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Soni S, Hettle D, Hutchings S, Wade S, Forrest-Jones K, Sequeiros I, Borman A, Johnson EM, Harding I. Promoting antifungal stewardship through an antifungal multidisciplinary team in a paediatric and adult tertiary centre in the UK. JAC Antimicrob Resist 2024; 6:dlae119. [PMID: 39104771 PMCID: PMC11299947 DOI: 10.1093/jacamr/dlae119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 07/08/2024] [Indexed: 08/07/2024] Open
Abstract
Background Invasive fungal infections (IFIs) present significant challenges, especially among immunocompromised patients, with associated high morbidity, mortality and significant economic impact. Diagnostic difficulties and the emergence of antifungal resistance necessitates enhanced antifungal stewardship (AFS) efforts. Methods We report outcomes from a review of our multidisciplinary approach to AFS, based in a 1300-bed teaching hospital in the South-West of England. Retrospectively reviewing all adult and paediatric cases over 12 months in 2022, we investigated demographics, diagnosis, antifungal therapy and adherence to AFS advice, including clinical, mycological, financial and teamwork metrics. Data were extracted from our AFS database, supported by pharmacy records. Results The AFS multidisciplinary team (MDT) reviewed 111 patients, with 30 day and 1 year mortality of 22.7% and 35.4%, respectively. IFIs classified as proven accounted for 26%, with fungal pathogens identified in 36.3% of cases. Antifungal consumption (by 25.1%) and expenditure (by 59.9%) decreased from 2018 to 2022. The AFS MDT issued 324 recommendations, with a 93% acceptance rate. Conclusions Our approach to AFS, centred around a weekly MDT, demonstrated improvements in IFI management, antifungal consumption and cost-efficiency. This single-centre study highlights the value of a comprehensive, collaborative approach to AFS involving experts in mycology, infection, radiology, antifungal therapies and clinical teams. The programme's success in paediatric and adult populations and the near-universal acceptance of its recommendations show its potential as a model for replication. It represents a model for enhancing patient care and AFS practices, with future directions aimed at expanding service reach and the integration of further rapid diagnostic modalities.
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Affiliation(s)
- Shuchita Soni
- Department of Microbiology, University Hospitals Bristol and Weston NHS Trust, Marlborough Street, Bristol BS1 3NU, UK
| | - David Hettle
- Department of Microbiology, University Hospitals Bristol and Weston NHS Trust, Marlborough Street, Bristol BS1 3NU, UK
| | - Stephanie Hutchings
- United Kingdom Health Security Agency (UKHSA) South-West Regional Laboratory, Southmead Hospital, Westbury-on-Trym, Bristol BS10 5NB, UK
| | - Susan Wade
- Pharmacy Department, University Hospitals Bristol and Weston NHS Trust, Marlborough Street, Bristol BS1 3NU, UK
| | - Kate Forrest-Jones
- Pharmacy Department, University Hospitals Bristol and Weston NHS Trust, Marlborough Street, Bristol BS1 3NU, UK
| | - Iara Sequeiros
- Department of Radiology, University Hospitals Bristol and Weston NHS Trust, Marlborough Street, Bristol BS1 3NU, UK
| | - Andrew Borman
- UK National Mycology Reference Laboratory, National Infection Service, United Kingdom Health Security Agency South-West, Bristol BS10 5NB, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, EX4 4QD, UK
| | - Elizabeth M Johnson
- UK National Mycology Reference Laboratory, National Infection Service, United Kingdom Health Security Agency South-West, Bristol BS10 5NB, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, EX4 4QD, UK
| | - Irasha Harding
- Department of Microbiology, University Hospitals Bristol and Weston NHS Trust, Marlborough Street, Bristol BS1 3NU, UK
- United Kingdom Health Security Agency, Bristol Royal Infirmary, Marlborough Street, Bristol BS1 3NU, UK
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Gupta AK, Talukder M, Shemer A, Galili E. Safety and efficacy of new generation azole antifungals in the management of recalcitrant superficial fungal infections and onychomycosis. Expert Rev Anti Infect Ther 2024; 22:399-412. [PMID: 38841996 DOI: 10.1080/14787210.2024.2362911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/29/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Terbinafine is considered the gold standard for treating skin fungal infections and onychomycosis. However, recent reports suggest that dermatophytes are developing resistance to terbinafine and the other traditional antifungal agents, itraconazole and fluconazole. When there is resistance to terbinafine, itraconazole or fluconazole, or when these agents cannot used, for example, due to potential drug interactions with the patient's current medications, clinicians may need to consider off-label use of new generation azoles, such as voriconazole, posaconazole, fosravuconazole, or oteseconazole. It is essential to emphasize that we do not advocate the use of newer generation azoles unless traditional agents such as terbinafine, itraconazole, or fluconazole have been thoroughly evaluated as first-line therapies. AREAS COVERED This article reviews the clinical evidence, safety, dosage regimens, pharmacokinetics, and management algorithm of new-generation azole antifungals. EXPERT OPINION Antifungal stewardship should be the top priority when prescribing new-generation azoles. First-line antifungal therapy is terbinafine and itraconazole. Fluconazole is a consideration but is generally less effective and its use may be off-label in many countries. For difficult-to-treat skin fungal infections and onychomycosis, that have failed terbinafine, itraconazole and fluconazole, we propose consideration of off-label voriconazole or posaconazole.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Mediprobe Research Inc., London, Ontario, Canada
| | - Mesbah Talukder
- Mediprobe Research Inc., London, Ontario, Canada
- School of Pharmacy, BRAC University, Dhaka, Bangladesh
| | - Avner Shemer
- Department of Dermatology, Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Galili
- Department of Dermatology, Sheba Medical Center, Ramat-Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Alsalman J, Althaqafi A, Alsaeed A, Subhi A, Mady AF, AlHejazi A, Francis B, Alturkistani HH, Ayas M, Bilbisi M, Alsharidah S. Middle Eastern Expert Opinion: Strategies for Successful Antifungal Stewardship Program Implementation in Invasive Fungal Infections. Cureus 2024; 16:e61127. [PMID: 38919246 PMCID: PMC11198984 DOI: 10.7759/cureus.61127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/27/2024] Open
Abstract
In recent years, global public health efforts have increasingly emphasized the critical role of antimicrobial stewardship (AMS) in improving outcomes, reducing costs, and combating the growing threat of antimicrobial resistance. However, antifungal stewardship (AFS) has remained relatively overlooked despite the staggering impact of invasive fungal infections (IFIs). This burden is particularly pronounced in hospitals worldwide, with the Middle East facing significant unmet needs. The rising population of immunocompromised individuals vulnerable to IFI has prompted an increased reliance on antifungal agents for both prevention and treatment. Given the considerable mortality associated with IFIs and the emergence of antifungal resistance, implementing AFS programs in hospital settings is becoming increasingly urgent. In this article, we offer expert insights into the strategies that can be used for successful antifungal stewardship program implementation in IFI. Drawing upon the extensive clinical experience of a multinational and multidisciplinary panel, we present recommendations for optimizing AFS practices. We delve into the challenges and practical considerations of tailoring local AFS initiatives to the evolving landscape of fungal infections. Additionally, we provide actionable recommendations and position statements for the effective implementation of AFS programs, informed by the collective clinical experiences of panel members across their respective countries of practice.
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Affiliation(s)
| | - Abdulhakeem Althaqafi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Infectious Diseases, King Abdullah International Medical Research Center, Jeddah, SAU
- Department of Medicine/Infectious Diseases, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Ahmad Alsaeed
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Adult Hematology and Stem Cell Transplantation, Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of the National Guard Health Affairs, Jeddah, SAU
| | - Ahmad Subhi
- Adult Infectious Diseases, Department of Medicine, Al-Qassimi Hospital, Emirates Health Services, Sharjah, ARE
| | - Ahmed F Mady
- Critical Care Medicine, King Saud Medical City, Riyadh, SAU
| | - Ayman AlHejazi
- Department of Oncology, King Abdulaziz Medical City Riyadh, Riyadh, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Bassam Francis
- Hematology, Hematology and Bone Marrow Transplant Center, Baghdad, IRQ
| | | | - Mouhab Ayas
- Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU
| | - Montaser Bilbisi
- Department of Infectious Diseases, Abdali Medical Center, Amman, JOR
| | - Sondus Alsharidah
- Pediatric Stem Cell Transplant Unit, Department of Pediatric Hematology/Oncology, National Bank of Kuwait (NBK) Children's Specialized Hospital, Sabah Central Health Region, KWT
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Gupta AK, Mann A, Polla Ravi S, Wang T. Navigating fungal infections and antifungal stewardship: drug resistance, susceptibility testing, therapeutic drug monitoring and future directions. Ital J Dermatol Venerol 2024; 159:105-117. [PMID: 38088126 DOI: 10.23736/s2784-8671.23.07694-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/24/2024]
Abstract
Antifungal stewardship refers to the rational use of antifungal agents. Historically, in some instances, the misuse or overuse of antifungal agents has predisposed patients to an elevated risk of systemic side-effects and treatment resistance, as well as increased healthcare costs. Superficial mycoses, such as onychomycosis, are sometimes treated without any diagnostic testing and is associated with a high likelihood of self-diagnosis and self-treatment, potentially leading to the emergence of resistance against commonly used antifungals like terbinafine. Practitioners need to ensure that a proper clinical diagnosis is backed up by appropriate testing. This may include the traditional light microscopy and culture; additionally, molecular techniques (such as polymerase chain reaction, terbinafine gene mutational analysis) and antifungal susceptibility testing are considerations as appropriate. The choice of antifungal agent should be guided by what is the standard of care in the location where the clinician practices as well as more broadly state and national prescription patterns. Recently, reports of treatment resistance concerning both superficial and deep fungal infections have added another layer of difficulty to clinical practice. This review aims to explore the phenomenon of antifungal drug resistance, and highlights the importance of adopting antifungal stewardship programs. We provide an overview of treatment resistance and mechanisms of resistance reported thus far in dermatophytes. Challenges of performing antifungal susceptibility testing and therapeutic drug monitoring are discussed, as well as principles, recommendations and future directions of antifungal stewardship programs.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada -
- Mediprobe Research Inc, London, ON, Canada -
| | | | | | - Tong Wang
- Mediprobe Research Inc, London, ON, Canada
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Procacci C, Marras L, Maurmo L, Vivanet G, Scalone L, Bertolino G. Antifungal Stewardship in Invasive Fungal Infections, a Systematic Review. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024. [PMID: 38337088 DOI: 10.1007/5584_2024_798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Invasive fungal infections (IFI) are a group of life-threatening diseases associated with significant morbidity, mortality and high healthcare costs. Some modern management programs known as AFS (antifungal stewardship programs) have now been developed. The purpose of this systematic review is to evaluate the different declinations of antifungal stewardship programs (AFPs). METHODS Articles were systematically reviewed using the PRISMA checklist 2020. EMBASE and MEDLINE/PubMED were searched using the term "antifungal stewardship" (2012-2022 data) on 2 January 2023. Eligible studies were those that described an AFS and included an intervention, performance evaluation and outcome measures. RESULTS A total of 22/796 studies were included. Approximately two-thirds (16) were published between 2018 and 2022. 16 (72.7%) stated a minimal complete AFS team. 12 (54.5%) adopted a non-compulsory AFS approach, 6(27.3%) had an Educational AFS and 4(18.2%) a compulsory AFS. Cost analyses of 12 studies showed a decrease for 7 (31.8%) compared to an increase for 5 (22.7%). In terms of outcomes, 18 studies showed a lower (10;45.5%) or the same (8;36.4%) pre-post intervention mortality rate. CONCLUSION AFS programs seem to be related to lower costs and better outcomes and should thus be implemented in tandem with antimicrobial stewardship programs.
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Affiliation(s)
- Cataldo Procacci
- Pharmaceutical Department, ASL BAT, Barletta - Adria - Trani, Italy
| | | | - Leonarda Maurmo
- School of Specialization in Hospital Pharmacy, University of Bari "Aldo Moro", Bari, Italy
| | - Grazia Vivanet
- Unity of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | | | - Giacomo Bertolino
- Pharmaceutical Department, Azienda Ospedaliero-Universitaria di Cagliari, Cagliari, Italy.
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Yamada K, Kakeya H. Status and Challenge of Antifungal Stewardship at the Osaka Metropolitan University Hospital. Med Mycol J 2024; 65:33-38. [PMID: 38825528 DOI: 10.3314/mmj.24.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Antifungal stewardship (AFS), compared with antimicrobial stewardship (AS), requires more advanced knowledge, skills, and multidisciplinary collaboration in its implementation. Therefore, fewer facilities are performing AFS compared with AS. At our hospital, we started AS and AFS in 2014. Our AFS programs include the following: i) interventions for patients with yeast-positive blood cultures, ii) introduction of a conditional antifungal notification system, and iii) commencement of AS team rounds. AFS for filamentous fungi includes bronchoscopy and microbial identification, including genetic and drug susceptibility testing. These AFS activities have improved several processes and outcome measures. However, our AFS team has faced several problems owing to the impact of COVID-19. This review introduces the practice of AFS, which we initiated at our hospital in 2014, and presents the current problems.
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Affiliation(s)
- Koichi Yamada
- Department of Infection Control Science, Graduate School of Medicine, Osaka Metropolitan University
- Department of Infection Control and Prevention, Osaka Metropolitan University Hospital
- Research Center for Infectious Disease Sciences, Graduate School of Medicine, Osaka Metropolitan University
| | - Hiroshi Kakeya
- Department of Infection Control Science, Graduate School of Medicine, Osaka Metropolitan University
- Department of Infection Control and Prevention, Osaka Metropolitan University Hospital
- Research Center for Infectious Disease Sciences, Graduate School of Medicine, Osaka Metropolitan University
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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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Gupta AK, Talukder M, Carviel JL, Cooper EA, Piguet V. Combatting antifungal resistance: Paradigm shift in the diagnosis and management of onychomycosis and dermatomycosis. J Eur Acad Dermatol Venereol 2023; 37:1706-1717. [PMID: 37210652 DOI: 10.1111/jdv.19217] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/26/2023] [Indexed: 05/22/2023]
Abstract
Antifungal resistance has become prevalent worldwide. Understanding the factors involved in spread of resistance allows the formulation of strategies to slow resistance development and likewise identify solutions for the treatment of highly recalcitrant fungal infections. To investigate the recent explosion of resistant strains, a literature review was performed focusing on four main areas: mechanisms of resistance to antifungal agents, diagnosis of superficial fungal infections, management, and stewardship. The use of traditional diagnostic tools such as culture, KOH analysis and minimum inhibitory concentration values on treatment were investigated and compared to the newer techniques such as molecular methods including whole genome sequencing, and polymerase chain reaction. The management of terbinafine-resistant strains is discussed. We have emphasized the need for antifungal stewardship including increasing surveillance for resistant infection.
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Affiliation(s)
- Aditya K Gupta
- Mediprobe Research Inc., London, Ontario, Canada
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mesbah Talukder
- Mediprobe Research Inc., London, Ontario, Canada
- School of Pharmacy, BRAC University, Dhaka, Bangladesh
| | | | | | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Dermatology, Women's College Hospital, Toronto, Ontario, Canada
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Fallas-Mora A, Díaz-Madriz JP, Chaverri-Fernández JM, Zavaleta-Monestel E. Evaluation of Systemic Antifungal Use in a Latin American General Care Hospital: A Retrospective Study. PHARMACY 2023; 11:108. [PMID: 37489339 PMCID: PMC10366784 DOI: 10.3390/pharmacy11040108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/19/2023] [Accepted: 06/23/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Invasive fungal infections significantly contribute to mortality and morbidity rates. Despite the presence of all four major classes of antifungal medications, it is estimated that these infections result in the death of 1.5 million people each year, and death rates are increasing at an alarming rate. With increasing concerns about the emergence of antifungal resistance, there is a growing consideration in many countries to incorporate antifungal stewardship into existing antimicrobial stewardship programs. This approach aims to address issues hindering the appropriate use of antifungal drugs and to optimize their utilization. METHODS An analytical retrospective study of 48 hospitalized patients was conducted to assess factors related to the use of systemic antifungals and develop and implement an internal protocol to improve its use. RESULTS All patients with severe comorbidity had SOFA scores linked with a mortality risk of more than 10%. Based on 48 evaluations of antifungal orders, 62.5% were considered appropriate, 14.6% were considered debatable, and 22.9% were considered inappropriate. Infectious disease physicians made most of the prescriptions considered appropriate in this study. CONCLUSIONS Comorbidities and risk factors in patients receiving systemic antifungals can be associated with the development of more serious fungal infections; hence, the implementation of antifungal stewardship as a complement to antimicrobial stewardship programs can help facilitate decision-making when dealing with a suspected case of fungal infection.
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Affiliation(s)
- Abigail Fallas-Mora
- Pharmacy Department, Hospital Clinica Biblica, San Jose 1307-1000, Costa Rica
- Department of Pharmacology, Toxicology and Pharmacodependence, University of Costa Rica, San Jose 1260-1000, Costa Rica
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Ibrahim SM, Adlan N, Alomair SM, Butaiban I, Alsalman A, Bawazeer A, Alqahtani M, Mohamed D, Emeka PM. Evaluation of Systemic Antifungal Prescribing Knowledge and Practice in the Critical Care Setting among ICU Physicians and Clinical Pharmacists: A Cross-Sectional Study. Antibiotics (Basel) 2023; 12:antibiotics12020238. [PMID: 36830149 PMCID: PMC9952359 DOI: 10.3390/antibiotics12020238] [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: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
Management of invasive fungal infections (IFI) and subsequent treatment choices remain challenging for physicians in the ICU. Documented evidence shows increased practice of the inappropriate use of antifungal agents in the ICU. Continuous education of healthcare providers (HCPs) represents the cornerstone requirement for starting an antifungal stewardship program (AFS). This study aimed at evaluating knowledge gaps in systemic antifungal prescribing among physicians and clinical pharmacists in a critical care setting. A cross-sectional, multi-center, survey-based study was conducted in five tertiary hospitals located in Al-Ahsaa, Saudi Arabia between January and May 2021. A self-administered questionnaire was distributed among the targeted clinicians. A total of 63 clinicians were involved (65.5% ICU physicians and 34.5% clinical pharmacists). It was noted that a minority of the participating HCPs (3.2%) had overall good knowledge about antifungal prescribing, but the majority had either moderate (46%) or poor (50.8%) knowledge. The difference in overall knowledge scores between the ICU physicians and the clinical pharmacists (p = 0.925) was not significant. However, pharmacists showed better scores for the pharmacokinetics of antifungal therapy (p = 0.05). This study has revealed a significant gap in the knowledge and practice of clinicians as regards prescribing antifungal therapy in our area. Although the results cannot be generalized, the outcome of this study has exposed the need for a tailored training program essential for carrying out an AFS program.
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Affiliation(s)
- Sahar Mohamed Ibrahim
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsaa 31982, Saudi Arabia
- Correspondence: (S.M.I.); (P.M.E.)
| | - Nosiyba Adlan
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsaa 31982, Saudi Arabia
| | - Sufyan Mohammed Alomair
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsaa 31982, Saudi Arabia
| | - Ibrahim Butaiban
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsaa 31982, Saudi Arabia
| | - Ahmed Alsalman
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsaa 31982, Saudi Arabia
| | - Abdulmajeed Bawazeer
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsaa 31982, Saudi Arabia
| | - Monahi Alqahtani
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsaa 31982, Saudi Arabia
| | - Dalia Mohamed
- Department of Pharmacy, Almoosa Specialist Hospital, Al-Ahsaa 31982, Saudi Arabia
| | - Promise Madu Emeka
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsaa 31982, Saudi Arabia
- Correspondence: (S.M.I.); (P.M.E.)
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Study of Prescription-Indication of Outpatient Systemic Anti-Fungals in a Colombian Population. A Cross-Sectional Study. Antibiotics (Basel) 2022; 11:antibiotics11121805. [PMID: 36551462 PMCID: PMC9774786 DOI: 10.3390/antibiotics11121805] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022] Open
Abstract
The inappropriate use of antifungals is associated with greater antimicrobial resistance, costs, adverse events, and worse clinical outcomes. The aim of this study was to determine prescription patterns and approved and unapproved indications for systemic antifungals in a group of patients in Colombia. This was a cross-sectional study on indications for the use of systemic antifungals in outpatients from a drug dispensing database of approximately 9.2 million people affiliated with the Colombian Health System. Sociodemographic, pharmacological, and clinical variables were considered. Descriptive, bivariate, and multivariate analyses were performed. A total of 74,603 patients with antifungal prescriptions were identified; they had a median age of 36.0 years (interquartile range: 22.0−53.0 years), and 67.3% of patients were women. Fluconazole (66.5%) was the most prescribed antifungal for indications such as vaginitis, vulvitis, and vulvovaginitis (35.0%). A total of 29.3% of the prescriptions were used in unapproved indications. A total of 96.3% of ketoconazole users used the medication in unapproved indications. Men (OR: 1.91; CI95%: 1.79−2.04), <18 years of age (OR: 1.20; CI95%: 1.11−1.31), from the Caribbean region (OR: 1.26; CI95%: 1.18−1.34), with chronic obstructive pulmonary disease (OR: 1.80; CI95%: 1.27−2.54), prescriptions made by a general practitioner (OR: 1.17; CI95%: 1.04−1.31), receiving comedications (OR: 1.58; CI95%: 1.48−1.69), and the concomitant use of other antimicrobials (OR: 1.77; CI95%: 1.66−1.88) were associated with a higher probability that the antifungal was used for unapproved indications; deep mycosis (OR: 0.49; CI95%: 0.41−0.58), prescribing fluconazole (OR: 0.06; CI95%: 0.06−0.06), and having diabetes mellitus (OR: 0.33; CI95%: 0.29−0.37), cancer (OR: 0.13; CI95%: 0.11−0.16), or HIV (OR: 0.07; CI95%: 0.04−0.09) reduced this risk. Systemic antifungals were mostly used for the management of superficial mycoses, especially at the gynecological level. In addition, more than a quarter of patients received these medications in unapproved indications, and there was broad inappropriate use of ketoconazole.
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Alshehri AF, Almangour TA, Alhifany AA, Alhossan A. Assessment of Caspofungin use at a Tertiary Teaching Hospital and compliance with IDSA guidelines and FDA labeling. Saudi Pharm J 2022; 30:212-216. [PMID: 35498226 PMCID: PMC9051971 DOI: 10.1016/j.jsps.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/27/2021] [Indexed: 12/04/2022] Open
Abstract
Objective The aim of this study is to evaluate the utilization pattern of Caspofungin in an academic tertiary care hospital in Riyadh, Saudi Arabia. Methods This is a retrospective study, conducted at King Saud University Medical City, Riyadh, Saudi Arabia. Adult patients who received Caspofungin from January 2015 to December 2018 were included. The appropriate use of Caspofungin was evaluated according to the international guidelines and approved recommendations. Caspofungin doses were assessed according to the FDA-approved loading and maintenance doses as well as dose-adjustment per hepatic function for cirrhotic patients and drug-drug interactions. Cultures and laboratory tests were used to evaluate the appropriate duration of Caspofungin therapy. Results 388 patients were included. Caspofungin was inappropriately used in 253 (64%) patients. This included 78 (20%) due to inappropriate indication, 165 (42%) due to wrong dosage, and 10 (2%) patients who had a wrong duration of therapy. Conclusion The rate of inappropriate use of Caspofungin was high. Hence, developing antifungal stewardship and drug restriction program is highly recommended.
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Affiliation(s)
- Abrar F. Alshehri
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
- Corresponding author at: College of Pharmacy, Umm Al-Qura University, P.O. Box: 13578, Zip Code: 21955, Saudi Arabia.
| | - Thamer A. Almangour
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah A. Alhifany
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Abdulaziz Alhossan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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13
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Khanina A, Tio SY, Ananda‐Rajah MR, Kidd SE, Williams E, Chee L, Urbancic K, Thursky KA. Consensus guidelines for antifungal stewardship, surveillance and infection prevention, 2021. Intern Med J 2021; 51 Suppl 7:18-36. [DOI: 10.1111/imj.15586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Anna Khanina
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Victoria Australia
| | - Shio Yen Tio
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Victoria Australia
| | - Michelle R. Ananda‐Rajah
- Department of General Medicine Alfred Health Melbourne Victoria Australia
- Department of Infectious Diseases Alfred Health Melbourne Victoria Australia
| | - Sarah E. Kidd
- National Mycology Reference Centre Microbiology and Infectious Diseases, SA Pathology Adelaide South Australia Australia
- School of Biological Sciences University of Adelaide Adelaide South Australia Australia
| | - Eloise Williams
- Department of Microbiology Royal Melbourne Hospital Melbourne Victoria Australia
- Department of Microbiology and Immunology The Peter Doherty Institute for Immunity and Infection, The University of Melbourne Melbourne Parkville Victoria Australia
| | - Lynette Chee
- Department of Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
| | - Karen Urbancic
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
- Pharmacy Department Austin Health Melbourne Victoria Australia
- National Centre for Antimicrobial Stewardship Melbourne Victoria Australia
| | - Karin A. Thursky
- National Centre for Infections in Cancer Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Melbourne Victoria Australia
- National Centre for Antimicrobial Stewardship Melbourne Victoria Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Victorian Infectious Diseases Service The Peter Doherty Institute for Immunity and Infection, Royal Melbourne Hospital Melbourne Victoria Australia
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14
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Aldrees A, Ghonem L, Almajid F, Barry M, Mayet A, Almohaya AM. Evaluating the Inappropriate Prescribing and Utilization of Caspofungin, a Four-Year Analysis at a Teaching Hospital in Saudi Arabia. Antibiotics (Basel) 2021; 10:antibiotics10121498. [PMID: 34943710 PMCID: PMC8698732 DOI: 10.3390/antibiotics10121498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/01/2021] [Accepted: 12/04/2021] [Indexed: 11/16/2022] Open
Abstract
The appropriate use of antimicrobial agents improves clinical outcomes and reduces antimicrobial resistance. Nevertheless, data on inappropriate prescription and negative outcomes are inconsistent. The objective of this study was to assess the prescription appropriateness of Caspofungin at a tertiary teaching hospital in Saudi Arabia and the impact on mortality at 30 days. A retrospective chart review was performed for patients who received Caspofungin from May 2015 to December 2019 to obtain prescription information and culture and susceptibility tests. The appropriateness of the dosage (ApD), initiation time (ApI), agent selection (ApS), and duration of therapy (ApDUR) was evaluated based on recommendations of the infectious diseases society of America. 355 eligible patients who received 3458 Caspofungin doses were identified. Their median age was 54 years (range 18-96). Overall, 270 (76.1%) patients received empirical prescriptions, of which 74.4% had the appropriate dose, and 56.3% had received it for more than five days, despite no proven Candida infection. This was not influenced by past medical history (p = 0.394). Only 39% of patients who received definitive prescriptions met all four study criteria for appropriate prescription. Therefore, antimicrobial stewardship programs can improve the appropriate utilization of antifungal therapies.
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Affiliation(s)
- Abdulwahab Aldrees
- Infectious Disease Unit, College of Medicine and King Saud University Medical City, King Saud University, Riyadh 12372, Saudi Arabia; (A.A.); (F.A.); (M.B.)
- Department of Medicine, Al-Diriyah General Hospital, Ar-Rihab, Ad Diriyah 13717, Saudi Arabia
| | - Leen Ghonem
- Department of Pharmacy, King Saudi University Medical City, Riyadh 11451, Saudi Arabia; (L.G.); (A.M.)
| | - Fahad Almajid
- Infectious Disease Unit, College of Medicine and King Saud University Medical City, King Saud University, Riyadh 12372, Saudi Arabia; (A.A.); (F.A.); (M.B.)
| | - Mazin Barry
- Infectious Disease Unit, College of Medicine and King Saud University Medical City, King Saud University, Riyadh 12372, Saudi Arabia; (A.A.); (F.A.); (M.B.)
| | - Ahmed Mayet
- Department of Pharmacy, King Saudi University Medical City, Riyadh 11451, Saudi Arabia; (L.G.); (A.M.)
| | - Abdulellah M. Almohaya
- Infectious Disease Unit, College of Medicine and King Saud University Medical City, King Saud University, Riyadh 12372, Saudi Arabia; (A.A.); (F.A.); (M.B.)
- Department of Medicine, Al-Diriyah General Hospital, Ar-Rihab, Ad Diriyah 13717, Saudi Arabia
- Correspondence: ; Tel.: +966-11-835-6500
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15
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Wang Y, Van Driel ML, McGuire TM, Hollingworth SA. Trends in systemic antifungal use in Australia, 2005-2016: a time-series analysis. Jpn J Infect Dis 2021; 75:254-261. [PMID: 34588371 DOI: 10.7883/yoken.jjid.2021.505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Data on antifungal utilization trends are important to encourage antifungal stewardship. This study explored the utilization of antifungal agents for systemic use and the impact of reimbursement policy changes in Australia. We analyzed national data from the Australian Pharmaceutical Benefits Scheme (PBS) (2005-2016). We examined patterns of use over time and the impact of reimbursement decisions on antifungal use with an interrupted time-series model. In 2005-2016, there has been an increase in the use of most antifungals, especially fluconazole, itraconazole and posaconazole. Ketoconazole was the most commonly dispensed systemic antifungal (46.0%) before its PBS listing removal, when it was replaced by fluconazole (69.8%). The PBS event "Fluconazole and itraconazole restrictions eased" led to increased use of fluconazole (0.025/1000 per day with no delay). Both the largest rates and numerical increase were among obstetricians and gynecologists (1,969%; 1,851 dispensed prescriptions) and dermatologists (1,723%; 1,689 dispensed prescriptions) except general practitioner (2010-2016). This is the first Australian national longitudinal estimate of systemic antifungal use. It shows an overall increase in prescribing of most antifungals during study period, with reimbursement decisions impacting utilization. These data provide a baseline to inform development of national antifungal guidelines and policies to encourage more targeted antifungal stewardship.
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Affiliation(s)
- Yan Wang
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, China.,School of Pharmacy, University of Queensland, Australia
| | - Mieke L Van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Australia
| | - Treasure M McGuire
- School of Pharmacy, University of Queensland, Australia.,Faculty of Health Sciences & Medicine, Bond University, Australia.,Mater Pharmacy, Mater Health, Australia
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16
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Implementation of Pharmacist-Driven Antifungal Stewardship Program in a Tertiary Care Hospital. Antimicrob Agents Chemother 2021; 65:e0062921. [PMID: 34152808 DOI: 10.1128/aac.00629-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Antifungal stewardship (AFS) is recommended to reduce the inappropriate use of antifungal drugs. In this study, the role of AFS in providing appropriate antifungal therapy was evaluated. This study included three periods, consisting of observation, feedback/education, and daily AFS activities. In the observation period, the use of systemic antifungals was evaluated for a baseline measurement of appropriateness. In the second period, monthly meetings were organized to provide feedback and education to physicians regarding antifungal therapy and the rate of adherence to the clinical guidelines. In the final period, a clinical pharmacist participated in daily ward rounds to evaluate the appropriateness of the antifungal therapy. A scoring system for appropriateness was used for comparison between the three periods. Four hundred eighteen episodes of antifungal therapy were evaluated. Baseline demographics of patients were similar in all three periods for age, gender, and the number of comorbidities. The indications for antifungal use were for prophylaxis in 22.7%, Candida infections in 58.6%, and invasive mold infections in 18.7%. During the third period, 157 (78.9%) recommendations were made and 151 (96.2%) were accepted. The overall appropriateness of antifungal use increased significantly for prophylaxis (30.8%, 17.9%, and 46.3%; P = 0.046) and treatment of fungal diseases (27.8%, 32.4%, and 71.9%; P < 0.001) between the first, second, and third periods, respectively. The 30-day mortality was not significantly changed between the three periods (19%, 15.6%, and 27.5%; P = 0.050). Appropriateness in antifungal therapy can be augmented by the integration of an AFS program. A team-based evaluation of fungal infections and assessment of patients by a clinical pharmacist with a therapeutic perspective may help to increase the quality of antifungal therapy.
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17
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D'Ordine RL, Garcia KA, Roy J, Zhang Y, Markley B, Finkelman MA. Performance characteristics of Fungitell STAT™, a rapid (1→3)-β-D-glucan single patient sample in vitro diagnostic assay. Med Mycol 2021; 59:41-49. [PMID: 32400855 PMCID: PMC7779209 DOI: 10.1093/mmy/myaa028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/26/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023] Open
Abstract
Serum (1→3)-β-D-glucan (BDG), is an adjunct test in the diagnosis of invasive fungal disease (IFD). Fungitell STAT™, a facile, rapid, single patient option, executable for one or more patient specimens in approximately an hour, has been developed to address a need for rapid in-house testing. This method presents qualitative information concerning serum BDG levels, using an index value that allows the rapid categorization of patients as positive, negative, or indeterminate relative to serum BDG titer. The categorical and analytical performance of Fungitell STAT was evaluated. The categorical agreement between methods was established by testing patient samples which had been previously categorized with Fungitell. Receiver Operating Characteristic curves were used to identify cut-offs using 93 de-identified patient specimens. Subsequently, using these cutoffs, an independent group of 488 patient specimens was analyzed. Positive percent agreement (PPA) with, and without, indeterminate results was 74% and 99%, respectively. Negative percent agreement (NPA) was 91% and 98% with, and without, indeterminate results, respectively. Additionally, commercially available normal off-the-clot sera were spiked with Saccharomyces cerevisiae-derived (1→3)-β-D-glucan to produce analytical samples. Analytical reproducibility using spiked samples was excellent with 94% of the CV (coefficient of variation) values ≤10% among three independent laboratories. Good correlation with the predicate method was demonstrated with correlation coefficients of 0.90 or better with patient samples and 0.99 with spiked samples. The Fungitell STAT index assay provides a rapid and suitable method for serum BDG testing.
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Affiliation(s)
| | - Kevin A Garcia
- Associates of Cape Cod, Inc., East Falmouth, Massachusetts, USA
| | - Josee Roy
- Associates of Cape Cod, Inc., East Falmouth, Massachusetts, USA
| | - Yonglong Zhang
- Associates of Cape Cod, Inc., East Falmouth, Massachusetts, USA
| | - Barbara Markley
- Associates of Cape Cod, Inc., East Falmouth, Massachusetts, USA
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18
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Alegria W, Patel PK. The Current State of Antifungal Stewardship in Immunocompromised Populations. J Fungi (Basel) 2021; 7:352. [PMID: 33946217 PMCID: PMC8145600 DOI: 10.3390/jof7050352] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 01/05/2023] Open
Abstract
Inappropriate antifungal use is prevalent and can lead to drug-resistant fungi, expose patients to adverse drug events, and increase healthcare costs. While antimicrobial stewardship programs have traditionally focused on antibiotic use, the need for targeted antifungal stewardship (AFS) intervention has garnered interest in recent years. Despite this, data on AFS in immunocompromised patient populations is limited. This paper will review the current state of AFS in this complex population and explore opportunities for multidisciplinary collaboration.
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Affiliation(s)
- William Alegria
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, 300 Pasteur Drive, Lane 134 L1C36, Stanford, CA 94305, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, CA 94305, USA
| | - Payal K. Patel
- Division of Infectious Diseases, Department of Internal Medicine, Ann Arbor VA Medical Center, Ann Arbor, MI 48105, USA;
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, 2215 Fuller Rd, Ann Arbor, MI 48105, USA
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19
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Khanina A, Cairns KA, Kong DCM, Thursky KA, Slavin MA, Roberts JA. The impact of pharmacist‐led antifungal stewardship interventions in the hospital setting: a systematic review. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2021. [DOI: 10.1002/jppr.1721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Anna Khanina
- Peter MacCallum Cancer Centre The National Centre for Infections in Cancer Melbourne Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Australia
| | | | - David C. M. Kong
- The National Centre for Antimicrobial Stewardship The Peter Doherty Institute for Infection and Immunity Melbourne Australia
- Centre for Medicine Use and Safety Monash Institute of Pharmaceutical SciencesMonash University Parkville Australia
- Ballarat Health Services Parkville Australia
| | - Karin A. Thursky
- Peter MacCallum Cancer Centre The National Centre for Infections in Cancer Melbourne Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Australia
- The National Centre for Antimicrobial Stewardship The Peter Doherty Institute for Infection and Immunity Melbourne Australia
- Department of Medicine University of Melbourne Parkville Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Australia
| | - Monica A. Slavin
- Peter MacCallum Cancer Centre The National Centre for Infections in Cancer Melbourne Australia
- Sir Peter MacCallum Department of Oncology The University of Melbourne Melbourne Australia
- Department of Medicine University of Melbourne Parkville Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Australia
| | - Jason A. Roberts
- Faculty of Medicine The University of Queensland University of Queensland Centre for Clinical Research Brisbane Australia
- Departments of Pharmacy and Intensive Care Medicine Royal Brisbane and Women’s Hospital Brisbane Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine Nîmes University Hospital University of Montpellier Nîmes France
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20
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Johnson MD, Lewis RE, Dodds Ashley ES, Ostrosky-Zeichner L, Zaoutis T, Thompson GR, Andes DR, Walsh TJ, Pappas PG, Cornely OA, Perfect JR, Kontoyiannis DP. Core Recommendations for Antifungal Stewardship: A Statement of the Mycoses Study Group Education and Research Consortium. J Infect Dis 2021; 222:S175-S198. [PMID: 32756879 DOI: 10.1093/infdis/jiaa394] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In recent years, the global public health community has increasingly recognized the importance of antimicrobial stewardship (AMS) in the fight to improve outcomes, decrease costs, and curb increases in antimicrobial resistance around the world. However, the subject of antifungal stewardship (AFS) has received less attention. While the principles of AMS guidelines likely apply to stewarding of antifungal agents, there are additional considerations unique to AFS and the complex field of fungal infections that require specific recommendations. In this article, we review the literature on AMS best practices and discuss AFS through the lens of the global core elements of AMS. We offer recommendations for best practices in AFS based on a synthesis of this evidence by an interdisciplinary expert panel of members of the Mycoses Study Group Education and Research Consortium. We also discuss research directions in this rapidly evolving field. AFS is an emerging and important component of AMS, yet requires special considerations in certain areas such as expertise, education, interventions to optimize utilization, therapeutic drug monitoring, and data analysis and reporting.
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Affiliation(s)
- Melissa D Johnson
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Russell E Lewis
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elizabeth S Dodds Ashley
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, Laboratory of Mycology Research, McGovern Medical School, Houston, Texas, USA
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California, Davis, Sacramento, California, USA
| | - David R Andes
- Department of Medicine and Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases, Weill Cornell Medicine of Cornell University, New York, New York, USA
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Oliver A Cornely
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Centre for Infection Research, partner site Bonn-Cologne, Cologne, Germany.,CECAD Cluster of Excellence, University of Cologne, Cologne, Germany.,Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, MD Anderson Cancer Center, Houston, Texas, USA
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21
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Gupta AK, Venkataraman M, Renaud HJ, Summerbell R, Shear NH, Piguet V. The increasing problem of treatment-resistant fungal infections: a call for antifungal stewardship programs. Int J Dermatol 2021; 60:e474-e479. [PMID: 33729567 DOI: 10.1111/ijd.15495] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 12/14/2022]
Abstract
Antimicrobial stewardship (AMS) programs have been widely recognized among the public health community. These programs focus majorly on bacterial infections, efficient antibiotic use, and measures to curb increasing antibacterial resistance. AMS programs are successfully established around the globe; however, very few include antifungal stewardship (AFS). The increasing incidence of superficial and invasive fungal infections, combined with delayed or inaccurate diagnosis, has contributed to the overprescribing and overuse of antifungal agents. Such increased exposure to antifungal agents may be a reason for the emergence of increasing antifungal resistance among fungal pathogens. With mounting reports of treatment failures and resistant infections, the evidence to support the need for AFS programs is increasing. AFS is an emerging branch of AMS programs that requires global attention and recognition.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Mediprobe Research Inc., London, ON, Canada
| | | | | | - Richard Summerbell
- Sporometrics, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Neil H Shear
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Vincent Piguet
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Dermatology, Women's College Hospital, Toronto, ON, Canada
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22
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Khanina A, Douglas AP, Thursky KA. Implementation of Effective Antifungal Stewardship in Cancer Patients—A Review of Current Evidence. CURRENT FUNGAL INFECTION REPORTS 2020. [DOI: 10.1007/s12281-020-00408-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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23
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Reslan Z, Lindsay J, Kerridge I, Gellatly R. Pharmacist review of high-risk haematology outpatients to improve appropriateness of antifungal prophylaxis. Int J Clin Pharm 2020; 42:1412-1418. [PMID: 33009604 DOI: 10.1007/s11096-020-01090-5] [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: 02/16/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
Abstract
Background Patients with haematological malignancies are at high risk of invasive fungal infections. However, there is a lack of information about the utilisation of the recommended Australian antifungal prophylaxis guidelines in haematology outpatients. Objective To assess the impact of a weekly pharmacist review of high-risk adult haematology outpatients on the utilisation of appropriate antifungal prophylaxis. Setting Outpatient cancer centre, tertiary referral hospital in Sydney, Australia. Method A 3-month pre-and post-interventional study was conducted. A retrospective audit was conducted to obtain baseline utilisation of antifungal guidelines in adult haematology outpatients with acute myeloid leukemia, acute lymphoblastic leukemia and myelodysplastic syndrome receiving chemotherapy. This was followed by a weekly pharmacist review over a 3-month period of all eligible outpatients assessing the appropriateness of antifungal agent, dose, use of therapeutic drug monitoring and presence of drug-interactions/contraindications. Recommendations to physicians were conveyed weekly and outcomes recorded. Main outcome measure Appropriate utilisation of antifungal prophylaxis guidelines in outpatient haematology patients before and after implementation of a 3-month weekly pharmacist review service. Results Forty patients were included in the retrospective group, equating to 348 reviews, while 42 patients equating to 269 reviews were included in the prospective group. Appropriate utilisation of antifungal prophylaxis guidelines increased from 31 to 54% post implementation of a pharmacist review (Odds Ratio = 2.44, 95% Confidence Interval: 1.07-5.58, p = 0.0344). The most common reason for nonadherence to guidelines in both groups was lack of therapeutic drug monitoring and failure to prescribe antifungal prophylaxis where indicated. The percentage of appropriate use of antifungal prophylaxis in patients with acute myeloid leukemia increased from 13 to 46% (p value < 0.01) after pharmacist intervention. The pharmacist made 153 recommendations from 269 reviews, with a percentage uptake of 40%. Moderate to severe drug interactions were identified in 19 reviews from 10 patients. One major azole antifungal-chemotherapy interaction was avoided. Conclusions Appropriate utilisation of antifungal prophylaxis guidelines can be improved through a regular pharmacist review. Future studies should identify whether improving adherence to antifungal guidelines leads to improved patient outcomes.
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Affiliation(s)
- Zainab Reslan
- Pharmacy Department, Royal North Shore Hospital, Level 1 ASB, Reserve Road, Sydney, NSW, Australia. .,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Julian Lindsay
- Hematology and Bone Marrow Transplant Unit, Royal North Shore Hospital, Sydney, NSW, Australia.,National Centre for Infection in Cancer (NCIC), Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Ian Kerridge
- Hematology and Bone Marrow Transplant Unit, Royal North Shore Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health Science, University of Sydney, Sydney, NSW, Australia
| | - Rochelle Gellatly
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
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24
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Mularoni A, Adamoli L, Polidori P, Ragonese B, Gioè SM, Pietrosi A, Tuzzolino F, Guadagnino G, Monaco F, Grossi PA, Conaldi PG, Luca A, Mikulska M. How can we optimise antifungal use in a solid organ transplant centre? Local epidemiology and antifungal stewardship implementation: A single-centre study. Mycoses 2020; 63:746-754. [PMID: 32358860 DOI: 10.1111/myc.13098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE We aimed to implement and to assess the impact of the antifungal stewardship programme (AFSp) on prescription appropriateness of antifungals, management and outcomes of candidaemia patients, and antifungal consumption and costs at our solid organ transplant (SOT) institute. METHODS Local epidemiology of invasive fungal infections (IFIs) from 2009 to 2017 was analysed in order to prepare an effective AFSp, implemented in January 2018. It included suspension of empirical antifungal prescriptions after 72 hours (antifungal time-out), automated alert and infectious disease (ID) consult for empirical prescriptions and for every patient with IFI, and indication for step-down to oral fluconazole when possible. We used process measures and results measures to assess the effects of the implemented programme. RESULTS The ASFp led to significant improvements in selection of the appropriate antifungal (40.5% in pre-AFS vs 78.6% in post-AFS), correct dosing (51.2% vs 79.8%), correct length of treatment (55.9% vs 75%) and better management of patients with candidaemia. Analysis of prescribed empirical antifungal revealed that defined daily doses (DDDs) per 100 patient days decreased by 36.7% in 2018 compared to the average of pre-AFSp period, with important savings in costs. CONCLUSION This AFSp led to a better use of antifungal drugs in terms of appropriateness and consumption, with stable clinical and microbiological outcomes in patients with IFI.
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Affiliation(s)
- Alessandra Mularoni
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Lucia Adamoli
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Piera Polidori
- Clinical Pharmacy Service, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Barbara Ragonese
- Department of Accreditation and Quality, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Santi Mauro Gioè
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Astrid Pietrosi
- Department of Management Control and Decision Support, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Fabio Tuzzolino
- Research Office, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Giuliana Guadagnino
- Department of Infectious and Tropical Diseases, St. Annunziata Hospital, Cosenza, Italy
| | - Francesco Monaco
- Laboratory of Clinical Pathology, Microbiology, and Virology, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Paolo Antonio Grossi
- Clinica delle Malattie Infettive e Tropicali, Università degli Studi dell'Insubria, Varese, Italy
| | - Pier Giulio Conaldi
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Angelo Luca
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Malgorzata Mikulska
- Division of Infectious Diseases, University of Genoa (DISSAL) and Ospedale Policlinico San Martino, Genoa, Italy
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Variability in antifungal stewardship strategies among Society for Healthcare Epidemiology of America (SHEA) Research Network facilities. Infect Control Hosp Epidemiol 2020; 41:585-589. [PMID: 32252846 DOI: 10.1017/ice.2020.76] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To characterize antifungal stewardship among antimicrobial stewardship programs (ASPs) at a diverse range of hospitals and to correlate antifungal stewardship with hospital characteristics. DESIGN Cross-sectional survey. PARTICIPANTS ASP physician and/or pharmacist members at Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) hospitals. METHODS An electronic survey administered August-September 2018 via the SRN to 111 hospitals. The χ2 test was used to test associations between ASP and hospital characteristics and use of antifungal stewardship strategies. RESULTS Of 111 hospitals, 45 (41%) responded; most were academic medical centers (65%) caring for stem-cell patients (73.3%) and solid-organ transplant patients (80.0%). Most hospitals have large, well-established ASPs: 60% had >5 team members and 68.9% had a duration ≥6 years. In 43 hospitals (95.6%), ASPs used antifungal stewardship strategies, most commonly prospective audit and feedback (73.3%) by a pharmacist (71.4%). Half of ASPs (51.1%) created guidelines for invasive fungal infection (IFI) management. Most hospitals (71.1%) offered rapid laboratory tests to diagnose IFI, but polymerase chain reaction (PCR) testing and antifungal susceptibility testing varied. Also, 29 ASPs (64.4%) perform surveillance of antifungal utilization, but only 9 (31%) reported to the CDC National Healthcare Safety Network. ASP size, duration, and presence of transplant populations were not associated with a higher likelihood of using antifungal stewardship strategies (P > .05 for all). CONCLUSIONS The use of antifungal stewardship strategies was high at SRN hospitals, but they mainly involved audit and feedback. ASPs should be encouraged (1) to disseminate guidelines for IFI management, (2) to promote access to laboratory tests for rapid and accurate IFI diagnosis, and (3) to perform surveillance for antifungal utilization with reporting to the CDC.
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Whitney L, Al-Ghusein H, Glass S, Koh M, Klammer M, Ball J, Youngs J, Wake R, Houston A, Bicanic T. Effectiveness of an antifungal stewardship programme at a London teaching hospital 2010-16. J Antimicrob Chemother 2020; 74:234-241. [PMID: 30376118 DOI: 10.1093/jac/dky389] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/24/2018] [Indexed: 12/15/2022] Open
Abstract
Background The need for antifungal stewardship is gaining recognition with increasing incidence of invasive fungal infection (IFI) and antifungal resistance alongside the high cost of antifungal drugs. Following an audit showing suboptimal practice we initiated an antifungal stewardship programme and prospectively evaluated its impact on clinical and financial outcomes. Patients and methods From October 2010 to September 2016, adult inpatients receiving amphotericin B, echinocandins, intravenous fluconazole, flucytosine or voriconazole were reviewed weekly by an infectious diseases consultant and antimicrobial pharmacist. Demographics, diagnosis by European Organization for Research and Treatment of Cancer (EORTC) criteria, drug, indication, advice, acceptance and in-hospital mortality were recorded. Antifungal consumption and expenditure, and candidaemia species and susceptibility data were extracted from pharmacy and microbiology databases. Results A total of 432 patients were reviewed, most commonly receiving AmBisome® (35%) or intravenous fluconazole (29%). Empirical treatment was often unnecessary, with 82% having no evidence of IFI. Advice was given in 64% of reviews (most commonly de-escalating or stopping treatment) and was followed in 84%. Annual antifungal expenditure initially reduced by 30% (£0.98 million to £0.73 million), then increased to 20% above baseline over a 5 year period; this was a significantly lower rise compared with national figures, which showed a doubling of expenditure over the same period. Inpatient mortality, Candida species distribution and rates of resistance were not adversely affected by the intervention. Conclusions Provision of specialist input to optimize antifungal prescribing resulted in significant cost savings without compromising on microbiological or clinical outcomes. Our model is readily implementable by hospitals with high numbers of at-risk patients and antifungal expenditure.
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Affiliation(s)
- Laura Whitney
- Pharmacy Department, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Hasan Al-Ghusein
- Department of Infection, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Stephen Glass
- Department of Infection, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Mickey Koh
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Matthias Klammer
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Jonathan Ball
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Jonathan Youngs
- Department of Infection, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Rachel Wake
- Department of Infection, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Angela Houston
- Department of Infection, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Tihana Bicanic
- Department of Infection, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
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Reslan Z, Lindsay J, Kerridge I, Gellatly R. Adherence to Antifungal Guidelines in Malignant Hematology Patients: A Review of the Literature. J Pharm Technol 2019; 35:270-280. [PMID: 34753155 DOI: 10.1177/8755122519859976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective: To review the published literature assessing adherence rates to antifungal guidelines and reasons for nonadherence in the adult malignant hematology inpatient setting. Data sources: The databases Embase, MEDLINE, and PubMed (from data inception to May 2019) were searched using the terms hematology, oncology, antifungal, guidelines, adherence, and stewardship with the search limited to adult human subjects and published in English. This yielded 123 articles. From this list, studies that were published in peer-reviewed journals were extracted, leaving 10 citations that met the final inclusion criteria. Study Selection and Data Extraction: Ten studies were selected assessing adherence to consensus antifungal guidelines in the malignant hematology setting. These included studies investigating the introduction of antifungal stewardship programs in tertiary hospitals. Data Synthesis: Although the studies were heterogeneous, all focused on appropriateness of antifungal therapy in the inpatient setting. Adherence to antifungal guidelines for optimal antifungal prophylaxis and treatment was low in most studies, with rates of inappropriate antifungal therapy ranging from 25% to 70% of fungal prescriptions. Relevance to Patient Care and Clinical Practice: Adherence rates with guidelines for antifungal therapy are low in the hematology inpatient setting. This may affect infection rates influencing morbidity and mortality in this high-risk population. Conclusion: Given the prevalence of invasive fungal infections in malignant hematology inpatients, suboptimal adherence with antifungal guidelines is concerning. This demands a focus on education, antifungal stewardship, and updating guidelines to meet real-world scenarios. Adherence with antifungal guidelines in the outpatient hematology setting is unknown and requires further research.
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Affiliation(s)
- Zainab Reslan
- Royal North Shore Hospital, Sydney, New South Wales, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Julian Lindsay
- Royal North Shore Hospital, Sydney, New South Wales, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Ian Kerridge
- Royal North Shore Hospital, Sydney, New South Wales, Australia.,University of Sydney, New South Wales, Australia
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Capoor MR, Subudhi CP, Collier A, Bal AM. Antifungal stewardship with an emphasis on candidaemia. J Glob Antimicrob Resist 2019; 19:262-268. [DOI: 10.1016/j.jgar.2019.05.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/23/2019] [Accepted: 05/31/2019] [Indexed: 12/28/2022] Open
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Abstract
PURPOSE OF REVIEW To outline key drivers and components of antifungal stewardship (AFS) programmes, the evidence for specific interventions, and methods to assess performance of programmes. RECENT FINDINGS Recent developments in antifungal resistance and breakthrough invasive fungal diseases have increased the urgency for effective AFS. In practice, however, few hospitals have dedicated AFS programmes. To date, AFS programmes have centred around the provision of expert bedside reviews and have reduced costs and consumption of antifungal agents. Incorporating tools such as fungal diagnostics and therapeutic drug monitoring into AFS programme models is recommended. However, the application and impact of these tools in this context have not been adequately assessed. The effectiveness of AFS programmes has been measured in multiple ways but a standardized method of evaluation remains elusive. Few studies have explored the impact of AFS interventions on patient outcomes. SUMMARY The uptake of formal AFS programmes has been slow. New initiatives integrating AFS tools in programmes, and measuring the impacts on patient outcomes are required given such data are not readily available. A comprehensive approach to evaluate AFS programmes by correlating the quantity and quality of antifungal prescribing with impacts on patient outcomes is needed. Consensus definitions for core AFS metrics are required to benchmark performance and are essential to the resourcing and sustainability of these programmes.
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Wang Y, McGuire TM, Hollingworth SA, Dong Y, Van Driel ML. Antifungal agents for invasive candidiasis in non-neutropenic critically ill adults: What do the guidelines recommend? Int J Infect Dis 2019; 89:137-145. [PMID: 31639522 DOI: 10.1016/j.ijid.2019.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/07/2019] [Accepted: 10/13/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Recommendations in clinical practice guidelines (CPG) may differ and cause confusion. Our objective was to appraise CPGs for antifungal treatment of invasive candidiasis (IC) in non-neutropenic critically ill adult patients. METHODS We systematically searched the literature for CPGs published between 2008 and 2018. We assessed the quality of each guideline using six domains of the AGREE II instrument. We extracted and compared recommendations for different treatment strategies and assessed content quality. RESULTS Of 19 guidelines, the mean overall AGREE II score was 58%. The domain 'clarity of presentation' received the highest scores (88%) and 'applicability' the lowest (18%). CPGs provided detailed recommendations on antifungal prophylaxis (n = 10), with fluconazole recommended as initial prophylaxis in all seven CPGs citing a specific drug. Echinocandin was recommended as the initial drug in all 16 CPGs supporting empirical/pre-emptive treatment; and in 18 of 19 for targeted invasive candidiasis treatment. However, it remains unclear when to initiate prophylaxis, empirical or pre-emptive therapy or when to step down. CONCLUSIONS The methodological quality of CPGs for antifungal treatment of IC in non-neutropenic critically ill patients is suboptimal. Some treatment recommendations were inconsistent across indications and require local guidance to help clinicians make better informed decisions.
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Affiliation(s)
- Yan Wang
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia.
| | - Treasure M McGuire
- School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia; Faculty of Health Sciences & Medicine, Bond University, Robina, Queensland, Australia; Mater Pharmacy, Mater Health, Brisbane, Queensland, Australia.
| | | | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Mieke L Van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Herston, Queensland, Australia.
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Hart E, Nguyen M, Allen M, Clark CM, Jacobs DM. A systematic review of the impact of antifungal stewardship interventions in the United States. Ann Clin Microbiol Antimicrob 2019; 18:24. [PMID: 31434563 PMCID: PMC6702721 DOI: 10.1186/s12941-019-0323-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/14/2019] [Indexed: 12/19/2022] Open
Abstract
Background Antimicrobial resistance is a widely recognized public health threat, and stewardship interventions to combat this problem are well described. Less is known about antifungal stewardship (AFS) initiatives and their influence within the United States. The purpose of this study was to evaluate evidence on the impact of AFS interventions on clinical and performance measures. Methods A systematic review of English language studies identified in the PubMed and EMBASE databases was performed through November 2017. The review was conducted in accordance with PRISMA. Search terms included antifungal stewardship, antimicrobial stewardship, Candida, candidemia, candiduria, and invasive fungal disease. Eligible studies were those that described an AFS program or intervention occurring in the US and evaluated clinical or performance measures. Results Fifty-four articles were identified and 13 were included. Five studies evaluated AFS interventions and reported clinical outcomes (mortality and length of stay) and performance measures (appropriate antifungal choice and time to therapy). The remaining eight studies evaluated general stewardship interventions and reported data on antifungal consumption. All studies were single center, quasi-experimental with varying interventions across studies. AFS programs had no impact on mortality (3 of 3 studies), with an overall rate of 27% in the intervention group and 23% in the non-intervention group. Length of stay (5 of 5) was also similar between groups (range, 9–25 vs. 11–22). Time to antifungal therapy improved in 2 of 5 studies, and appropriate choice of antifungal increased in 2 of 2 studies. Antifungal consumption was significantly blunted or reduced following stewardship initiation (8 of 8), although a direct comparison between studies was not possible due to a lack of common units. Conclusion The available evidence suggests that AFS interventions can improve performance measures and decrease antifungal consumption. Although this review did not detect improvements in clinical outcomes, significant adverse outcomes were not reported.
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Affiliation(s)
- Emily Hart
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Melanie Nguyen
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Meghan Allen
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Collin M Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - David M Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA.
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Einav S, Raveh D, Lachish T, Baumstarck K, Martin C, Martin-Loeches I, Leone M. Candida Prophylaxis and Treatment in Critically Ill Patients after Abdominal Surgery: A Survey of Practice. Surg Infect (Larchmt) 2019; 20:510-518. [PMID: 31099715 DOI: 10.1089/sur.2018.267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Purpose: To survey current intensive care unit (ICU) practice in initiating antifungal therapy for prophylaxis and treatment of suspected candidiasis after abdominal surgery. The goal was to establish the need to prioritize research toward standardized care of such patients. Methods: Online questionnaire survey of clinical practice based on theoretical case scenarios. These were structured with expert input to investigate management of: hemodynamically stable/unstable patient after urgent upper/lower gastrointestinal surgery with/without fungal growth in culture. The link to the survey was sent to all active members of the European Society of Intensive Care Medicine (ESICM). Results: The survey was completed by 101 respondents from 29 countries. Fewer than half (48.5%) stated that in their center, ICU antibiotic and antifungal therapy is managed by a dedicated specialist physician/team that manages all ICU patients. Respondents exhibited a greater tendency toward administering antifungal agents, mainly fluconazole, to hemodynamically unstable patients. One week after surgery for a perforated duodenal ulcer, only half responded they would use antifungal agents when a patient develops septic shock. Most respondents chose to administer antifungal therapy in patients with septic shock if Candida had been identified in any culture. The source of infection, location of surgery, or type of Candida were not viewed as triggers for therapeutic decisions. Conclusion: The current survey demonstrates large variability in antifungal use. Decisions are made irrespective of existing guidelines and seem to be driven by patient hemodynamic condition and identification of any Candida in any culture alone.
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Affiliation(s)
- Sharon Einav
- 1General and Surgical Intensive Care Unit, Shaare Zedek Medical Centre and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - David Raveh
- 2Infectious Diseases Unit, Shaare Zedek Medical Centre, Jerusalem, Israel
| | - Tamar Lachish
- 3Infectious Diseases Unit, Shaare Zedek Medical Centre and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Karine Baumstarck
- 4Maladies Chroniques et Qualité de Vie, School of Medicine, Aix Marseille Université, Marseille, France
| | - Claude Martin
- 5Service d'Anesthésie et de Réanimation, Chemin des Bourrely, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Ignacio Martin-Loeches
- 6Multidisciplinary Intensive Care, St. James's University Hospital, Department of Clinical Medicine, Trinity College, Wellcome Trust-HRB Clinical Research Facility, St. James Hospital, Dublin, Ireland
| | - Marc Leone
- 5Service d'Anesthésie et de Réanimation, Chemin des Bourrely, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
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Abstract
Candida infections in the elderly are an important and expanding clinical problem, with significantly higher mortality in this group than in younger patients. The increasing problem of invasive Candida infections may be related to higher prevalence of immunocompromised older people and the emergence of treatment resistance. Older people, especially the frail and critically ill, are at higher risk of medication-related harmful effects due to changes in pharmacokinetics and pharmacodynamics, which may be further complicated by organ dysfunction, diminished homeostatic control, co-morbidities and polypharmacy. Here, we review the available options for the treatment of Candida infections and provide insights into the challenges surrounding the optimal use of antifungal drugs in the elderly.
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Lachenmayr SJ, Berking S, Horns H, Strobach D, Ostermann H, Berger K. Antifungal treatment in haematological and oncological patients: Need for quality assessment in routine care. Mycoses 2018; 61:464-471. [PMID: 29575106 DOI: 10.1111/myc.12768] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 02/27/2018] [Accepted: 03/11/2018] [Indexed: 11/30/2022]
Abstract
Invasive fungal infections in haematological and oncological patients have a major impact on morbidity, mortality and treatment costs. Therefore, rational use of antifungal agents is important for optimal patient care and resource use. The study's objective was to analyse antifungal usage in a German tertiary teaching hospital, department of haematology and oncology, to evaluate quality of antifungal treatment and to assess the need for an antifungal stewardship programme. This retrospective observational study included patients ≥18 years receiving systemic antifungals for prophylaxis or therapy of invasive fungal infection between January and June 2016. Appropriateness of antifungal prescriptions was evaluated in accordance with guidelines of the German Society of Haematology and Oncology (DGHO) and drug labelling. In total, 104/1278 (8.1%) patients received antifungals. One hundred seventy-one antifungals were prescribed: 48 for prophylaxis, 104 for empirical and 19 for targeted therapy. In 127 (74.3%) prescriptions, indication was appropriate, and in 132 (77.2%), choice of drug. Antifungals were correctly dosed in 131 prescriptions (76.6%). Thirty-four antifungals (20.0%) were co-administrated with interacting drugs (5 mild to moderate, 29 severe interactions). Results of this analysis demonstrate that use of systemic antifungals in routine care differs in a substantial number of patients from guideline and labelling recommendations. To optimise antifungal use, the implementation of antifungal stewardship programmes seems to be justified.
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Affiliation(s)
- Sarah J Lachenmayr
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany.,Department of Pharmacy, University Hospital of Munich, Munich, Germany
| | - Sophie Berking
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany
| | - Heidi Horns
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany
| | - Dorothea Strobach
- Department of Pharmacy, University Hospital of Munich, Munich, Germany
| | - Helmut Ostermann
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany
| | - Karin Berger
- Department of Haematology/Oncology, University Hospital of Munich, Munich, Germany
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O'Leary RA, Einav S, Leone M, Madách K, Martin C, Martin-Loeches I. Management of invasive candidiasis and candidaemia in critically ill adults: expert opinion of the European Society of Anaesthesia Intensive Care Scientific Subcommittee. J Hosp Infect 2018; 98:382-390. [DOI: 10.1016/j.jhin.2017.11.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/29/2017] [Indexed: 12/27/2022]
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Murakami M, Komatsu H, Sugiyama M, Ichikawa Y, Ide K, Tsuchiya R, Kunieda K, Magishi A, Akiyama G, Miura F, Okada K, Ikezoe M. Antimicrobial stewardship without infectious disease physician for patients with candidemia: A before and after study. J Gen Fam Med 2018; 19:82-89. [PMID: 29744261 PMCID: PMC5931350 DOI: 10.1002/jgf2.159] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/23/2018] [Indexed: 11/28/2022] Open
Abstract
Background Little is known about the effects of antimicrobial stewardship team (AST) without infectious disease physician (IDP) on clinical outcome in patients with candidemia. Methods We conducted a before and after study involving patients with hospital‐acquired candidemia at a tertiary hospital without IDPs. The AST consisted of physicians, pharmacists, nurse, microbiologist, and administrative staff. A candidemia care bundle was developed based on the Infectious Disease Society of America (IDSA) guideline. The non‐IDP AST provided recommendations to the attending physicians whose patients developed candidemia during hospitalization. The primary outcome was 30‐day all‐cause mortality, while the secondary outcomes were adherence to the IDSA guidelines regarding the management of candidemia. Data of up to 3 years of preintervention and 3 years of intervention period were analyzed. Results By 30 days, 11 of 46 patients (23.9%) in the intervention group and 7 of 30 patients (23.3%) in the preintervention group died (adjusted hazard ratio for the intervention group: 0.68 [95% CI 0.24‐1.91]). The non‐IDP AST was associated with appropriate empirical antifungal therapy (100% vs 60.0%; proportion ratio 1.67 [95% CI 1.24‐2.23]), appropriate duration of treatment (84.7% vs 43.3%; 1.96 [1.28‐3.00]), removal of central venous catheters (94.4% vs 70.8%; 1.33 [1.02‐1.74]), and ophthalmological examination (93.5% vs 63.3%; 1.48 [1.12‐1.96]). Conclusions Although we found no significant difference in 30‐day mortality, the non‐IDP AST was associated with improved adherence to guidelines for management of candidemia.
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Affiliation(s)
| | | | | | - Yuhei Ichikawa
- Department of Pharmacy Saku Central Hospital Nagano Japan
| | - Kyoko Ide
- Department of Microbiology Saku Central Hospital Nagano Japan
| | - Rumi Tsuchiya
- Department of Nursing Saku Central Hospital Nagano Japan
| | - Kenji Kunieda
- Department of Gastroenterology Saku Central Hospital Nagano Japan
| | - Akiko Magishi
- Department of Surgery Saku Central Hospital Nagano Japan
| | - Gaku Akiyama
- Department of Surgery Saku Central Hospital Nagano Japan
| | - Fumihide Miura
- Department of Ophthalmology Saku Central Hospital Nagano Japan
| | - Kunihiko Okada
- Department of Emergency and Critical Care Medicine Saku Central Hospital Nagano Japan
| | - Masaya Ikezoe
- Department of Nephrology Saku Central Hospital Nagano Japan
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Colombo AL, de Almeida Júnior JN, Slavin MA, Chen SCA, Sorrell TC. Candida and invasive mould diseases in non-neutropenic critically ill patients and patients with haematological cancer. THE LANCET. INFECTIOUS DISEASES 2017; 17:e344-e356. [PMID: 28774702 DOI: 10.1016/s1473-3099(17)30304-3] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 01/06/2017] [Accepted: 03/07/2017] [Indexed: 12/11/2022]
Abstract
Critically ill patients and patients with haematological cancer are HIV-negative populations at high risk of invasive fungal infections. In intensive-care units, candidaemia and intra-abdominal candidiasis predominate, but aspergillosis has emerged as a lethal, under-recognised cause of pneumonia. In patients with haematological malignancies or who have undergone stem-cell transplantations, pulmonary disease due to aspergillus and other mould diseases predominate. In this Series paper, we provide an update on risk assessment, new diagnostic strategies, and therapeutic approaches. New concepts have emerged for use of risk prediction rules and an evidence base now exists for inclusion of biomarkers (eg, galactomannan, 1,3-β-D-glucan, and PCR assays for Aspergillus spp) into early diagnostic and therapeutic strategies. Imaging techniques remain helpful for early diagnosis of pulmonary mould diseases, with PET techniques offering potential improvements in diagnostic specificity and evaluation of clinical response. Echinocandins and triazoles have been validated extensively for prophylaxis, empirical therapy, and targeted therapy, but an increase in intrinsically resistant fungi and emergence of secondary resistance as a result of drug-induced selection pressure are of major concern. Echinocandins remain a major component of treatment of invasive candidiasis and new triazoles are the best alternative for prophylaxis and therapy of invasive aspergillosis.
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Affiliation(s)
- A L Colombo
- Department of Medicine, Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
| | - J N de Almeida Júnior
- Central Laboratory Division (LIM03) and Laboratory of Medical Mycology (LIM53), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Center, Melbourne, VIC, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute, Melbourne, VIC, Australia
| | - Sharon C-A Chen
- The Center for Infectious Diseases and Microbiology Laboratory Services, ICPMR Pathology West, New South Wales Health Pathology, Westmead and Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Westmead, NSW, Australia
| | - Tania C Sorrell
- Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney and Westmead Institute for Medical Research, Westmead, NSW, Australia
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Dong WH, Zhang GZ, Li JX, Wang Y, Wang TT, Dong YL. Development of indicators for evaluating the appropriate use of triazoles for invasive fungal disease: A Delphi panel survey. J Clin Pharm Ther 2017; 42:720-732. [PMID: 28597467 DOI: 10.1111/jcpt.12570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 05/09/2017] [Indexed: 01/05/2023]
Affiliation(s)
- W. H. Dong
- Department of Pharmacy; The First Affiliated Hospital of Xi'an Jiaotong University; Xi'an China
| | - G. Z. Zhang
- Department of Pharmacy; Xi'an NO.4 Hospital; Xi'an China
| | - J. X. Li
- Department of Pharmacy; The First Affiliated Hospital of Xi'an Jiaotong University; Xi'an China
| | - Y. Wang
- Department of Pharmacy; The First Affiliated Hospital of Xi'an Jiaotong University; Xi'an China
| | - T. T. Wang
- Department of Pharmacy; The First Affiliated Hospital of Xi'an Jiaotong University; Xi'an China
| | - Y. L. Dong
- Department of Pharmacy; The First Affiliated Hospital of Xi'an Jiaotong University; Xi'an China
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Fitzpatrick MA, Suda KJ, Evans CT, Hunkler RJ, Weaver F, Schumock GT. Influence of drug class and healthcare setting on systemic antifungal expenditures in the United States, 2005-15. Am J Health Syst Pharm 2017; 74:1076-1083. [PMID: 28522642 DOI: 10.2146/ajhp160943] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Overall and specific class trends in systemic antifungal expenditures in various U.S. healthcare settings from 2005 through 2015 were evaluated. METHODS Systemic antifungal expenditures from January 1, 2005, through December 31, 2015, were obtained from the QuintilesIMS National Sales Perspective database, which provides a statistically valid projection of medication purchases from multiple markets throughout the United States. Summary data for total antifungal expenditures over the entire period are reported, as are growth and the percentage change in expenditures from one year to the next. Expenditures were also assessed specifically by year, class, and healthcare setting. Expenditure trends over the study period were assessed using simple linear trend regression models. RESULTS Overall expenditures for the 11-year period were $9.37 billion. The greatest proportion of expenditures occurred in nonfederal hospitals (47.2%) and for triazoles (57.6%). From 2005 through 2015, total expenditures decreased from $1.1 billion to $894 million (-18.8%, p = 0.09); however, expenditures in clinics and retail pharmacies increased (202%, p < 0.01, and 13.8%, p = 0.04, respectively), a trend most pronounced after 2012. Expenditures for flucytosine also increased (968.1%, p < 0.01), particularly in clinics where there was a dramatic 6,640.9% increase (p < 0.01). CONCLUSION From 2005 through 2015, an increase in systemic antifungal expenditures was observed in community settings, despite an overall decrease in total antifungal expenditures in the United States. Large increases in flucytosine expenditures were observed, particularly in the community.
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Affiliation(s)
- Margaret A Fitzpatrick
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, and Department of Medicine, Division of Infectious Diseases, Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Katie J Suda
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, and Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago College of Pharmacy, Chicago, IL
| | - Charlesnika T Evans
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, and Department of Preventive Medicine, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Frances Weaver
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, IL, and Department of Public Health Sciences, Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Glen T Schumock
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL
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Poulat C, Nivoix Y, Launoy A, Lutun P, Bachellier P, Rohr S, Woehl ML, Levêque D, Bru V, Herbrecht R, Gourieux B. Assessment of high-priced systemic antifungal prescriptions. Med Mal Infect 2017; 47:382-388. [PMID: 28412043 DOI: 10.1016/j.medmal.2017.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 06/17/2016] [Accepted: 03/10/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess compliance with international guidelines for costly antifungal prescriptions and to compare these results with a first study performed in 2007. METHODS Retrospective study including all costly antifungal prescriptions made in surgical and medical intensive care units and in a hepatobiliary, pancreatic, and digestive surgery unit. Prescriptions were assessed in terms of indication, dosage, and antifungal de-escalation. RESULTS Seventy-four treatments were analyzed. Treatments were prescribed for prophylactic (1%), empirical (22%), pre-emptive (16%), or targeted therapy (61%). Caspofungin accounted for 68% of prescriptions, followed by voriconazole (20%) and liposomal amphotericin B (12%). Indication was appropriate in 91%, debatable in 1%, and inappropriate in 8%. Dosage was appropriate in 69%, debatable in 8%, and inappropriate in 23%. Prescriptions were inappropriate for the following reasons: lack of dosage adjustment in light of the hepatic function (10 cases), underdosage or excessive dosage by>25% of the recommended dose in seven cases. De-escalation to fluconazole was implemented in 40% of patients presenting with a fluconazole-susceptible candidiasis. CONCLUSION The overall incidence of appropriate use was higher in 2012 compared with 2007 (62% and 37% respectively, P=0.004). Nevertheless, costly antifungal prescriptions need to be optimized in particular for empirical therapy, dosage adjustment, and potential de-escalation to fluconazole.
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Affiliation(s)
- C Poulat
- Pharmacy, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
| | - Y Nivoix
- Pharmacy, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France.
| | - A Launoy
- Surgical Intensive Care Department, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
| | - P Lutun
- Medical Intensive Care Department, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
| | - P Bachellier
- Hepatobiliary, Pancreatic and Digestive Surgery Department, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
| | - S Rohr
- Hepatobiliary, Pancreatic and Digestive Surgery Department, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
| | - M-L Woehl
- Hepatobiliary, Pancreatic and Digestive Surgery Department, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
| | - D Levêque
- Pharmacy, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
| | - V Bru
- Institut de parasitologie et de pathologie tropicale, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
| | - R Herbrecht
- Oncology and Hematology Department, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
| | - B Gourieux
- Pharmacy, hôpitaux universitaires de Strasbourg, université de Strasbourg, 67098 Strasbourg, France
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Muñoz P, Bouza E. The current treatment landscape: the need for antifungal stewardship programmes. J Antimicrob Chemother 2016; 71:ii5-ii12. [DOI: 10.1093/jac/dkw391] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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de Souza MCP, dos Santos AG, Reis AMM. Drug utilization study of systemic antifungal agents in a Brazilian tertiary care hospital. Int J Clin Pharm 2016; 38:1398-1406. [DOI: 10.1007/s11096-016-0382-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 09/27/2016] [Indexed: 11/25/2022]
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de Souza MCP, Santos AGD, Reis AMM. Adverse Drug Reactions in Patients Receiving Systemic Antifungal Therapy at a High-Complexity Hospital. J Clin Pharmacol 2016; 56:1507-1515. [PMID: 27198583 DOI: 10.1002/jcph.772] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/07/2016] [Accepted: 05/14/2016] [Indexed: 11/06/2022]
Abstract
The aim of the present study was to determine the frequency of adverse drug reactions (ADRs) associated with the use of systemic antifungal drugs in patients hospitalized at a high-complexity hospital. In addition, factors associated with ADRs were investigated. This cross-sectional retrospective study involved the investigation of 183 medical records of patients receiving systemic antifungal therapy. Antifungal drugs were classified using the fourth level of the Anatomical Therapeutic Chemical System. ADR causality was classified using the Naranjo algorithm. Drug interactions were assessed using DRUG-REAX software. Data were analyzed with descriptive statistics and univariate and multivariate logistic regression. A total of 53 patients (29.0%) had at least 1 ADR involving antifungals. Ninety-six ADRs were detected. The main ADRs observed were an infusion reaction in 24 patients (25.0%), hypokalemia in 22 (22.9%), nephrotoxicity in 18 (18.7%), and hepatotoxicity in 15 (15.6%). Amphotericin B and voriconazole were associated with ADRs of major clinical impact. Eleven of the ADRs (11.4%) were related to drug interactions. The following 3 factors were contributors to the multivariate model for the occurrence of ADRs caused by antifungal drug use: neoplasm diagnosis (odds ratio [OR], 3.9; 1.9-7.9), length of hospital stay (OR, 2.2; 1.1-4.5), and the use of ≥13 drugs (OR, 3.4; 1.6-7.2). Our study revealed positive associations between the occurrence of ADRs and diagnosis of a neoplasm, the length of stay, and the use of multiple drugs concomitant with antifungals. These risk factors should be considered in antifungal stewardship, among other actions, to promote the rational use of antifungal agents.
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Affiliation(s)
- Maria Clara Padovani de Souza
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
| | - Andrezza Gouvêa Dos Santos
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
| | - Adriano Max Moreira Reis
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.,Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
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Antifungal Stewardship: an Emerging Practice in Antimicrobial Stewardship. CURRENT CLINICAL MICROBIOLOGY REPORTS 2016. [DOI: 10.1007/s40588-016-0039-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Muñoz P, Valerio M, Vena A, Bouza E. Antifungal stewardship in daily practice and health economic implications. Mycoses 2016; 58 Suppl 2:14-25. [PMID: 26033252 DOI: 10.1111/myc.12329] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 03/31/2015] [Accepted: 04/01/2015] [Indexed: 11/26/2022]
Abstract
During recent years, inappropriate antifungal use has contributed to the global increase in antifungal resistance and has played a role in the shift in the aetiology of invasive fungal infections. Moreover, overuse of antifungals may also lead to higher toxicity associated with unnecessary medication exposure and to increased healthcare costs. Antifungal stewardship (AFS) programmes consist of multidisciplinary interventions, led by specialists in infectious disease, microbiology and pharmacy that cooperate and communicate with the major prescribing departments in order to optimise antifungal therapies evaluating the indication, dose, streamlining and duration. Herein, we review the available evidence for the use of AFS and their impact on health economics. We also describe our AFS program, the successive steps we followed and the main difficulties we found.
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Affiliation(s)
- Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Department of Medicine, Complutense University of Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - Antonio Vena
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Department of Medicine, Complutense University of Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Department of Medicine, Complutense University of Madrid, Madrid, Spain.,Instituto de Investigación Sanitaria del Hospital Gregorio Marañón, Madrid, Spain
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Gedik H. The expenditures related to the use of antifungal drugs in patients with hematological cancers: a cost analysis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:537-43. [PMID: 26622185 PMCID: PMC4639477 DOI: 10.2147/ceor.s92455] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Objective The aim of this study is to analyze the expenditures related to the use of antifungal drugs in patients with hematological malignancies. Methods In this retrospective study, the expenditures related to use of antifungal drugs for treatment of invasive fungal infections in patients with hematological malignancies between November 2010 and November 2012 were analyzed. Expenditures of antifungal drugs were calculated by converting the price billed to the Republic of Turkey Social Security Institution per patient using the US dollar ($) exchange rate. Results We retrospectively analyzed the expenditures related to the use of antifungal drugs in 282 febrile episodes of 126 neutropenic patients. Voriconazole (VOR), caspofungin, and liposomal amphotericin B (L-AmB) were administered as a first-line antifungal therapy to treat 72 febrile episodes of 65 neutropenic patients, 45 febrile episodes of 37 neutropenic patients, and 34 febrile episodes of 32 neutropenic patients, respectively. The expenditures related to the use of antifungal drugs per febrile neutropenic episode were $3,857.85 for VOR; $15,783.34 for caspofungin, and $21,561.02 for L-AmB, respectively. The expenditure related to the use of posaconazole (POS) was $32,167.39 per patient for primary or secondary prophylaxis. Conclusion Improving conditions in the patient’s room, choosing pre-emptive antifungal treatment instead of empirical antifungal treatment, switching to tablet form of VOR after initiation of its intravenous form, secondary prophylaxis with VOR against invasive aspergillosis, primary prophylaxis with POS in high-risk patients, and choosing less L-AmB as being an alternative to other antifungal drugs, may reduce expenditures related to the use of antifungal drugs in the treatment of invasive fungal infections during febrile neutropenic episodes of patients with hematological malignancies.
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Affiliation(s)
- Habip Gedik
- Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Okmeydanı Training and Research Hospital, Istanbul, Turkey
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Pfaller MA, Castanheira M. Nosocomial Candidiasis: Antifungal Stewardship and the Importance of Rapid Diagnosis. Med Mycol 2015; 54:1-22. [PMID: 26385381 DOI: 10.1093/mmy/myv076] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/20/2015] [Indexed: 01/12/2023] Open
Abstract
Candidemia and other forms of candidiasis are associated with considerable excess mortality and costs. Despite the addition of several new antifungal agents with improved spectrum and potency, the frequency of Candida infection and associated mortality have not decreased in the past two decades. The lack of rapid and sensitive diagnostic tests has led to considerable overuse of antifungal agents resulting in increased costs, selection pressure for resistance, unnecessary drug toxicity, and adverse drug interactions. Both the lack of timely diagnostic tests and emergence of antifungal resistance pose considerable problems for antifungal stewardship. Whereas antifungal stewardship with a focus on nosocomial candidiasis should be able to improve the administration of antifungal therapy in terms of drug selection, proper dose and duration, source control and de-escalation therapy, an important parameter, timeliness of antifungal therapy, remains a victim of slow and insensitive diagnostic tests. Fortunately, new proteomic and molecular diagnostic tools are improving the time to species identification and detection. In this review we will describe the potential impact that rapid diagnostic testing and antifungal stewardship can have on the management of nosocomial candidiasis.
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Affiliation(s)
- Michael A Pfaller
- T2Biosystems, Lexington, Massachusetts JMI Laboratories, North Liberty, Iowa University of Iowa College of Medicine College of Public Health, Iowa City, Iowa
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Hasseine L, Cassaing S, Robert-Gangneux F, Fillaux J, Marty P, Gangneux JP, Sirvent A, Mondain V, Hyvernat H, Rosenthal E, Cointault O, Lavayssière L, Georges B, Berry A, de Guibert S, Nimubona S, Revest M, Tattevin P. High negative predictive value diagnostic strategies for the reevaluation of early antifungal treatment: A multicenter prospective trial in patients at risk for invasive fungal infections. J Infect 2015; 71:258-65. [DOI: 10.1016/j.jinf.2015.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 03/09/2015] [Accepted: 04/10/2015] [Indexed: 11/25/2022]
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50
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Gedik H, Şimşek F, Yıldırmak T, Kantürk A, Arıca D, Aydın D, Demirel N, Yokuş O. Novel antifungal drugs against fungal pathogens: do they provide promising results for treatment? Indian J Hematol Blood Transfus 2015; 31:196-205. [PMID: 25825558 PMCID: PMC4375158 DOI: 10.1007/s12288-014-0370-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 03/06/2014] [Indexed: 01/19/2023] Open
Abstract
The febrile neutropenia episodes of hematological patients and their outcomes were evaluated with respect to fungal pathogens and antifungal therapy in this retrospective study. All patients, who were older than 14 years of age and developed at least one neutropenic episode after chemotherapy due to hematological cancer from November 2010 to November 2012, were included into the study. We retrospectively collected demographic, treatment, and survival data of 126 patients with neutropenia and their 282 febrile episodes. The mean Multinational Association for Supportive Care in Cancer score was 17.18 ± 8.27. Systemic antifungal drugs were initiated in 22 patients with 30 culture-proven invasive fungal infections (IFIs), 25 attacks of 19 patients with probable invasive pulmonary aspergillosis (IPA), 42 attacks of 38 patients with possible IPA, and 31 attacks of 30 patients with suspected IFI. Voriconazole (VOR), caspofungin and liposomal amphotericin B were used to treat 72 episodes of 65 patients, 45 episodes of 37 patients and 34 episodes of 32 patients as a first-line therapy, respectively. Unfavorable conditions of our hematology ward are thought to increase the number of cases with invasive pulmonary aspergillosis and VOR use. It should be taken into consideration that increased systemic and per oral VOR usage predisposes patients to colonization and infection with azole-resistant fungal strains. Catheters should be removed in cases where patients' conditions are convenient to remove it. Acute myeloblastic leukemia cases that are more likely to develop invasive fungal infections should be monitored closely for early diagnosis and timely initiation of antifungal drugs which directly correlates with survival rates.
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Affiliation(s)
- Habip Gedik
- />Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Okmeydanı Training and Research Hospital, S. B. Okmeydanı Eğitim ve Araştırma Hastanesi Şişli, Istanbul, Turkey
| | - Funda Şimşek
- />Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Okmeydanı Training and Research Hospital, S. B. Okmeydanı Eğitim ve Araştırma Hastanesi Şişli, Istanbul, Turkey
| | - Taner Yıldırmak
- />Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Okmeydanı Training and Research Hospital, S. B. Okmeydanı Eğitim ve Araştırma Hastanesi Şişli, Istanbul, Turkey
| | - Arzu Kantürk
- />Department of Infectious Diseases and Clinical Microbiology, Ministry of Health Okmeydanı Training and Research Hospital, S. B. Okmeydanı Eğitim ve Araştırma Hastanesi Şişli, Istanbul, Turkey
| | - Deniz Arıca
- />Department of Hematology, Ministry of Health Okmeydanı Training and Research Hospital, S. B. Okmeydanı Eğitim ve Araştırma Hastanesi Şişli, Istanbul, Turkey
| | - Demet Aydın
- />Department of Hematology, Ministry of Health Okmeydanı Training and Research Hospital, S. B. Okmeydanı Eğitim ve Araştırma Hastanesi Şişli, Istanbul, Turkey
| | - Naciye Demirel
- />Department of Hematology, Ministry of Health Okmeydanı Training and Research Hospital, S. B. Okmeydanı Eğitim ve Araştırma Hastanesi Şişli, Istanbul, Turkey
| | - Osman Yokuş
- />Department of Hematology, Ministry of Health Okmeydanı Training and Research Hospital, S. B. Okmeydanı Eğitim ve Araştırma Hastanesi Şişli, Istanbul, Turkey
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