A quality improvement initiative to improve the appropriateness of candidemia management by the implementation of a comprehensive candidemia care bundle at a tertiary care hospital in South India

Abstract

Management of candidemia in developing countries like India encounters laxity in appropriate clinical management and challenges in terms of healthcare capacity, despite its association with high morbidity and mortality. Our study aims to evaluate the impact of a comprehensive candidemia care bundle implementation on appropriateness of therapy and major clinical outcomes.The single-center, quasi-experimental study conducted at a south Indian tertiary care center included adult patients diagnosed with candidemia. Following a retrospective review of candidemia patients of the pre-implementation period (January 2013-December 2015), the hospital antifungal stewardship team instituted a clinical pharmacist driven comprehensive candidemia care bundle for candidemia patients during the post-implementation period (October 2017-2019) and its impact on appropriateness of antifungal prescriptions and inpatient mortality was evaluated.The study included 175 patients with candidemia, comprising of 103 patients in the pre-implementation period and 72 patients in the post-implementation period. Appropriateness of antifungal prescriptions rose to 65% during post-implementation period from 30% observed in pre-implementation phase (P = .0005). The inhospital mortality rate reduced from 40% in the pre-implementation phase to 36% in the post-implementation phase, recording a 10% reduction over 2 years post-implementation (P = .26). No significant difference was observed in terms length of stay (P = .17).Our study demonstrates the successful implementation of an antifungal stewardship led comprehensive care bundle in a low middle income countries setting. The results of our study will have profound implications in improving the appropriateness of management of candidemia and feasibility of scaling up to wider settings could be explored.

The battle against fungi: lessons in antifungal stewardship from COVID 19 times

“…A systematic review showed that a reduction in antifungal consumption was the single most effective measure in relation to impact assessment of AFS [113] . A clinical pharmacist-led candidemia treatment bundle implemented in a tertiary care facility in India significantly increased the appropriateness of antifungal prescriptions from 30% to 65% in the post-implementation period, with a reduction in in-hospital mortality rate from 40% to 36% (P=0.26; not significant), demonstrating successful implementation of an AFS program in a low-middle income country setting [114] . In a study from Greece that assessed the impact of the implementation of a non-compulsory AFS program with educational intervention to increase the awareness on proper use of antifungals, statistical analysis revealed a large, immediate decline in improper prescriptions and total consumption following intervention, with a downward trend thereafter.…”

Guideline Adherence and Outcomes of Patients with Candidemia in Brazil

“…Several published studies have shown that both adherence to the guidelines and consultation with an infectious disease specialist improve the survival of patients with candidemia [20][21][22][23][24][25][26]. Table 4 summarizes the percentages of adherence to these studies.…”

“…Moni et al [22] analyzed candidemia mortality before and after an implementation of a bundle of recommendations for a sample in India. However, the authors found an increase in adherence to the practices after the implementation of the bundle, although appropriate therapy, duration of treatment, and complementary exams were not associated with survival.…”