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Albahar F, Alhamad H, Abu Assab M, Abu-Farha R, Alawi L, Khaleel S. The Impact of Antifungal Stewardship on Clinical and Performance Measures: A Global Systematic Review. Trop Med Infect Dis 2023; 9:8. [PMID: 38251205 PMCID: PMC10820751 DOI: 10.3390/tropicalmed9010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/06/2023] [Accepted: 09/13/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programs (ASP) have been proposed as an opportunity to optimize antifungal use. The antifungal resistance is a significant and emerging threat. The literature on antifungal stewardship (AFS) and its influence on performance and clinical outcome measures is scarce. This study aimed to examine global evidence of the impact of AFS on patients and performance measures. METHODS The "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) was used for the flow of identification, screening, eligibility, and inclusion. PubMed and MEDLINE were searched using the term ''antifungal stewardship'' on 15 February 2023. Search terms included antifungal stewardship, antimicrobial stewardship, candida, candidemia, candiduria, and invasive fungal disease. Of the 1366 records, 1304 were removed since they did not describe an antifungal stewardship intervention. Among the 62 full texts assessed, 21 articles were excluded since they were non-interventional studies and did not include the outcome of interest. Thus, 41 articles were eligible for systematic review. Eligible studies were those that described an AFS program and evaluated clinical or performance measures. RESULTS Of the 41 included studies, the primary performance measure collected was antifungal consumption (22 of 41), and mortality (22 of 41), followed by length of stay (11 of 41) and cost (9 of 41). Most studies were single-center, quasi-experimental, with varying interventions across studies. The principal finding from most of the studies in this systematic review is a reduction in mortality expressed in different units and the use of antifungal agents (13 studies out of 22 reporting mortality). Antifungal consumption was significantly blunted or reduced following stewardship initiation (10 of 22). Comparing studies was impossible due to a lack of standard units, making conducting a meta-analysis unfeasible, which would be a limitation of our study. CONCLUSION It has been shown that AFS interventions may improve antifungal consumption and other performance measures. According to available published studies, antifungal consumption and mortality appear to be the possible performance measures to evaluate the impact of AFS.
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Affiliation(s)
- Fares Albahar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan; (H.A.); (M.A.A.)
| | - Hamza Alhamad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan; (H.A.); (M.A.A.)
| | - Mohammad Abu Assab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan; (H.A.); (M.A.A.)
| | - Rana Abu-Farha
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, P.O. Box 541350, Amman 11937, Jordan;
| | - Lina Alawi
- Department of Physiology and Pharmacology, Faculty of Medicine and Health Sciences, An Najah National University, Nablus P.O. Box 7, Palestine;
| | - Sara Khaleel
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Al Zaytoonah University, P.O. Box 130, Amman 11733, Jordan;
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O’Donnell M, Shields RK, Marini RV, Groetzinger LM, Potoski BA, Falcione BA, Shah S, McCreary EK, Clarke L, Brant E, McVerry BJ, Liegey S, Pasculle AW, Clancy CJ, Nguyen MH. Stewardship-Guided T2Candida Testing Shortens Time to Antifungal Treatment and Reduces Antifungal Usage Among Medical Intensive Care Unit Patients With Septic Shock. Open Forum Infect Dis 2023; 10:ofad538. [PMID: 38023565 PMCID: PMC10651185 DOI: 10.1093/ofid/ofad538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Indexed: 12/01/2023] Open
Abstract
Background Diagnosis of invasive candidiasis (IC) is limited by insensitivity and slow turnaround of cultures. Our objectives were to define the performance of T2Candida, a nonculture test, under guidance of a diagnostic stewardship program, and evaluate impact on time to antifungal initiation and antifungal utilization. Methods This was a retrospective study of adult medical intensive care unit (MICU) patients with septic shock for whom T2Candida testing was performed from March 2017 to March 2020. Patients with positive T2Candida results during this period were compared to MICU patients who did not undergo T2Candida testing but had septic shock and blood cultures positive for Candida from January 2016 through March 2020. Results Overall, 155 T2Candida tests from 143 patients were included. Nine percent of T2Candida tests were positive compared to 4.5% of blood cultures. Sensitivity, specificity, positive predictive value, and negative predictive value of T2Candida for proven and probable IC were 78%, 95%, 50%, and 99%, respectively. Patients who tested positive for T2Candida (n = 14) were diagnosed earlier and initiated on antifungal therapy sooner than patients with IC (n = 14) diagnosed by blood culture alone (median, 5.6 vs 60 hours; P < .0001). Median antifungal days of therapy/1000 patient-days were 23.3/month preimplementation and 15/month postimplementation (P = .007). Following a negative T2Candida result, empiric antifungals were either not administered in 58% or discontinued within 72 hours in 96% of patients. Conclusions Diagnostic stewardship guided T2Candida testing resulted in reduced time to IC diagnosis, faster initiation of antifungal therapy, and lower antifungal usage among MICU patients with septic shock.
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Affiliation(s)
- Matthew O’Donnell
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Division of Infectious Diseases, UPMC, Pittsburgh, Pennsylvania, USA
- Antibiotic Management Program, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Ryan K Shields
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Division of Infectious Diseases, UPMC, Pittsburgh, Pennsylvania, USA
- Antibiotic Management Program, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Pharmacy, UPMC, Pittsburgh, Pennsylvania, USA
| | - Rachel V Marini
- Division of Infectious Diseases, UPMC, Pittsburgh, Pennsylvania, USA
- Antibiotic Management Program, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Pharmacy, UPMC, Pittsburgh, Pennsylvania, USA
| | | | - Brian A Potoski
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Division of Infectious Diseases, UPMC, Pittsburgh, Pennsylvania, USA
- Antibiotic Management Program, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Pharmacy, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bonnie A Falcione
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Division of Infectious Diseases, UPMC, Pittsburgh, Pennsylvania, USA
- Antibiotic Management Program, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Pharmacy, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sunish Shah
- Division of Infectious Diseases, UPMC, Pittsburgh, Pennsylvania, USA
- Antibiotic Management Program, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Pharmacy, UPMC, Pittsburgh, Pennsylvania, USA
| | - Erin K McCreary
- Division of Infectious Diseases, UPMC, Pittsburgh, Pennsylvania, USA
| | - Lloyd Clarke
- Antibiotic Management Program, UPMC, Pittsburgh, Pennsylvania, USA
| | - Emily Brant
- Department of Critical Care Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Bryan J McVerry
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, UPMC, Pittsburgh, Pennsylvania, USA
| | - Susan Liegey
- Division of Clinical Microbiology, UPMC, Pittsburgh, Pennsylvania, USA
| | - A William Pasculle
- Division of Clinical Microbiology, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Veterans Affairs Pittsburgh Healthcare System, Department of Medicine, Division of Infectious Diseases, Pittsburgh, Pennsylvania, USA
| | - M Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Division of Infectious Diseases, UPMC, Pittsburgh, Pennsylvania, USA
- Antibiotic Management Program, UPMC, Pittsburgh, Pennsylvania, USA
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Chakrabarti A, Mohamed N, Capparella MR, Townsend A, Sung AH, Yura R, Muñoz P. The role of diagnostics-driven antifungal stewardship in the management of invasive fungal infections: a systematic literature review. Open Forum Infect Dis 2022; 9:ofac234. [PMID: 35873300 PMCID: PMC9297315 DOI: 10.1093/ofid/ofac234] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/10/2022] [Indexed: 12/02/2022] Open
Abstract
Antifungal stewardship (AFS) programs are key to optimizing antifungal use and improving outcomes in patients with invasive fungal infections. Our systematic literature review evaluated the impact of diagnostics in AFS programs by assessing performance and clinical measures. Most eligible studies were from Europe and the United States (n = 12/17). Diagnostic approaches included serum β-1–3-D-glucan test (n/N studies, 7/17), galactomannan test (4/17), computed tomography scan (3/17), magnetic resonance (2/17), matrix-assisted laser desorption and ionization time-of-flight mass spectrometry (MALDI-TOF MS; 2/17), polymerase chain reaction (1/17), peptide nucleic acid fluorescent in situ hybridization (PNA-FISH) assay (1/17), and other routine methods (9/17). Time to species identification decreased significantly using MALDI-TOF and PNA-FISH (n = 2). Time to targeted therapy and length of empiric therapy also decreased (n = 3). Antifungal consumption decreased by 11.6%–59.0% (7/13). Cost-savings ranged from 13.5% to 50.6% (5/10). Mortality rate (13/16) and length of stay (6/7) also decreased. No negative impact was reported on patient outcomes. Diagnostics-driven interventions can potentially improve AFS measures (antifungal consumption, cost, mortality, and length of stay); therefore, AFS implementation should be encouraged.
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Affiliation(s)
- Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Andy Townsend
- Correspondence: Andy Townsend, PhD, 2 Valley View Congleton, CW12 4EN ()
| | | | - Renee Yura
- WRD & Medical, Pfizer, Cambridge, Massachusetts, USA
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- CIBER Enfermedades Respiratorias – CIBERES (CB06/06/0058), Madrid, Spain
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Aldossary S, Shah A. Healthcare Utilization and Impact of Antifungal Stewardships Within Respiratory Care Settings: A Systematic Literature Review. Mycopathologia 2021; 186:673-684. [PMID: 33991279 PMCID: PMC8536614 DOI: 10.1007/s11046-021-00547-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/17/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Fungal infection and sensitization are common in chronic respiratory patient populations such as bronchiectasis, chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF) and are often associated with prolonged antifungal therapy (Hohmann et al. in Clin Infect Dis 15:939-940, 2010; Vissichelli et al. in Infect Prev Pract 1:100029, 2019), morbidity, and mortality. Although the use of antifungal stewardship (AFS) is increasing within an invasive fungal disease setting, its use and impact within a chronic respiratory setting have not been defined. METHODS A systematic literature review was conducted using PRISMA guidelines to evaluate the use of antifungal stewardship within a chronic respiratory care setting. Three databases have been searched, Medline via Ovid, Embase and GlobalHealth, for papers published between 1949 and 2020. RESULTS The initial search identified 987 papers from Medline, 1761 papers from Embase, and 481 papers from GlobalHealth. Only 28 papers met the criteria for inclusion in this systematic literature review. The included studies were subjected to CASP and GRADE assessments to rank their quality and applicability. Only two studies were focussed on Aspergillus species infection. CONCLUSION Although antifungal stewardship is increasing, its applications are still limited in chronic respiratory care settings despite the prolonged requirement for antifungal therapy and high antimicrobial resistance.
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Affiliation(s)
- Salma Aldossary
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anand Shah
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
- MRC Centre of Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK.
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