A Prospective Real-World Study of the Impact of an Antifungal Stewardship Program in a Tertiary Respiratory-Medicine Setting

Abstract

There has been an increase in fungal infections in patients with chronic lung disease over the past decades, which is associated with rapidly increasing costs to health care systems. An antifungal stewardship team was introduced to a tertiary cardiopulmonary hospital, consisting of a medical mycologist and pharmacy support providing weekly stewardship ward rounds, twice-monthly multidisciplinary team meetings, and a dedicated weekly outpatient clinic. A database was set up to record the activity of the stewardship team. During the first 18 months of implementation, the antifungal stewardship team had reviewed 178 patients, with 285 recommendations made to inpatients, and 287 outpatient visits. The commonest diagnoses treated were allergic bronchopulmonary aspergillosis and chronic pulmonary aspergillosis. Cystic fibrosis was the largest patient group treated, followed by asthma and interstitial lung disease. There was a significant sustained reduction in monthly antifungal expenditure ( = 0.005) by £130,000 per month. There was also a significant reduction in antifungal use, measured as the defined daily dose/100 bed days ( = 0.017). There were no significant changes in expenditure on diagnostic tests. There has been a trend toward more patients having therapeutic levels of voriconazole ( = 0.086) and a significant increase in therapeutic levels of posaconazole ( < 0.0001). This study shows that an effective antifungal stewardship program can significantly reduce expenditure in a specialist respiratory service.

The impact of pharmacist‐led antifungal stewardship interventions in the hospital setting: a systematic review

“…Over the previous 10 years, there has been an increase in studies assessing the impact of antifungal stewardship (AFS) interventions, demonstrating improvements in the quality of antifungal prescribing, [15][16][17][18] reduction in the consumption of high-cost antifungals, 19 and improvements in the application of fungal diagnostics 17 and therapeutic drug monitoring (TDM) of antifungals. 20 Pharmacists are key members of antimicrobial stewardship (AMS) teams globally and have shown that they can lead AMS programs. 21 Despite a recent focus on AFS, 22 the role of the pharmacist in AFS has not been extensively explored.…”

Healthcare Utilization and Impact of Antifungal Stewardships Within Respiratory Care Settings: A Systematic Literature Review

“…However, there are significant limitations in the evidence on antifungal stewardship application in a chronic respiratory care setting [22,23,24]. Two of the included studies (Nwanko et al and Browne et al) are classified as low-quality evidence according to GRADE classification [9,17]. The prospective and retrospective studies highlighting antifungal stewardship in respiratory care settings may contain bias given the small sample size utilized in both studies with imprecisions due to a confidence interval of less than 95% in the results obtained.…”

“…The predominant fungal infection studied in the eligible articles with inclusion of patients with underlying chronic respiratory disease was Candida species with 25 out of 29 articles focussing on invasive fungal disease infection (IFI). Although fourteen studies included sample populations consisting of patients with chronic respiratory illnesses, only two studies (Nwanko et al and Browne et al) had a focus specifically on chronic respiratory fungal infections and pulmonary aspergillosis, indicating a gap in existing knowledge/evidence base in the use of antifungal stewardship in this field [9,17]. Although focussed in an invasive fungal infection setting, the implementation of antifungal stewardship was shown to be an effective intervention in a number of the included studies, with some (n = 3) having a moderate GRADE quality of evidence.…”

“…Of the two studies that analysed implementation of antifungal stewardship in a chronic respiratory disease setting, Nwanko et al conducted a prospective cohort study over a 18-month period with 178 patients to determine the impact of an antifungal stewardship team in patients with chronic lung diseases at a tertiary cardio-pulmonary hospital [17]. The researchers implemented an antifungal stewardship team Low consisting of a mycologist and pharmacist provided weekly stewardship rounds, a multidisciplinary meeting twice a week and an outpatient clinic.…”

Utility of 1,3 β-d-Glucan Assay for Guidance in Antifungal Stewardship Programs for Oncologic Patients and Solid Organ Transplant Recipients

“…Antifungal stewardship programs (ASPs) have been proposed as an opportunity to optimize antifungal use [ 3 , 4 , 5 , 6 , 7 ]. Most of the ASPs are exclusively based on restrictive prescription strategies or pharmacy alerts, and few of them are based on bedside interventions [ 8 , 9 , 10 , 11 , 12 ]. While different models of ASPs have been designed for intensive care units (ICUs) and onco-hematology units [ 13 , 14 ], not much attention has been paid to SOT and oncologic units.…”