Antifungal stewardship in critical care: Implementing a diagnostics-driven care pathway in the management of invasive candidiasis

Abstract

Summary Background Invasive candidiasis (IC) is the most common invasive fungal disease in patients admitted to critical care and is associated with high mortality rates. Diagnosis can be delayed by the poor sensitivity of culture-based methods, leading to unnecessary use of empirical antifungal therapy (EAFT). The fungal biomarker (1–3)-β-d-glucan (BDG) has been shown to aid in the diagnosis of IC in critical care and has been incorporated into antifungal stewardship (AFS) programmes. Aim To describe our experience using a diagnostics-driven AFS programme incorporating the fungal biomarker BDG, analyse its impact on antifungal therapy (AFT), and gain an improved understanding of the epidemiology of IC in our critical care unit (CrCU). Methods An AFS care pathway incorporating BDG was introduced in the CrCU in St James's Hospital, Dublin. Following an educational programme, compliance with the pathway was prospectively audited between December 1st, 2017 and July 31 st , 2018. Results and Conclusion One hundred and nine AFT episodes were included, of which 95 (87%) had a BDG sent. Of those with BDG results available at the time of decision-making, 38 (63%) were managed in accordance with the care pathway. In compliant episodes without IC, median EAFT duration was 5.5 days [IQR 4–7] and no increase in mortality or subsequent IC was observed. Although adopting a diagnostics-driven approach was found to be useful in the cohort of patients with BDG results available, the use of once-weekly BDG testing did not result in an observed reduction in the consumption of anidulafungin, highlighting an important limitation of this approach.

Lessons from an Educational Invasive Fungal Disease Conference on Hospital Antifungal Stewardship Practices across the UK and Ireland

“…The examples discussed throughout this article demonstrate how different hospitals, trusts, and regions have employed their own AFS strategies [ 5 , 6 , 7 , 21 , 22 ]. To ensure the effective management of IFDs, guidelines need to be developed by individual hospitals and trusts based on local epidemiology and in-house diagnostic capacity.…”

“…At the Wythenshawe Hospital, quizzes and posters were employed to educate staff across the hospital on the management of IFD [ 5 ]. At St. James’s Hospital (SJH) in Ireland, AFS relied on a series of formal and informal lectures for critical care (medical and nursing), by clinical and laboratory staff in clinical microbiology on the proposed new care pathway for the management of invasive candidiasis [ 21 ]. Additional activities included posters throughout the hospital, MDT meetings, and updates at departmental meetings [ 21 ].…”

“…In Ireland, a survey of mycology practices and fungal diagnostics identified challenges in IFD management, including delays in diagnosis and incredulity in negative results due to the poor sensitivity of culture-based diagnostic methods, and on average 8–10 days of empiric AFT in patients with no diagnostic evidence of candidiasis [ 21 , 24 ]. A prospective observational study of critical care patients tested the utility of 1–3-β-D-glucan (BDG) and galactomannan (GM) testing, and concluded that these biomarkers, particularly BDG, would enhance diagnosis of IFD [ 25 ].…”

“…The AFS programme, led by an in-house AFS team set up and validated the use of BDG testing to identify patients who could safely discontinue empirical treatment. The AFS team then carried out education and training for the microbiology and critical care units, followed by further audits and surveys to monitor the progress of the programme [ 21 ]. Currently, to the best of our knowledge, there are no published data describing AFS in Northern Ireland, but this is being addressed.…”

“…and Candida spp. [ 21 ]. Evidence to support the utility of susceptibility testing in the UK is limited; however, testing in many instances could be guided by clinical progression, as recommended by the UK Clinical Mycology Network within the Identification and Sensitivity Testing of Yeast Isolates—Practice Guide [ 42 ].…”