A non-compulsory stewardship programme for the management of antifungals in a university-affiliated hospital

Abstract

Antimicrobial stewardship programmes promote excellence in the use of antimicrobials by selecting the appropriate antimicrobial agent and the correct dose, route of administration and duration of treatment. However, there is limited experience with such programmes targeting antifungal treatments. We present the results of a non-compulsory programme for the control of antifungals. For 12 months, prescriptions of oral voriconazole or intravenous voriconazole, caspofungin and liposomal amphotericin B were reviewed, and non-compulsory recommendations were made. The incidence and outcome of fungal infections were examined. The results for the dispensed defined daily doses (DDDs) and expenditure on antifungals were compared with those for the previous 12 months. The number of antifungal treatments reviewed was 662. A recommendation to change treatment was made in 29% of the cases, including a change from intravenous to oral treatment (15%), cessation of antifungal treatment (8%), and a change to fluconazole (6%). The DDDs of intravenous voriconazole and caspofungin were reduced by 31.4% and 20.2%, respectively. The DDDs of oral voriconazole and dispensed vials of liposomal amphotericin B were increased by 8.2% and 13.9%, respectively. Expenditure on antifungals was reduced by US$370681.78 (11.8% reduction). The programme was not related to significant increases in the incidence of candidaemia, percentage of persistent/relapsing candidaemia cases, percentage of fluconazole-resistant Candida species, incidence of infections by filamentous fungi, or 12-month mortality in patients with filamentous fungal infections. In conclusion, a stewardship programme targeting antifungals achieved a reduction in antifungal expenditure without reducing the quality of care provided.

Antifungal stewardship considerations for adults and pediatrics

“…[108][109][110] One study reviewed 636 prescriptions, of which 72% were from the adult and pediatric hematology-oncology services, over 6 y. 108 The ASP provided feedback to the primary teams regarding diagnostic investigations, TDM, and antifungal prescribing and found a high compliance rate (88%) with ASP recommendations.…”

“…A second study targeted high-cost antifungals in 173 patients at a tertiary hospital over a 12-month period. 109 The ASP provided clinical 110 Studies specific to antifungal de-escalation have focused on candidemia with the advent of antifungal susceptibility testing. The timing of when to de-escalate has not been clearly established, but the 2016 IDSA guideline for the management of candidemia recommends transitioning from an echinocandin or amphotericin-based product to oral fluconazole (or voriconazole for C. krusei infection) within 5-7 d provided that the patient is clinically stable, has a susceptible isolate, and has negative repeat blood cultures on antifungal therapy.…”

Antifungal Stewardship

“…Bunlar antifungal kullanımının onaya bağlı olması, otomatik "stop order" gibi kısıtlayıcı veya eğitimle destekleme, rehber oluşturma ve konunun uzmanlarıyla hasta başı değerlendirme gibi ikna edici yöntemler de olabilir [11,12] . Antimikrobiyal kullanımında kısıtlama yönteminin değerlendi-rildiği bir çalışmada dört yıl süreyle kaspofungin, itrakonazol, vorikonazol ve amfoterisin B lipid formülü de kısıtlanmıştır.…”

“…İkna edici yöntemler daha fazla zaman ve gayret gerektirir, fakat uzun dönemde kısıtlamadan daha iyi ilerlemeye neden olur. "Stop order" kullanmak antibiyotik yönetimi programlarında önerilmektedir fakat fungal infeksiyonların tanısı daha zor olduğu için deneyim gerektirir [11,14] .…”

“…Bu dö-nemde vorikonazol kullanımında %31.4, kaspofungin kullanımında %20.2 azalma olduğu bildirilmiş-tir. Antifungal maliyeti 370.681 Dolar azalırken kandidemi insidansı, flukonazole dirençli kandida infeksiyonu ve mortalitede artış bildirilmemiştir [11] . AFY programlarında; eğitim faaliyetleri, doz ayarlama araçları, antifungal reçeteleme formlarının kullanımı, reçetelerin kontrol edilmesi gibi birden fazla yöntemin bir arada kullanıldığı demet uygulamaları da tavsiye edilmektedir [9] .…”