Efficacy and safety of a comprehensive educational antimicrobial stewardship program focused on antifungal use

Martín-Gutiérrez, Guillermo; Peñalva, Germán; Pipaón, Maite Ruiz-Pérez de; Aguilar, Manuela; Gil-Navarro, María Victoria; Pérez-Blanco, José Luis; Pérez-Moreno, María Antonia; Amaya-Villar, Rosario; Ferrándiz-Millón, Carmen; Gascón, María Lucía Bermá; Goycochea-Valdivia, Walter Alfredo; Me, Jiménez-Mejías; Navarro, María Dolores; Lepe, José Antonio; Álvarez‐Marín, Rocío; Neth, Olaf; Guisado-Gil, Ana Belén; Infante-Domínguez, Carmen; Molina, José Antonio; Cisneros, José Miguel

doi:10.1016/j.jinf.2020.01.002

Cited by 16 publications

(25 citation statements)

References 47 publications

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“…Regarding AF prescription evaluations, a high proportion (89%) of prescriptions were considered correct, similar to the study by Santiago-García et al, that described 93% of appropriate AF prescriptions in a paediatric cancer department [ 8 ]. In contrast, a multicentric study by Ferreras-Antolín et al considered that only 34% of prescriptions were optimal, similar to another study focused on adult patients with hospital-acquired candidemia that found 47% of correct prescriptions [ 7 , 20 ]. Remarkably, the level of non-optimal prescriptions was higher in patients receiving treatment (12/75; 16%) compared with prophylaxis (12/144, 8%), probably due to the higher availability of institutional protocols aimed at prophylaxis.…”

Section: Discussionmentioning

confidence: 96%

Antifungal stewardship in a tertiary care paediatric hospital: the PROAFUNGI study

et al. 2021

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Background The increasing use of antifungal drugs (AF) in children and the concern for related adverse events and costs has led to the development of specific AF stewardship programmes (AFS). Studies in adult patients have shown improvements in AF prescription and usage after implementation, but paediatric data are scant. The aim of this PROAFUNGI study was to describe the use and appropriateness of AF in a high complexity paediatric centre. Methods Observational, prospective, single-centre, modified point-prevalence study (11 surveys, July–October 2018), including paediatric (< 18 years) patients receiving at least one systemic AF. Prescriptions were evaluated by the AFS team. Results The study included 119 prescriptions in 55 patients (53% males, median age 8.7 years [IQR 2.4–13.8]). The main underlying condition was cancer (45.5% of patients; HSCT in 60% of them); and the first indication for AF was prophylaxis (75 prescriptions, 63.2%). Liposomal amphotericin B was used most commonly (46% prescriptions), mainly as prophylaxis (75%). Among the 219 evaluations, 195 (89%) were considered optimal. The reason for non-optimal prescriptions was mostly lack of indication (14/24), especially in critical patients with ventricular assist devices. The use of AF without paediatric approval accounted for 8/24 inappropriate prescriptions. Conclusions A high rate of AF appropriateness was found for the children’s hospital as a whole, in relation with a well-established AFS. Nonetheless, the identification of specific areas of improvement should guide future actions of the AFS team, which will focus mainly on prophylaxis in critically ill patients receiving circulatory assistance and the use of non-approved drugs in children.

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Section: Discussionmentioning

confidence: 96%

Antifungal stewardship in a tertiary care paediatric hospital: the PROAFUNGI study

et al. 2021

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“…Candidemia is the fourth cause (4.9%) of hospital-acquired BSIs in our hospital. The decrease in the duration of all antibiotic treatments, the increase in de-escalation from carbapenems to narrower-spectrum antibiotics and the lesser development of colonization caused by yeast in patients in whom the intervention was accepted, have all undoubtedly contributed to the decrease in candidemia and the consumption of antifungals, without having carried out a direct intervention on the adequate use of antifungals as in other hospitals [27]. The decrease in the incidence of yeast infection has occurred despite the increase in the number of surgical interventions and the increase of intravascular catheter-associated BSIs, with similar use of parenteral nutrition throughout the study period [28].…”

Section: Discussionmentioning

confidence: 99%

Long-Term Carbapenems Antimicrobial Stewardship Program

et al. 2020

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Objective. To evaluate clinical and antibiotic resistance impact of carbapenems stewardship programs. Methods: descriptive study, pre-post-intervention, between January 2012 and December 2019; 350-bed teaching hospital. Prospective audit and feedback to prescribers was carried out between January 2015 and December 2019. We evaluate adequacy of carbapenems prescription to local guidelines and compare results between cases with accepted or rejected intervention. Analysis of antibiotic-consumption and hospital-acquired multidrug-resistant (MDR) bloodstream infections (BSIs) was performed. Results: 1432 patients were followed. Adequacy of carbapenems prescription improved from 49.7% in 2015 to 80.9% in 2019 (p < 0.001). Interventions on prescription were performed in 448 (31.3%) patients without carbapenem-justified treatment, in 371 intervention was accepted, in 77 it was not. Intervention acceptance was associated with shorter duration of all antibiotic treatment and inpatient days (p < 0.05), without differences in outcome. During the period 2015–2019, compared with 2012–2014, decreased meropenem consumption (Rate Ratio 0.58; 95%CI: 0.55–0.63), candidemia and hospital-acquired MDR BSIs rate (RR 0.62; 95%CI: 0.41–0.92, p = 0.02), and increased cefepime (RR 2; 95%CI: 1.77–2.26) and piperacillin-tazobactam consumption (RR 1.17; 95%CI: 1.11–1.24), p < 0.001. Conclusions: the decrease and better use of carbapenems achieved could have clinical and ecological impact over five years, reduce inpatient days, hospital-acquired MDR BSIs, and candidemia, despite the increase in other antibiotic-consumption.

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“…In a systematic review, Bienvenu et al concluded that active intervention, such as post-prescription review, had more impact than guideline implementation. 255 Reported outcomes include reduced mortality, [256][257][258] reductions in time to appropriate antifungal therapy, [259][260][261] reduced antifungal consumption, [256][257][258]262 reduced number of patients treated for IC, 256 improved guideline or bundle of care adherence, 260,263 increase in optimal antifungal prescribing 262,264,265 and reduced cost. 257,262 Implementation of an educational antimicrobial stewardship (AMS) programme focusing on appropriate antibacterial therapy resulted in a reduction in the incidence and mortality rate of hospital-acquired candidaemia.…”

Section: Afs and Guideline Implementationmentioning

confidence: 99%

“…Rautemaa-Richardson et al reported a fall in crude mortality due to IC from 45% to 19%, Kawaguchi et al observed a nonsignificant decrease in 30-day mortality (40.9-30.0%) and in-hospital mortality (63.6-36.7%), and Martin-Gutierrez et al reported a fall in 14-day crude death rate over a 9-year period from 0.044 to 0.0017 per 1000 bed days (P = 0.09). [256][257][258] Significant improvements in prescribing parameters have been reported following implementation of AFS programmes, including increases in appropriate therapy, 265 optimal dosing 262 and reductions in inappropriate antifungal prescriptions. 255,256 Time to effective therapy has been observed to improve median 13.5 to 1.3 h 261 and by 1.5 h in another study, 260 and overall reductions in antifungal consumption reported.…”

Section: Afs and Guideline Implementationmentioning

confidence: 99%

Consensus guidelines for the diagnosis and management of invasive candidiasis in haematology, oncology and intensive care settings, 2021

Keighley

Cooley

Morris

et al. 2021

Internal Medicine Journal

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Patients with haematological malignancies, haemopoietic stem cell transplant recipients and patients requiring admission to intensive care settings are at high risk for invasive candidiasis (IC). Over the past decade, there has been increased reporting of nonalbicans species and fluconazole resistance in Australia. These guidelines provide updated evidence-based recommendations for the diagnosis and management of IC in adult and paediatric haematology, oncology and intensive care settings. Optimal pharmacological and non-pharmacological management are discussed. Recent studies strengthen the recommendation for an echinocandin agent as first-line therapy for high-risk patients with IC. Mortality benefit has also been demonstrated for nonpharmacological management, including removal of central venous catheters, infectious diseases consultation and use of care bundles. Healthcare facilities managing immunocompromised patient populations should therefore adopt implementation strategies for these multimodal interventions.

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Efficacy and safety of a comprehensive educational antimicrobial stewardship program focused on antifungal use

Cited by 16 publications

References 47 publications

Antifungal stewardship in a tertiary care paediatric hospital: the PROAFUNGI study

Antifungal stewardship in a tertiary care paediatric hospital: the PROAFUNGI study

Long-Term Carbapenems Antimicrobial Stewardship Program

Consensus guidelines for the diagnosis and management of invasive candidiasis in haematology, oncology and intensive care settings, 2021

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