Commercially available lipid formulations of amphotericin B (Abelcet, Amphotec, and AmBisome) represent a significant advance in drug delivery technology. Differences in biochemical, pharmacokinetic, and pharmacodynamic properties among the lipid products have been shown in in vitro and in vivo models. Clinical experience with these products has been primarily in patients either refractory to or intolerant of conventional amphotericin B deoxycholate (AmBd). None of the lipid-based products demonstrates superior efficacy when prospectively compared with AmBd in the treatment of documented infections. When used for the empirical treatment of febrile neutropenia, AmBisome significantly reduced the incidence of proven emergent fungal infections but did not improve short-term survival rates, in comparison with AmBd. Acute infusion-related adverse events vary, whereas nephrotoxicity is reduced with all three lipid formulations. Until superior efficacy is clearly shown (for documented infections) or pharmacoeconomic analyses document the value of these drugs, use of such expensive agents should be highly restricted to those who are intolerant of or refractory to AmBd.

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The use and misuse of antimicrobial agents is well documented in the literature. A variety of mechanisms has been used to enhance the appropriate use of these agents. A widely used initial strategy is the formation of multidisciplinary groups, such as Pharmacy and Therapeutics Committees or antimicrobial subcommittees, which are responsible for all antimicrobial policies for the health-care facility. Other techniques include the use of antimicrobial order sheets, automatic stop orders, therapeutic substitution, antibiotic restriction systems, and the use of selective antimicrobial susceptibility reporting systems. Many of these strategies have been reported to be effective in the management of antimicrobial usage; however, they also result in increased administrative and monitoring costs. Antimicrobial control systems must be individualized to the health-care facility.

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