Clinical mycology capacity and access to antifungal treatment in Portugal

Abstract

The success of the clinical management of invasive fungal diseases (IFD) is highly dependent on the availability of suitable tools for the timely and accurate diagnosis for effective treatment. Unfortunately, the lack of appropriate diagnostic tools remains still one major hurdle contributing to the high mortality rates associated with these infections. An in-depth analysis of the ability of European institutions to promptly and accurately diagnose IFD was previously conducted to identify limitations and aspects to improve. Here, we evaluated and discuss the specific case of Portugal, for which, to our knowledge, there are no reports describing the national mycological diagnostic capacity and access to antifungal treatments. Data from 16 Portuguese medical institutions were collected via an online electronic case report form covering different parameters, including institution profile, self-perceived IFD incidence, target patients, diagnostic methods and reagents, and available antifungals. The majority of participating institutions (69%) reported a low-very low incidence of IFD, with Candida spp. indicated as the most relevant fungal pathogen, followed by Aspergillus spp., and Cryptococcus spp. All the institutions had access to culture and microscopy, whereas 94% and 88% were able to run antigen-detection assays and molecular tests, respectively. Regarding the antifungal availability in the country, 100% of the institutions capable of providing antifungal therapy, declared to have access to at least one formulation. However, echinocandins were only available at 85% of the sites. Therapeutic drug monitoring (TDM) was reported to remain a very restricted practice in Portugal, being available in 19% of the institutions, with the TDM of itraconazole and posaconazole performed in only 6% of them. Importantly, despite some of these resources being well-represented among Portuguese institutions, most of them are outsourced to external entities. With the exception of TDM, Portugal appears to be well-prepared with regard to the overall capacity to diagnose and treat IFD. Future efforts should focus on promoting the widespread availability of TDM and improved access to multiple classes of antifungals, to further improve patient outcomes.