Survival rate for the infants who require CPR in the NICU remains extremely poor. This poor outcome needs to be discussed with parents and the option of the "do not resuscitate" (DNR) order may be appropriate for these infants, especially for those infants with multiple organ failure unresponsive to therapy.

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Invasive fungal infection due to Candida albicans (CA) is increasingly common in ELBW infants. Persistent CA sepsis in ELBW is associated with increased mortality and morbidity. We present a case of persistent CA sepsis in an ELBW infant with a deteriorating clinical condition in spite of a standard combined therapy of amphotericin B and 5-flucytosine. The infant cleared the CA sepsis after the therapy was changed to amphotericin B and caspofungin.Case Report780 g ELBW infant developed CA sepsis at day 7 of life. Positive blood cultures persisted for 45 days while the infant received amphotericin B alone for 6 days, then together with 5-flucytosine for the next 39 days. CSF remained sterile; ophthalmoscopic examination, abdominal and renal ultrasounds, and echocardiogram were unremarkable. Central lines were removed. Because the infant clinical condition began to deteriorate, on the 45th day of treatment caspofungin at 1.5 mg/kg was begun, amphotericin B at 1.5 mg/kg was continued, and 5-flucytosine was stopped. Starting from the 8th day of the new therapy, blood culture remained negative throughout the course. Elevation of liver enzymes was noted seven days after initiation of combined therapy and continued to rise over the next two weeks, reaching a peak of aspartate aminotranferase at 129 U/L, alanine aminotranferase at 87 U/L, and alkaline phosphatase at 587 U/L. The caspofungin dose was decreased to 1 mg/kg for the last 7 of the total 28 days of the new combined therapy. The level of enzymes steadily decreased after the dose was reduced though they never returned to normal. At the start of caspofungin therapy, total bilirubin was 2.2 mg/dL and direct bilirubin was 1.3 mg/dL. Both levels rose to 6.5 mg/dL for total bilirubin and 4.7 mg/dL for direct bilirubin, where it continued to remain for many weeks. These abnormalities were thought to be most consistent with cholestasis caused by prolonged parenteral nutrition. Combined antifungal therapy consisting of caspofungin and amphotericin B can be considered a possible therapy for ELBW infants with persistent candidemia.

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