Current antifungal prophylaxis policies and practices in UK NICUs

Background:
Invasive fungal infections cause significant mortality and morbidity in the neonatal intensive care unit (NICU). In 2021, the National Institute for Health and Care Excellence (NICE) recommended the use of antifungals to prevent fungal infections in preterm, <30 weeks’ gestation and birthweight up to 1500g during antibiotic treatment for late-onset sepsis. We aimed to review current policies and practices for antifungal prophylaxis in UK tertiary-level NICUs.
Methods
Between January and May 2024, we contacted all 53 UK level 3 NICUs via telephone/e-mail to request a copy of their local antifungal prophylaxis guidelines.
Results
We obtained the guidelines from all 53/53 (100%) NICUs. 45/53 (85%) units had clear written guidance for the use of antifungal prophylaxis, while 8 (15%) units had no recommendation for routine antifungal prophylaxis. In comparison with NICE guidelines, there was great variability in terms of recommendation for the gestational age (GA), birth weight (BW) for high risk neonates and the choice of antifungal prophylaxis. Only 16/53 (30%) units followed the specific NICE
recommendations for GA and BW cutoffs. 19/53 (36%) units used either oral Nystatin or intravenous Fluconazole as first line depending on oral tolerance, GA and BW. 15/53 (28%) units used IV Fluconazole as first line, some stated switching to oral fluconazole when able but oral Nystatin was not considered despite the NICE recommendation. 4/53 (8%) unit guidelines stated necrotising
enterocolitis as an indication to initiate antifungal prophylaxis.
Conclusion
Compared to a previous UK survey done in 2006-7, our survey has found that use of antifungal prophylaxis has increased significantly but is still not universal. At-risk preterm neonates in units not receiving antifungal prophylaxis may be at an increased risk of invasive fungal infection, compared to those who receive antifungal prophylaxis in line with NICE recommendation.