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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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Chakrabarti A, Patel AK, Soman R, Todi S. Overcoming clinical challenges in the management of invasive fungal infections in low- and middle-income countries (LMIC). Expert Rev Anti Infect Ther 2023; 21:1057-1070. [PMID: 37698201 DOI: 10.1080/14787210.2023.2257895] [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: 06/09/2023] [Accepted: 09/07/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION The management of invasive fungal infections (IFIs) in low- and middle-income countries (LMIC) is a serious challenge due to limited epidemiology studies, sub-optimal laboratory facilities, gap in antifungal management training and resources. Limited studies highlighted distinctive epidemiology of IFIs in those countries, and difficulty in distinguishing from closely related infections. To overcome the gaps for appropriate management of IFIs, innovative approaches are required. AREAS COVERED Extensive literature search and discussion with experts have helped us to summarize the epidemiology, diagnostic and management difficulties in managing IFIs in LMIC, and recommend certain solutions to overcome the challenges. EXPERT OPINION The strategies to overcome the challenges in diagnosis may include local epidemiology study, training of healthcare workers, association of fungal infections with already existing budgeted national programs, development and incorporation of point-of-care test (POCT) for prompt diagnosis, simplifying clinical diagnostic criteria suitable for LMIC, judicious use of available expertise, and diagnostic stewardship. For management strategies judicious use of antifungal, partnering with industry for inexpensive antifungal agents, development of LMIC specific guidelines for cost-effective management of IFIs and fungal outbreaks, improvement of infection control practices, advocacy for implementation of WHO recommended antifungal use, and integration of IFIs with public health.
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Affiliation(s)
- Arunaloke Chakrabarti
- Department of Infectious Disease and Microbiology, Doodhadhari Burfani Hospital & Research Institute, Haridwar, India
| | - Atul K Patel
- Infectious Diseases Department, Sterling Hospital, Ahmedabad, India
| | - Rajeev Soman
- Infectious Diseases Physician, Jupiter Hospital and Deenanath Mangeskar Hospital, Pune, India
| | - Subhash Todi
- Critical Care and Emergency Medicine, AMRI Hospitals, Kolkata, India
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Ray A, Das A, Panda S. Antifungal stewardship: What we need to know. Indian J Dermatol Venereol Leprol 2023; 89:5-11. [PMID: 36461808 DOI: 10.25259/ijdvl_91_2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 08/01/2022] [Indexed: 11/10/2022]
Abstract
Antimicrobial stewardship refers to a well-coordinated program which promotes the scientific and rational use of antimicrobials, reduces the chances of drug resistance and improves patient outcomes. A comprehensive English language literature search was done across multiple databases (PubMed, EMBASE, MEDLINE and Cochrane) for the period 1990-2022, revealing a large volume of reports of growing resistance to established antifungal therapies, against a backdrop of irrational and unscientific prescriptions. As a result of this, antifungal stewardship, a new kid on the block, has recently garnered attention. This review article is an attempt to summarise the basic concept of stewardship programs, highlighting the dire need to implement the same in the present situation of antifungal resistance and treatment failure.
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Affiliation(s)
- Arunima Ray
- Department of Dermatology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anupam Das
- Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
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Bienvenu AL, Pavese P, Leboucher G, Berger P, Roux S, Charmillon A, Foroni L, Menotti J, Lebeaux D, Mayan R, Mondain V, Robin C, Lesprit P, Alfandari S, Kernéis S. Practical checklist for implementation of antifungal stewardship programmes. J Med Microbiol 2022; 71. [PMID: 35771615 DOI: 10.1099/jmm.0.001560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Antifungal stewardship programmes are needed in healthcare facilities to limit the overuse or misuse of antifungals, which are responsible for an increase in antifungal resistance.Hypothesis/Gap Statement. Core recommendations for antifungal stewardship were published by the Mycoses Study Group Education and Research Consortium, while the Centers for Disease Control and Prevention (CDC) provided a Core Elements of Hospital Antibiotic Stewardship Programs checklist. The recommendations offer global core elements for best practices in antifungal stewardship, but do not provide a framework for the implementation of antifungal stewardship programmes in healthcare facilities.Aim. In line with the recommendations, it is of the utmost importance to establish a practical checklist that may be used to implement antifungal stewardship programmes.Methodology. The practical checklist was established by a national consensus panel of experts involved in antifungal stewardship activities. A preliminary checklist was sent to all experts. The final document was approved by the panel after discussion and the resolution of any disagreements by consensus.Results. The final checklist includes the following items: leadership support; actions to support optimal antifungal use; actions to monitor antifungal prescribing, use and resistance; and an education programme.Conclusion. This antifungal stewardship checklist offers opportunities for antifungal resistance containment, given that antifungal stewardship activities promote the optimal use of antifungals.
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Affiliation(s)
- Anne-Lise Bienvenu
- Service Pharmacie, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, Malaria Research Unit, SMITh, ICBMS UMR 5246, Lyon, France
| | - Patricia Pavese
- Service des Maladies Infectieuses, CHU de Grenoble, Grenoble, France
| | - Gilles Leboucher
- Service Pharmacie, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - Pierre Berger
- Infectiologie, Institut Paoli Calmettes, Marseille, France
| | - Sandrine Roux
- Service des Maladies Infectieuses et Tropicales, Hospices Civils de Lyon, Lyon
| | | | - Luc Foroni
- Omédit, ARS Auvergne-Rhône-Alpes, Lyon, France
| | - Jean Menotti
- Service de Mycologie, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France
| | - David Lebeaux
- Maladies Infectieuses et Tropicales, Hôpital Européen Georges-Pompidou, Paris, France
| | - Rémi Mayan
- Infectiologie, Ramsay Sante, Clinique Belharra, Bayonne, France
| | | | - Christine Robin
- Service d'hématologie clinique et de thérapie cellulaire, APHP, Hôpital Henri Mondor, Créteil, France
| | - Philippe Lesprit
- Service des Maladies Infectieuses, CHU de Grenoble, Grenoble, France
| | - Serge Alfandari
- Service de Réanimation et Maladies Infectieuses, CH Dron, Tourcoing, France
| | - Solen Kernéis
- Equipe de Prévention du Risque Infectieux, Hôpital Bichat, Paris, France
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Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute. GMS HYGIENE AND INFECTION CONTROL 2022; 17:Doc07. [PMID: 35707229 PMCID: PMC9174886 DOI: 10.3205/dgkh000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.
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Anforderungen an die Infektionsprävention bei der medizinischen Versorgung von immunsupprimierten Patienten. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 64:232-264. [PMID: 33394069 PMCID: PMC7780910 DOI: 10.1007/s00103-020-03265-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Ananda-Rajah MR, Fitchett S, Ayton D, Peleg AY, Fleming S, Watson E, Cairns K, Peel T. Ushering in Antifungal Stewardship: Perspectives of the Hematology Multidisciplinary Team Navigating Competing Demands, Constraints, and Uncertainty. Open Forum Infect Dis 2020; 7:ofaa168. [PMID: 32577425 PMCID: PMC7299525 DOI: 10.1093/ofid/ofaa168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/12/2020] [Indexed: 11/14/2022] Open
Abstract
Background The social, contextual, and behavioral determinants that influence care in patients at risk for invasive fungal diseases (IFD) are poorly understood. This knowledge gap is a barrier to the implementation of emerging antifungal stewardship (AFS) programs. We aimed to understand the barriers and enablers to AFS, opportunities for improvement, and perspectives of AFS for hematology patients at a major medical center in Australia. Methods Semistructured, face-to-face interviews were conducted with 35 clinicians from 6 specialties (hematology, infectious diseases, pharmacy, nursing, radiology, respiratory), followed by thematic analysis mapped to a behavioral change framework. Results Access to fungal diagnostics including bronchoscopy was identified as the key barrier to rational prescribing. Collective decision making was the norm, aided by an embedded stewardship model with on-demand access to infectious diseases expertise. Poor self-efficacy/knowledge among prescribers was actually an enabler of AFS, because clinicians willingly deferred to infectious diseases for advice. A growing outpatient population characterized by frequent care transitions was seen as an opportunity for AFS but neglected by an inpatient focused model, as was keeping pace with emerging fungal risks. Ad hoc surveillance, audit, and feedback practices frustrated population-level quality improvement for all actors. Antifungal stewardship was perceived as a specialized area that should be integrated within antimicrobial stewardship but aligned with the cultural expectations of hematologists. Conclusions Antifungal stewardship is multifaceted, with fungal diagnostics a critical gap and outpatients a neglected area. Formal surveillance, audit, and feedback mechanisms are essential for population-level quality improvement. Resourcing is the next challenge because complex immunocompromised patients require personalized attention and audit of clinical outcomes including IFD is difficult.
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Affiliation(s)
- Michelle R Ananda-Rajah
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia.,General Medical Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Samuel Fitchett
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Darshini Ayton
- Monash Partners Academic Health Science Centre, Clayton, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Shaun Fleming
- Clinical Haematology, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Eliza Watson
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kelly Cairns
- Department of Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - Trisha Peel
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Therapeutic Drug Monitoring of Antifungal Drugs: Another Tool to Improve Patient Outcome? Infect Dis Ther 2020; 9:137-149. [PMID: 32026399 PMCID: PMC7054538 DOI: 10.1007/s40121-020-00280-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Indexed: 01/28/2023] Open
Abstract
Introduction This study aimed to examine the relationship among adequate dose, serum concentration and clinical outcome in a non-selected group of hospitalized patients receiving antifungals. Methods Prospective cross-sectional study performed between March 2015 and June 2015. Dosage of antifungals was considered adequate according to the IDSA guidelines, whereas trough serum concentrations (determined with HPLC) were considered adequate as follows: fluconazole > 11 µg/ml, echinocandins > 1 µg/ml, voriconazole 1–5.5 µg/ml and posaconazole > 0.7 µg/ml. Results During the study period, 84 patients (65.4% male, 59.6 years) received antifungals for prophylaxis (40.4%), targeted (31.0%) and empirical therapy (28.6%). The most frequent drug was micafungin (28/84; 33.3%) followed by fluconazole (23/84; 27.4%), voriconazole (15/84; 17.9%), anidulafungin (8/84; 9.5%), posaconazole (7/84; 8.3%) and caspofungin (3/84; 3.6%). Considerable interindividual variability was observed for all antifungals with a large proportion of the patients (64.3%) not attaining adequate trough serum concentrations, despite receiving an adequate antifungal dose. Attaining the on-target serum antifungal level was significantly associated with a favorable clinical outcome (OR = 0.02; 95% CI 0.01–0.64; p = 0.03), whereas the administration of an adequate antifungal dosage was not. Conclusions With the standard antifungal dosage, a considerable proportion of patients have low drug concentrations, which are associated with poor clinical outcome.
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Closing the Gap in Surveillance and Audit of Invasive Mold Diseases for Antifungal Stewardship Using Machine Learning. J Clin Med 2019; 8:jcm8091390. [PMID: 31491944 PMCID: PMC6780614 DOI: 10.3390/jcm8091390] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 12/22/2022] Open
Abstract
Clinical audit of invasive mold disease (IMD) in hematology patients is inefficient due to the difficulties of case finding. This results in antifungal stewardship (AFS) programs preferentially reporting drug cost and consumption rather than measures that actually reflect quality of care. We used machine learning-based natural language processing (NLP) to non-selectively screen chest tomography (CT) reports for pulmonary IMD, verified by clinical review against international definitions and benchmarked against key AFS measures. NLP screened 3014 reports from 1 September 2008 to 31 December 2017, generating 784 positives that after review, identified 205 IMD episodes (44% probable-proven) in 185 patients from 50,303 admissions. Breakthrough-probable/proven-IMD on antifungal prophylaxis accounted for 60% of episodes with serum monitoring of voriconazole or posaconazole in the 2 weeks prior performed in only 53% and 69% of episodes, respectively. Fiberoptic bronchoscopy within 2 days of CT scan occurred in only 54% of episodes. The average turnaround of send-away bronchoalveolar galactomannan of 12 days (range 7–22) was associated with high empiric liposomal amphotericin consumption. A random audit of 10% negative reports revealed two clinically significant misses (0.9%, 2/223). This is the first successful use of applied machine learning for institutional IMD surveillance across an entire hematology population describing process and outcome measures relevant to AFS. Compared to current methods of clinical audit, semi-automated surveillance using NLP is more efficient and inclusive by avoiding restrictions based on any underlying hematologic condition, and has the added advantage of being potentially scalable.
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Antifungal Stewardship in Low- and Middle-Income Countries. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-00197-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Gómez-Gómez B, Cornejo-Juárez P. Do We Need Antifungal Stewardship? CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-00185-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Wattal C, Javeri Y, Goel N, Dhar D, Saxena S, Singh S, Oberoi JK, Rao BK, Mathur P, Manchanda V, Nangia V, Kapil A, Rattan A, Ghosh S, Singh O, Singh V, Kaur I, Datta S, Gupta SS. Convergence of Minds: For Better Patient Outcome in Intensive Care Unit Infections. Indian J Crit Care Med 2017; 21:154-159. [PMID: 28400686 PMCID: PMC5363104 DOI: 10.4103/ijccm.ijccm_365_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is emergence of resistance to the last-line antibiotics such as carbapenems in Intensive Care Units (ICUs), leaving little effective therapeutic options. Since there are no more newer antibiotics in the armamentarium in the near future, it has become imperative that we harness the interdisciplinary knowledge for the best clinical outcome of the patient. AIMS The aim of the conference was to utilize the synergies between the clinical microbiologists and critical care specialists for better patient care and clinical outcome. MATERIALS AND METHODS A combined continuing medical education program (CME) under the aegis of the Indian Association of Medical Microbiologists - Delhi Chapter and the Indian Society of Critical Care Medicine, Delhi and national capital region was organized to share their expertise on the various topics covering epidemiology, diagnosis, management, and prevention of hospital-acquired infections in ICUs. RESULTS It was agreed that synergy between the clinical microbiologists and critical care medicine is required in understanding the scope of laboratory tests, investigative pathway testing, hospital epidemiology, and optimum use of antibiotics. A consensus on the use of rapid diagnostics such as point-of-care tests, matrix-assisted laser desorption ionization-time of flight mass spectrometry, and molecular tests for the early diagnosis of infectious disease was made. It was agreed that stewardship activities along with hospital infection control practices should be further strengthened for better utilization of the antibiotics. Through this CME, we identified the barriers and actionables for appropriate antimicrobial usage in Indian ICUs. CONCLUSIONS A close coordination between clinical microbiology and critical care medicine opens up avenues to improve antimicrobial prescription practices.
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Affiliation(s)
- Chand Wattal
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
- Address for correspondence: Dr. Chand Wattal, Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, New Delhi - 110 060, India. E-mail:
| | - Yash Javeri
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Neeraj Goel
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Debashish Dhar
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Sonal Saxena
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Sarman Singh
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | | | - B. K. Rao
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Purva Mathur
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Vikas Manchanda
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Vivek Nangia
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Arti Kapil
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Ashok Rattan
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Supradip Ghosh
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Omender Singh
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Vinod Singh
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Iqbal Kaur
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Sanghamitra Datta
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Sharmila Sen Gupta
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
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