs a central line, catheter reinsertion in the same location must be avoided and a new catheter has to be placed in another site. Frequently, catheter removal can be problematic in very ill neonates who require central lines for long-term parenteral nutrition and/or life saving therapies. Reinsertion may be technically challenging and may increase the risk of morbidity (limited venous access, coagulopathy, thrombocytopenia) and mortality. Therefore, the need for catheter salvage seems sometimes to overweight the risk of a delayed removal. In these cases, LT has been suggested as possible therapeutic option, 3 although poor experience still exists concerning its use. To our knowledge, this is the first report of a LT with both ethanol and echinocandins for the treatment of fungal catheter-related infection in an infant. Our experience suggests that the use of a combined LT, including the contemporary administration of ethanol and echinocandins, might allow catheter salvage in those patients with contraindications to CVC removal. Clinical trials are required to further define the efficacy of this kind of LT as well as the most appropriate dosage and dwell times.