# Clinical characteristics of invasive candidiasis in infants born before 30 weeks of gestation: a nested case series from a multicenter cohort study in the Netherlands and Belgium

## TL;DR

This study identifies clinical features of invasive candidiasis in extremely preterm infants and highlights the need for early diagnosis and treatment to improve outcomes.

## Contribution

The study reveals that vaginal delivery and specific clinical features may indicate vertical transmission of candidiasis, offering new prevention opportunities.

## Key findings

- Infants with invasive candidiasis were born at an average of 25.7 weeks with low birth weight and often delivered vaginally.
- Delayed antifungal treatment was common, and C-reactive protein and platelet count at diagnosis were linked to fatal outcomes.
- Most cases were caused by Candida albicans, and affected infants required significant medical interventions like ventilation and transfusions.

## Abstract

Invasive candidiasis poses a serious risk to preterm infants, due to its rapidly progressive and severe clinical course, resulting in considerable mortality and long-term morbidity. Therefore, the aim of the current study was to assess the clinical characteristics of invasive candidiasis in very preterm infants to increase awareness among clinicians. A multicenter cohort study database was screened for infants, born in one of ten Neonatal Intensive Care Units (NICUs) in the Netherlands and Belgium between October 2014 and May 2025, with blood- and/or cerebrospinal fluid culture-proven invasive candidiasis (gestational age < 30 weeks) in the first 29 days of life. Clinical data were retrospectively collected. Out of 2.824 infants, 24 were diagnosed with invasive candidiasis (0.8%), most frequently caused by Candida albicans (83%). Affected infants demonstrated distinct clinical features: extreme prematurity (mean 25.7 weeks ± 9 days), low birth weight (mean 827 ± 198 g), vaginal delivery (88%), and sepsis and/or gastrointestinal disease prior to clinical onset (46%). In 58%, initiation of antifungal treatment was delayed. The disease course was generally severe with end-organ disseminated candidiasis (33%), need for invasive ventilation (58%), cardiorespiratory support (42%), and red blood cell and/or platelet transfusion (71% and 33%). Both C-reactive protein and platelet count at diagnosis were associated with fatal outcome (p = 0.040 and p = 0.010, respectively).

Conclusion: In infants with distinct clinical features, clinicians should maintain a high index of suspicion, particularly in NICUs with a higher incidence of Candida colonization and/or infection. Our findings underline the need for a rapid diagnostic test to reduce treatment delays and improve clinical outcomes.
What is known:• Invasive candidiasis poses a risk to preterm infants due to its rapidly progressive disease course, high mortality, and long-term morbidity.• A critical need exists to enhance vigilance among clinicians, enabling timely diagnosis, and initiation of targeted treatment.What is new:• Affected infants are characterized by shared clinical features and substantial disease burden.• Frequent vaginal delivery in affected infants suggests that colonization and infection may result from vertical transmission, offering opportunities for early prevention.

What is known:

• Invasive candidiasis poses a risk to preterm infants due to its rapidly progressive disease course, high mortality, and long-term morbidity.

• A critical need exists to enhance vigilance among clinicians, enabling timely diagnosis, and initiation of targeted treatment.

What is new:

• Affected infants are characterized by shared clinical features and substantial disease burden.

• Frequent vaginal delivery in affected infants suggests that colonization and infection may result from vertical transmission, offering opportunities for early prevention.

The online version contains supplementary material available at 10.1007/s00431-025-06694-5.