Scenario

A 9-month-old child is admitted to the paediatric intensive care unit (PICU) with status epilepticus following a prolonged febrile convulsion. They are intubated and ventilated with a central venous catheter in situ. Broad-spectrum antibiotics have been started. A nurse asks you to write up some prophylactic oral nystatin as that is what the protocol says. The assumption is that the use of a non-absorbable antifungal will reduce the incidence of invasive fungal infection.

Structured clinical question

Do prophylactic topical non-absorbable antifungal medications (intervention) decrease the incidence of invasive fungal infections (outcome) in immunocompetent critically ill children on concomitant broad-spectrum antibiotics (patient)?

Search

AMED, EMBASE, HMIC, BNI, Medline, PsycInfo, CINAHL, HEALTH BUSINESS ELITE 2005 to 2015

Search term used:

((‘paediatric*’ ‘[Title/Abstract]) OR (‘pediatric*’ [Title/Abstract]) OR (‘child*’ [Title/Abstract]) OR (‘infant*’ [Title/Abstract]) OR (‘adolescen*’ [Title/Abstract]) AND (‘intensive care’ [Title/Abstract]) OR (‘critical care’ [Title/Abstract]) OR (‘critically ill’ [Title/Abstract]) AND

(‘nystatin’ [Title/Abstract]) OR (‘antifungal’ [Title/Abstract]) OR (‘anti-fungal’ [Title/Abstract]) OR (‘amphotericin’ [Title/Abstract]) AND

(‘prophyla*’ [Title/Abstract]) OR (‘prevent*’ [Title/Abstract])

No limits were placed on the search

Studies conducted on paediatric non-neutropenic/immunecompetent inpatient populations, aged 0–16 years, were included. There were a number of review articles and comparative studies involving neonatal, oncology or transplant patients, but all of these were mainly using ‘azole’ derivatives as prophylaxis. One study comparing nystatin with placebo was excluded as the cohort groups were extremely or very low birth weight infants on the neonatal unit. Of relevance to the question, two systematic reviews, one retrospective case–historical control study and …