Antifungal stewardship considerations for adults and pediatrics

Abstract

Antifungal stewardship refers to coordinated interventions to monitor and direct the appropriate use of antifungal agents in order to achieve the best clinical outcomes and minimize selective pressure and adverse events. Antifungal utilization has steadily risen over time in concert with the increase in number of immunocompromised adults and children at risk for invasive fungal infections (IFI). Challenges in diagnosing IFI often lead to delays in treatment and poorer outcomes. There are also emerging data linking prior antifungal exposure and suboptimal dosing to the emergence of antifungal resistance, particularly for Candida. Antimicrobial stewardship programs can take a multi-pronged bundle approach to ensure suitable prescribing of antifungals via postprescription review and feedback and/or prior authorization. Institutional guidelines can also be developed to guide diagnostic testing in at-risk populations; appropriate choice, dose, and duration of antifungal agent; therapeutic drug monitoring; and opportunities for de-escalation and intravenous-to-oral conversion.

Effect of an intervention to improve the prescription of antifungals in pediatric hematology‐oncology

“…Antifungal stewardship (AFS) programs have been successfully developed in adult institutions to ensure drug selection, dose, and length of therapy, but pediatric reports are scarce. Besides, children are unique in terms of underlying conditions, epidemiology, diagnostic performance, and pharmacokinetics, and specific strategies are needed to address their particular needs …”

“…Besides, children are unique in terms of underlying conditions, epidemiology, diagnostic performance, and pharmacokinetics, and specific strategies are needed to address their particular needs. 17,18 In this report, we describe two interventions prior to the establishment of an AFS program in our Pediatrics Department. In the first intervention, which was carried out in the Pediatric Hematology-Oncology Unit (PHOU), a multidisciplinary team implemented a consensual guideline on the use of antifungals, and evaluated the impact on the adequacy of antifungal use.…”

Fatal disseminated infection by Gymnascella hyalinospora in a heart transplant recipient

“…As part of additional preventive measures, antifungal prophylaxis is recommended for heart transplant recipients at high risk of IFI, including those with a history of reoperation, post‐transplant hemodialysis, acute rejection, or cytomegalovirus (CMV) disease . However, exposure to selective prophylactic antifungals may have an impact on the epidemiology of IFI caused by emerging fungi and should be carefully monitored and evaluated by antifungal stewardship programs . In our case, the patient presented other important risk factors for IFI, such as a delayed chest closure, hypogammaglobulinemia (IgG < 400 mg/dL), and peri‐transplant ECMO .…”

Antifungal stewardship: A budding branch of antimicrobial stewardship

“…Despite advances in improving turnaround time and identification of bacterial isolates, the ability to detect, identify, and obtain sensitivities on fungal isolates from blood has lagged behind . This is not only the case for invasive candida infections, where the sensitivity of blood culture may be only 50%, but also for invasive aspergillosis and other mold infections, where blood cultures are often negative.…”