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Taynton T, Allsup D, Barlow G. How can we optimize antifungal use and stewardship in the treatment of acute leukemia? Expert Rev Hematol 2024; 17:581-593. [PMID: 39037307 DOI: 10.1080/17474086.2024.2383401] [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: 04/26/2024] [Accepted: 07/18/2024] [Indexed: 07/23/2024]
Abstract
INTRODUCTION The global need for antifungal stewardship is driven by spreading antimicrobial and antifungal resistance. Triazoles are the only oral and relatively well-tolerated class of antifungal medications, and usage is associated with acquired resistance and species replacement with intrinsically resistant organisms. On a per-patient basis, hematology patients are the largest inpatient consumers of antifungal drugs, but are also the most vulnerable to invasive fungal disease. AREAS COVERED In this review we discuss available and forthcoming antifungal drugs, antifungal prophylaxis and empiric antifungal therapy, and how a screening based and diagnostic-driven approach may be used to reduce antifungal consumption. Finally, we discuss components of an antifungal stewardship program, interventions that can be employed, and how impact can be measured. The search methodology consisted of searching PubMed for journal articles using the term antifungal stewardship plus program, intervention, performance measure or outcome before 1 January 2024. EXPERT OPINION Initial focus should be on implementing effective antifungal stewardship programs by developing and implementing local guidelines and using interventions, such as post-prescription review and feedback, which are known to be effective. Technologies such as microbiome analysis and machine learning may allow the development of truly individualized risk-factor-based approaches to antifungal stewardship in the future.
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Affiliation(s)
- Thomas Taynton
- Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Centre for Biomedical Research, Hull York Medical School, Hull, UK
| | - David Allsup
- Biomedical Institute for Multimorbidity, Hull York Medical School, Hull, UK
- Queen's Centre for Oncology and Haematology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Gavin Barlow
- Department of Infection, Hull University Teaching Hospitals NHS Trust, Hull, UK
- York Biomedical Research Institute and Hull York Medical School, University of York, York, UK
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2
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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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Flett L, Abdelatif R, Baz SA, Brady S, Corbacho B, Common K, Cowling A, Fairhurst C, Fitzmaurice E, Gandhi S, Hilton A, Hope W, Howard A, Laycock J, Lillie P, Mitchell G, Parker A, Peel M, Sheard L, Sneddon J, Taynton T, Tharmanathan P, Torgerson D, Wang HI, Allsup D, Barlow G. Biomarker Driven Antifungal Stewardship (BioDriveAFS) in acute leukaemia-a multi-centre randomised controlled trial to assess clinical and cost effectiveness: a study protocol for a randomised controlled trial. Trials 2024; 25:427. [PMID: 38943201 PMCID: PMC11214238 DOI: 10.1186/s13063-024-08272-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/19/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Acute leukaemias (AL) are life-threatening blood cancers that can be potentially cured with treatment involving myelosuppressive, multiagent, intensive chemotherapy (IC). However, such treatment is associated with a risk of serious infection, in particular invasive fungal infection (IFI) associated with prolonged neutropenia. Current practice guidelines recommend primary antifungal (AF) prophylaxis to be administered to high-risk patients to reduce IFI incidence. AFs are also used empirically to manage prolonged neutropenic fever. Current strategies lead to substantial overuse of AFs. Galactomannan (GM) and β-D-glucan (BG) biomarkers are also used to diagnose IFI. Combining both biomarkers may enhance the predictability of IFI compared to administering each test alone. Currently, no large-scale randomised controlled trial (RCT) has directly compared a biomarker-based diagnostic screening strategy without AF prophylaxis to AF prophylaxis (without systematic biomarker testing). METHODS BioDriveAFS is a multicentre, parallel, two-arm RCT of 404 participants from UK NHS Haematology departments. Participants will be allocated on a 1:1 basis to receive either a biomarker-based antifungal stewardship (AFS) strategy, or a prophylactic AF strategy, which includes existing standard of care (SoC). The co-primary outcomes will be AF exposure in the 12-month post randomisation and the patient-reported EQ-5D-5L measured at 12-month post randomisation. Secondary outcomes will include total AF exposure, probable/proven IFI, survival (all-cause mortality and IFI mortality), IFI treatment outcome, AF-associated adverse effects/events/complications, resource use, episodes of neutropenic fever requiring hospital admission or outpatient management, AF resistance in fungi (non-invasive and invasive) and a Desirability of Outcome Ranking. The trial will have an internal pilot phase during the first 9 months. A mixed methods process evaluation will be integrated in parallel to the internal pilot phase and full trial, aiming to robustly assess how the intervention is delivered. Cost-effectiveness analysis will also be performed. DISCUSSION The BioDriveAFS trial aims to further the knowledge of strategies that will safely optimise AF use through comparison of the clinical and cost-effectiveness of a biomarker-led diagnostic strategy versus prophylactic AF to prevent and manage IFI within acute leukaemia. The evidence generated from the study will help inform global clinical practice and approaches within antifungal stewardship. TRIAL REGISTRATION ISRCTN11633399. Registered 24/06/2022.
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Affiliation(s)
- Lydia Flett
- Department of Health Sciences, University of York, York, UK.
| | | | | | - Samantha Brady
- Department of Health Sciences, University of York, York, UK
| | - Belén Corbacho
- Department of Health Sciences, University of York, York, UK
| | - Kate Common
- Patient and Public Involvement, University of York, York, UK
| | - Abbie Cowling
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Andrea Hilton
- Faculty of Health Sciences, University of Hull, Hull, UK
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Alex Howard
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Joanne Laycock
- Department of Health Sciences, University of York, York, UK
| | | | - Gemma Mitchell
- Institute for Social Marketing and Health, University of Stirling, Stirling, UK
| | - Adwoa Parker
- Department of Health Sciences, University of York, York, UK
| | - Mary Peel
- Patient and Public Involvement, University of York, York, UK
| | - Laura Sheard
- Department of Health Sciences, University of York, York, UK
| | | | | | | | | | - Han-I Wang
- Department of Health Sciences, University of York, York, UK
| | - David Allsup
- Biomedical Institute for Multimorbidity, Hull York Medical School, University of Hull, Hull, UK
| | - Gavin Barlow
- Department of Experimental Medicine & Biomedicine, Hull York Medical School, University of York, York, UK
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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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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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Micallef C, Sung AH, Gheorghe M, Maladwala R, Grady K, Kouppas C, Enoch DA. Using Behavior Change Theory to Identify Drivers and Barriers for Antifungal Treatment Decisions: A Case Study in a Large Teaching Hospital in the East of England, UK. Infect Dis Ther 2023; 12:1393-1414. [PMID: 37173572 PMCID: PMC10181917 DOI: 10.1007/s40121-023-00796-z] [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: 12/30/2022] [Accepted: 03/23/2023] [Indexed: 05/15/2023] Open
Abstract
INTRODUCTION Antifungal stewardship (AFS) programs are recognized to contribute to optimizing antifungal prescribing for treatment and prophylaxis. However, only a small number of such programs are implemented. Consequently, evidence on behavioral drivers and barriers of such programs and learnings from existing successful AFS programs is limited. This study aimed to leverage a large AFS program in the UK and derive learnings from it. The objective was to (a) investigate the impact of the AFS program on prescribing habits, (a) use a Theoretical Domains Framework (TDF) based on the COM-B (Capability, Opportunity, and Motivation for Behavior) to qualitatively identify drivers and barriers for antifungal prescribing behaviors across multiple specialties, and (c) semiquantitatively investigate trends in antifungal prescribing habits over the last 5 years. METHODS Qualitative interviews and a semiquantitative online survey were conducted across hematology, intensive care, respiratory, and solid organ transplant clinicians at Cambridge University Hospital. The discussion guide and survey used were developed to identify drivers of prescribing behavior, based on the TDF. RESULTS Responses were received from 21/25 clinicians. Qualitative outcomes demonstrated that the AFS program was effective in supporting optimal antifungal prescribing practices. We found seven TDF domains influencing antifungal prescribing decisions-five drivers and two barriers. The key driver was collective decision-making among the multidisciplinary team (MDT) while key barriers were lack of access to certain therapies and fungal diagnostic capabilities. Furthermore, over the last 5 years and across specialties, we observed an increasing tendency for prescribing to focus on more targeted rather than broad-spectrum antifungals. CONCLUSIONS Understanding the basis for linked clinicians' prescribing behaviors for identified drivers and barriers may inform interventions on AFS programs and contribute to consistently improving antifungal prescribing. Collective decision-making among the MDT may be leveraged to improve clinicians' antifungal prescribing. These findings may be generalized across specialty care settings.
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Affiliation(s)
- Christianne Micallef
- Pharmacy Department, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Anita H Sung
- Pfizer Inc., 235 E 42nd St, New York, NY, 10017, USA.
| | | | | | | | | | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, National Infection Service, UK Health Security Agency, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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Yazdanpanah S, Ahmadi M, Zare Z, Nikoupour H, Arabsheybani S, Jabrodini A, Eghtedarnejad E, Chamanpara P, Geramizadeh B, Anbardar MH, Malekizadeh Z, Gashtasebi M, Mohsenzadeh M, Shafiekhani M, Zomorodian K. Assessment of Risk Factors and Clinical Outcomes in Hospitalized COVID-19 Patients with Candida spp. Co-infections: Species Distribution and Antifungal Susceptibility Patterns of Isolates. Mycopathologia 2022; 188:9-20. [PMID: 36495418 PMCID: PMC9739341 DOI: 10.1007/s11046-022-00694-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/12/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Fungal co-infections are considered an important complication in hospitalized patients with SARS-CoV-2 that can be attributed to disease aggravation, increased mortality, and poor outcomes. This study was conducted to determine the species distribution and antifungal susceptibility patterns of Candida isolates from hospitalized COVID-19 patients in Shiraz, Iran, in addition to associated risk factors and outcomes of co-infections with Candida species. MATERIALS AND METHODS In this single-center study, a total of 106 hospitalized COVID-19 patients were evaluated for clinical characteristics and outcomes. Species identification was performed by ITS1-5.8S-ITS2 gene sequencing. Antifungal susceptibility testing to fluconazole, itraconazole, voriconazole, posaconazole, caspofungin, amphotericin B, and nystatin was determined according to the M27-A3/S4 CLSI protocol. RESULTS Candida species were recovered from 48% (51/106) of hospitalized COVID-19 patients. Statistical analysis showed that patients who had heart failure, bacterial co-infection, and were receiving empirical antifungal therapy had a higher risk of developing Candida co-infection. In total, 71 Candida isolates were recovered, of which C. albicans (69%) was the most prevalent isolate. The majority of the Candida isolates were susceptible to all classes of tested antifungal drugs. DISCUSSION Our results elucidate a high rate of Candida co-infections among hospitalized COVID-19 patients. Comorbidities such as heart failure, HTN, COPD, bacterial infections as well as therapeutic interventions including catheterization, mechanical ventilation, and ICU admission increased the risk of Candida spp. isolation from the bloodstream, respiratory tract and urine samples, which led to a higher in-hospital mortality rate. Additionally, obtained data clarified that empirical antifungal therapy was not as successful as anticipated.
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Affiliation(s)
- Somayeh Yazdanpanah
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran ,Department of Medical Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Ahmadi
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Zare
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamed Nikoupour
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Arabsheybani
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Jabrodini
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran ,Department of Medical Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Esmaeel Eghtedarnejad
- Student Research Committee, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran ,Department of Medical Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Parisa Chamanpara
- Department of Biostatistics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bita Geramizadeh
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Hossein Anbardar
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Malekizadeh
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Gashtasebi
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Mohsenzadeh
- Cellular and Molecular Research Center, Gerash University of Medical Sciences, Gerash, Iran
| | - Mojtaba Shafiekhani
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz University of Medical Sciences, Shiraz, Iran ,Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran ,Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kamiar Zomorodian
- Department of Medical Parasitology and Mycology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran ,School of Medicine, Basic Sciences in Infectious Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Whitney L, Armstrong‐James D, Lyster HS, Reed AK, Dunning J, Nwankwo L, Cheong J. Antifungal stewardship in solid‐organ transplantation: What is needed? Transpl Infect Dis 2022; 24:e13894. [DOI: 10.1111/tid.13894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 05/15/2022] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Haifa S. Lyster
- Department of Heart and Lung Transplantation The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital Harefield Middlesex UK
| | - Anna K. Reed
- Department of Lung Transplantation Royal Brompton and Harefield National Health Service (NHS) Foundation Trust London UK
| | - John Dunning
- Department of Lung Transplantation Royal Brompton and Harefield National Health Service (NHS) Foundation Trust London UK
| | - Lisa Nwankwo
- Department of Pharmacy Royal Brompton & Harefield NHS Foundation Trust London UK
| | - Jamie Cheong
- Department of Pharmacy Royal Brompton & Harefield NHS Foundation Trust London UK
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Fisher MC, Alastruey-Izquierdo A, Berman J, Bicanic T, Bignell EM, Bowyer P, Bromley M, Brüggemann R, Garber G, Cornely OA, Gurr SJ, Harrison TS, Kuijper E, Rhodes J, Sheppard DC, Warris A, White PL, Xu J, Zwaan B, Verweij PE. Tackling the emerging threat of antifungal resistance to human health. Nat Rev Microbiol 2022; 20:557-571. [PMID: 35352028 PMCID: PMC8962932 DOI: 10.1038/s41579-022-00720-1] [Citation(s) in RCA: 355] [Impact Index Per Article: 177.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 12/12/2022]
Abstract
Invasive fungal infections pose an important threat to public health and are an under-recognized component of antimicrobial resistance, an emerging crisis worldwide. Across a period of profound global environmental change and expanding at-risk populations, human-infecting pathogenic fungi are evolving resistance to all licensed systemic antifungal drugs. In this Review, we highlight the main mechanisms of antifungal resistance and explore the similarities and differences between bacterial and fungal resistance to antimicrobial control. We discuss the research and innovation topics that are needed for risk reduction strategies aimed at minimizing the emergence of resistance in pathogenic fungi. These topics include links between the environment and One Health, surveillance, diagnostics, routes of transmission, novel therapeutics and methods to mitigate hotspots for fungal adaptation. We emphasize the global efforts required to steward our existing antifungal armamentarium, and to direct the research and development of future therapies and interventions.
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Affiliation(s)
- Matthew C Fisher
- MRC Centre for Global Infectious Disease Outbreak Analysis, Imperial College London, London, UK.
| | - Ana Alastruey-Izquierdo
- Mycology Reference Laboratory, National Centre for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Judith Berman
- Shmunis School of Biomedical and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Ramat Aviv, Israel
| | - Tihana Bicanic
- Institute of Infection and Immunity, St George's University London, London, UK
| | - Elaine M Bignell
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Paul Bowyer
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Michael Bromley
- Manchester Fungal Infection Group, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Roger Brüggemann
- Department of Pharmacy, Radboudumc Institute for Health Sciences and Radboudumc - CWZ Centre of Expertise for Mycology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Gary Garber
- Department of Medicine and the School of Public Health and Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Oliver A Cornely
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Excellence Center for Medical Mycology (ECMM), Cologne, Germany
| | | | - Thomas S Harrison
- Institute of Infection and Immunity, St George's University London, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Ed Kuijper
- Centre for Infectious Diseases Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands
| | - Johanna Rhodes
- MRC Centre for Global Infectious Disease Outbreak Analysis, Imperial College London, London, UK
| | - Donald C Sheppard
- Infectious Disease in Global Health Program and McGill Interdisciplinary Initiative in Infection and Immunity, McGill University Health Centre, Montreal, Québec, Canada
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - P Lewis White
- Public Health Wales Mycology Reference Laboratory, University Hospital of Wales, Cardiff, UK
| | - Jianping Xu
- Department of Biology, McMaster University, Hamilton, Ontario, Canada
| | - Bas Zwaan
- Department of Plant Science, Laboratory of Genetics, Wageningen University & Research, Wageningen, Netherlands
| | - Paul E Verweij
- Centre for Infectious Diseases Research, Diagnostics and Laboratory Surveillance, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands.
- Department of Medical Microbiology and Radboudumc - CWZ Centre of Expertise for Mycology, Radboud University Medical Centre, Nijmegen, Netherlands.
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10
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Taynton T, Barlow G, Allsup D. PRO: Biomarker surveillance for invasive fungal infections without antifungal prophylaxis could safely reduce antifungal use in acute leukaemia. JAC Antimicrob Resist 2022; 4:dlac074. [PMID: 35873180 PMCID: PMC9305519 DOI: 10.1093/jacamr/dlac074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/07/2022] [Indexed: 11/14/2022] Open
Abstract
Mould-active antifungal prophylaxis is frequently used to prevent invasive fungal infection in patients with acute leukaemia being treated with intensive chemotherapy. Invasive fungal infections are difficult to diagnose, and despite the use of prophylaxis a high proportion of patients still receive therapeutic antifungals. Antifungal medications have important interactions, can cause serious adverse events, and may drive the proliferation of antifungal resistance. The use of two biomarkers, such as galactomannan in combination with the less-specific β-d-glucan, can mitigate the risk of not detecting non-Aspergillus species, as well as improving pooled sensitivity and specificity. We argue that regular biomarkers could be used safely as part of an antifungal stewardship strategy to reduce antifungal use, by both screening for infection in patients not on prophylaxis and ruling out infection in patients treated empirically.
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Affiliation(s)
- Thomas Taynton
- Hull University Teaching Hospitals NHS Trust, Castle Hill
Hospital, Castle Road, Cottingham, Hull, HU16
5JQ, UK
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical
School, University of Hull, Hull, HU6 7RX,
UK
| | - Gavin Barlow
- Hull University Teaching Hospitals NHS Trust, Castle Hill
Hospital, Castle Road, Cottingham, Hull, HU16
5JQ, UK
- Hull York Medical School, University of York, Heslington,
York, YO10 5DD, UK
| | - David Allsup
- Hull University Teaching Hospitals NHS Trust, Castle Hill
Hospital, Castle Road, Cottingham, Hull, HU16
5JQ, UK
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical
School, University of Hull, Hull, HU6 7RX,
UK
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11
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Hamilton DO, Lambe T, Howard A, Crossey P, Hughes J, Duarte R, Welters ID. Can Beta-D-Glucan testing as part of the diagnostic pathway for Invasive Fungal Infection reduce anti-fungal treatment costs? Med Mycol 2022; 60:6588046. [PMID: 35583234 DOI: 10.1093/mmy/myac034] [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: 02/07/2022] [Revised: 05/02/2022] [Accepted: 05/19/2022] [Indexed: 11/13/2022] Open
Abstract
We performed a cost comparison of the current diagnostic and treatment pathway for invasive fungal infection (IFI) versus a proposed pathway that incorporates Beta-D-Glucan (BDG) testing from the NHS perspective. A fungal pathogen was identified in 58/107 (54.2%) patients treated with systemic anti-fungals in the Critical Care Department. Mean therapy duration was 23 days (standard deviation [SD] = 22 days), and cost was £5590 (SD = £7410) per patient. Implementation of BDG tests in the diagnostic and treatment pathway of patients with suspected IFI could result in a mean saving of £1643 per patient should a result be returned within two days.
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Affiliation(s)
- David O Hamilton
- Critical Care Department, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom.,Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Tosin Lambe
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Alexander Howard
- Microbiology Department, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Patricia Crossey
- Critical Care Department, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Jennifer Hughes
- Critical Care Department, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom
| | - Rui Duarte
- Liverpool Reviews and Implementation Group, Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Ingeborg D Welters
- Critical Care Department, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom.,Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
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12
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Chakrabarti A, Mohamed N, Capparella MR, Townsend A, Sung AH, Yura R, Muñoz P. The role of diagnostics-driven antifungal stewardship in the management of invasive fungal infections: a systematic literature review. Open Forum Infect Dis 2022; 9:ofac234. [PMID: 35873300 PMCID: PMC9297315 DOI: 10.1093/ofid/ofac234] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/10/2022] [Indexed: 12/02/2022] Open
Abstract
Antifungal stewardship (AFS) programs are key to optimizing antifungal use and improving outcomes in patients with invasive fungal infections. Our systematic literature review evaluated the impact of diagnostics in AFS programs by assessing performance and clinical measures. Most eligible studies were from Europe and the United States (n = 12/17). Diagnostic approaches included serum β-1–3-D-glucan test (n/N studies, 7/17), galactomannan test (4/17), computed tomography scan (3/17), magnetic resonance (2/17), matrix-assisted laser desorption and ionization time-of-flight mass spectrometry (MALDI-TOF MS; 2/17), polymerase chain reaction (1/17), peptide nucleic acid fluorescent in situ hybridization (PNA-FISH) assay (1/17), and other routine methods (9/17). Time to species identification decreased significantly using MALDI-TOF and PNA-FISH (n = 2). Time to targeted therapy and length of empiric therapy also decreased (n = 3). Antifungal consumption decreased by 11.6%–59.0% (7/13). Cost-savings ranged from 13.5% to 50.6% (5/10). Mortality rate (13/16) and length of stay (6/7) also decreased. No negative impact was reported on patient outcomes. Diagnostics-driven interventions can potentially improve AFS measures (antifungal consumption, cost, mortality, and length of stay); therefore, AFS implementation should be encouraged.
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Affiliation(s)
- Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Andy Townsend
- Correspondence: Andy Townsend, PhD, 2 Valley View Congleton, CW12 4EN ()
| | | | - Renee Yura
- WRD & Medical, Pfizer, Cambridge, Massachusetts, USA
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain
- Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- CIBER Enfermedades Respiratorias – CIBERES (CB06/06/0058), Madrid, Spain
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13
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Ferreras-Antolín L, Irwin A, Atra A, Chapelle F, Drysdale SB, Emonts M, McMaster P, Paulus S, Patel S, Rompola M, Vergnano S, Whittaker E, Warris A. Pediatric Antifungal Prescribing Patterns Identify Significant Opportunities to Rationalize Antifungal Use in Children. Pediatr Infect Dis J 2022; 41:e69-e74. [PMID: 34784303 PMCID: PMC8826618 DOI: 10.1097/inf.0000000000003402] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The need for pediatric antifungal stewardship programs has been driven by an increasing consumption of antifungals for prophylactic and empirical use. Drivers and rational of antifungal prescribing need to be identified to optimize prescription behaviors. METHODS A prospective modified weekly Point Prevalence Survey capturing antifungal prescriptions for children (> 90 days to < 18 years of age) in 12 centers in England during 26 consecutive weeks was performed. Demographic, diagnostic and treatment information was collected for each patient. Data were entered into an online REDCap database. RESULTS One thousand two hundred fifty-eight prescriptions were included for 656 pediatric patients, 44.9% were girls, with a median age of 6.4 years (interquartile range, 2.5-11.3). Most common underlying condition was malignancy (55.5%). Four hundred nineteen (63.9%) received antifungals for prophylaxis, and 237 (36.1%) for treatment. Among patients receiving antifungal prophylaxis, 40.2% did not belong to a high-risk group. In those receiving antifungal treatment, 45.9%, 29.4%, 5.1% and 19.6% had a diagnosis of suspected, possible, probable of proven invasive fungal disease (IFD), respectively. Proven IFD was diagnosed in 78 patients, 84.6% (n = 66) suffered from invasive candidiasis and 15.4% (n = 12) from an invasive mold infection. Liposomal amphotericin B was the most commonly prescribed antifungal for both prophylaxis (36.6%) and empiric and preemptive treatment (47.9%). Throughout the duration of the study, 72 (11.0%) patients received combination antifungal therapy. CONCLUSIONS Antifungal use in pediatric patients is dominated by liposomal amphotericin B and often without evidence for the presence of IFD. A significant proportion of prophylactic and empiric antifungal use was seen in pediatric patients not at high-risk for IFD.
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Affiliation(s)
- Laura Ferreras-Antolín
- From the Medical Research Council Centre for Medical Mycology, University of Exeter, United Kingdom
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Adam Irwin
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London, United Kingdom
- The University of Queensland Centre for Clinical Research, Brisbane, Australia
| | - Ayad Atra
- Department of Paediatric Oncology, Royal Marsden Hospital, Downs Road, Sutton, London, United Kingdom
| | - Faye Chapelle
- Department of Infectious Diseases and Immunology, Evelina Children Hospital, London, United Kingdom
| | - Simon B. Drysdale
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Marieke Emonts
- Department of Paediatric Immunology, Infectious Diseases and Allergy, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paddy McMaster
- Department of Paediatric Infectious Diseases, Royal Manchester Childrens´ Hospital, Manchester, United Kingdom
| | - Stephane Paulus
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Sanjay Patel
- Department of Paediatric Infectious Diseases, University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Menie Rompola
- Dept. of Paediatric Haematology and Oncology, Leeds General Infirmary, Leeds, United Kingdom
| | - Stefania Vergnano
- Department of Paediatric Infectious Diseases, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Elizabeth Whittaker
- Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust and Section of Paediatrics, Department of Infectious Diseases, Imperial College, London, United Kingdom
| | - Adilia Warris
- From the Medical Research Council Centre for Medical Mycology, University of Exeter, United Kingdom
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London, United Kingdom
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14
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Zou ZY, Sun KJ, Fu G, Huang JJ, Yang ZJ, Zhou ZP, Ma SL, Zhu F, Wu M. Impact of early empirical antifungal therapy on prognosis of sepsis patients with positive yeast culture: A retrospective study from the MIMIC-IV database. Front Microbiol 2022; 13:1047889. [PMID: 36466647 PMCID: PMC9712452 DOI: 10.3389/fmicb.2022.1047889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/26/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Mortality and other clinical outcomes of culture-negative and culture-positive among patients with fungal sepsis have not been documented, and whether antifungal therapy prior to fungal culture reports is related to decreased mortality among patients remains largely controversial. This study aimed to determine the mortality and other clinical outcomes of patients with positive yeast cultures and further investigate the effects of initial empiric antifungal therapy. METHODS A retrospective study was conducted among septic patients using the Medical Information Mart for Intensive Care (MIMIC)-IV database. Patients with sepsis were divided into two groups based on first fungal culture status during intensive care unit (ICU) stay, and initial empirical antifungal therapy was prescribed based on physician's experience prior to fungal culture reports within 48 h. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30-day all-cause mortality, 60-day all-cause mortality, length of ICU stay and length of hospital stay. Multivariate logistic regression, propensity score matching (PSM), subgroup analyses and survival curve analyses were performed. RESULTS This study included 18,496 sepsis patients, of whom 3,477 (18.8%) had positive yeast cultures. Patients with positive yeast cultures had higher in-hospital all-cause mortality, 60-day all-cause mortality, and longer lengths of ICU stay and hospital stay than those with negative yeast cultures after PSM (all p < 0.01). Multivariate logistic regression analysis revealed that positive yeast culture was a risk factor for in-hospital mortality in the extended model. Subgroup analyses showed that the results were robust among the respiratory infection, urinary tract infection, gram-positive bacterial infection and bacteria-free culture subgroups. Interestingly, empiric antifungal therapy was not associated with lower in-hospital mortality among patients with positive yeast cultures, mainly manifested in stratification analysis, which showed that antifungal treatment did not improve outcomes in the bloodstream infection (odds ratio, OR 2.12, 95% CI: 1.16-3.91, p = 0.015) or urinary tract infection groups (OR 3.24, 95% CI: 1.48-7.11, p = 0.003). CONCLUSION Culture positivity for yeast among sepsis patients was associated with worse clinical outcomes, and empiric antifungal therapy did not lower in-hospital all-cause mortality in the bloodstream infection or urinary tract infection groups in the ICU.
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Affiliation(s)
- Zhi-ye Zou
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
| | - Kai-jun Sun
- Department of Cardiovascular Medicine, Weifang People's Hospital, Weifang, China
| | - Guang Fu
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Jia-jia Huang
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Zhen-jia Yang
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Zhi-peng Zhou
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
| | - Shao-lin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Shao-lin Ma,
| | - Feng Zhu
- Department of Critical Care Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Burn and Trauma ICU, The First Affiliated Hospital, Naval Medical University, Shanghai, China
- Feng Zhu,
| | - Ming Wu
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
- Shantou University Medical College, Shantou, China
- Ming Wu,
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15
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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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16
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Aldossary S, Shah A. Healthcare Utilization and Impact of Antifungal Stewardships Within Respiratory Care Settings: A Systematic Literature Review. Mycopathologia 2021; 186:673-684. [PMID: 33991279 PMCID: PMC8536614 DOI: 10.1007/s11046-021-00547-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/17/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Fungal infection and sensitization are common in chronic respiratory patient populations such as bronchiectasis, chronic obstructive pulmonary disease (COPD), and cystic fibrosis (CF) and are often associated with prolonged antifungal therapy (Hohmann et al. in Clin Infect Dis 15:939-940, 2010; Vissichelli et al. in Infect Prev Pract 1:100029, 2019), morbidity, and mortality. Although the use of antifungal stewardship (AFS) is increasing within an invasive fungal disease setting, its use and impact within a chronic respiratory setting have not been defined. METHODS A systematic literature review was conducted using PRISMA guidelines to evaluate the use of antifungal stewardship within a chronic respiratory care setting. Three databases have been searched, Medline via Ovid, Embase and GlobalHealth, for papers published between 1949 and 2020. RESULTS The initial search identified 987 papers from Medline, 1761 papers from Embase, and 481 papers from GlobalHealth. Only 28 papers met the criteria for inclusion in this systematic literature review. The included studies were subjected to CASP and GRADE assessments to rank their quality and applicability. Only two studies were focussed on Aspergillus species infection. CONCLUSION Although antifungal stewardship is increasing, its applications are still limited in chronic respiratory care settings despite the prolonged requirement for antifungal therapy and high antimicrobial resistance.
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Affiliation(s)
- Salma Aldossary
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anand Shah
- Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
- MRC Centre of Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, London, UK.
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17
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Lessons from an Educational Invasive Fungal Disease Conference on Hospital Antifungal Stewardship Practices across the UK and Ireland. J Fungi (Basel) 2021; 7:jof7100801. [PMID: 34682223 PMCID: PMC8538376 DOI: 10.3390/jof7100801] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 01/23/2023] Open
Abstract
Invasive fungal disease (IFD) is a growing health burden. High mortality rates, increasing numbers of at-risk hosts, and a limited availability of rapid diagnostics and therapeutic options mean that patients are increasingly exposed to unnecessary antifungals. High rates of prescriptions promote patient exposure to undue toxicity and drive the emergence of resistance. Antifungal stewardship (AFS) aims to guide antifungal usage and reduce unnecessary exposure and antifungal consumption whilst maintaining or improving outcomes. Here, we examine several AFS approaches from hospitals across the UK and Ireland to demonstrate the benefits of AFS practices and support the broader implementation of AFS as both a necessary and achievable strategy. Since the accuracy and turnaround times (TATs) of diagnostic tools can impact treatment decisions, several AFS strategies have included the development and implementation of diagnostic-driven care pathways. AFS informed treatment strategies can help stratify patients on a risk basis ensuring the right patients receive antifungals at the optimal time. Using a multidisciplinary approach is also key due to the complexity of managing and treating patients at risk of IFD. Through knowledge sharing, such as The Gilead Antifungal Information Network (GAIN), we hope to drive practices that improve patient management and support the preservation of antifungals for future use.
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18
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Alaalm L, Crunden JL, Butcher M, Obst U, Whealy R, Williamson CE, O'Brien HE, Schaffitzel C, Ramage G, Spencer J, Diezmann S. Identification and Phenotypic Characterization of Hsp90 Phosphorylation Sites That Modulate Virulence Traits in the Major Human Fungal Pathogen Candida albicans. Front Cell Infect Microbiol 2021; 11:637836. [PMID: 34513723 PMCID: PMC8431828 DOI: 10.3389/fcimb.2021.637836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/24/2021] [Indexed: 01/13/2023] Open
Abstract
The highly conserved, ubiquitous molecular chaperone Hsp90 is a key regulator of cellular proteostasis and environmental stress responses. In human pathogenic fungi, which kill more than 1.6 million patients each year worldwide, Hsp90 governs cellular morphogenesis, drug resistance, and virulence. Yet, our understanding of the regulatory mechanisms governing fungal Hsp90 function remains sparse. Post-translational modifications are powerful components of nature’s toolbox to regulate protein abundance and function. Phosphorylation in particular is critical in many cellular signaling pathways and errant phosphorylation can have dire consequences for the cell. In the case of Hsp90, phosphorylation affects its stability and governs its interactions with co-chaperones and clients. Thereby modulating the cell’s ability to cope with environmental stress. Candida albicans, one of the leading human fungal pathogens, causes ~750,000 life-threatening invasive infections worldwide with unacceptably high mortality rates. Yet, it remains unknown if and how Hsp90 phosphorylation affects C. albicans virulence traits. Here, we show that phosphorylation of Hsp90 is critical for expression of virulence traits. We combined proteomics, molecular evolution analyses and structural modeling with molecular biology to characterize the role of Hsp90 phosphorylation in this non-model pathogen. We demonstrated that phosphorylation negatively affects key virulence traits, such as the thermal stress response, morphogenesis, and drug susceptibility. Our results provide the first record of a specific Hsp90 phosphorylation site acting as modulator of fungal virulence. Post-translational modifications of Hsp90 could prove valuable in future exploitations as antifungal drug targets.
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Affiliation(s)
- Leenah Alaalm
- Department of Biology & Biochemistry, University of Bath, Bath, United Kingdom
| | - Julia L Crunden
- Department of Biology & Biochemistry, University of Bath, Bath, United Kingdom.,School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Mark Butcher
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Ulrike Obst
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Ryann Whealy
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | | | - Heath E O'Brien
- MRC Centre for Neuropsychiatric Genetics & Genomics, Division of Psychological Medicine & Clinical Neurosciences, Cardiff University, Cardiff, United Kingdom
| | | | - Gordon Ramage
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - James Spencer
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - Stephanie Diezmann
- Department of Biology & Biochemistry, University of Bath, Bath, United Kingdom.,School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
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19
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Murri R, Lardo S, De Luca A, Posteraro B, Torelli R, De Angelis G, Giovannenze F, Taccari F, Pavan L, Parroni L, Sanguinetti M, Fantoni M. Post-Prescription Audit Plus Beta-D-Glucan Assessment Decrease Echinocandin Use in People with Suspected Invasive Candidiasis. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57070656. [PMID: 34206911 PMCID: PMC8306264 DOI: 10.3390/medicina57070656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/13/2021] [Accepted: 06/23/2021] [Indexed: 01/08/2023]
Abstract
Background and Objectives: Overtreatment with antifungal drugs is often observed. Antifungal stewardship (AFS) focuses on optimizing the treatment for invasive fungal diseases. The objective of the present study was to evaluate the utility of a post-prescription audit plus beta-D-glucan (BDG) assessment on reducing echinocandin use in persons with suspected invasive candidiasis. Materials and Methods: This is a prospective, pre-post quasi-experimental study of people starting echinocandins for suspected invasive candidiasis. The intervention of the study included review of each echinocandin prescription and discontinuation of treatment if a very low probability of fungal disease or a negative BDG value were found. Pre-intervention data were compared with the intervention phase. The primary outcome of the study was the duration of echinocandin therapy. Secondary outcomes were length of hospital stay and mortality. Results: Ninety-two echinocandin prescriptions were reviewed, 49 (53.3%) in the pre-intervention phase and 43 (46.7%) in the intervention phase. Discontinuation of antifungal therapy was possible in 21 of the 43 patients in the intervention phase (48.8%). The duration of echinocandin therapy was 7.4 (SD 4.7) in the pre-intervention phase, 4.1 days (SD 2.9) in persons undergoing the intervention, and 8.6 (SD 7.3) in persons in whom the intervention was not feasible (p at ANOVA = 0.016). Length of stay and mortality did not differ between pre-intervention and intervention phases. Conclusions: An intervention based on pre-prescription restriction and post-prescription audit when combined with BDG measurement is effective in optimizing antifungal therapy by significantly reducing excessive treatment duration.
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Affiliation(s)
- Rita Murri
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Infectious Diseases Section, Department of Safety and Bioethics, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-333-456-2124
| | - Sara Lardo
- A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy;
| | - Alessio De Luca
- Pharmacy Complex Operative Unit, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (A.D.L.); (L.P.); (L.P.)
| | - Brunella Posteraro
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Department of Basic Biotechnology, Clinical Intensive Care and Perioperative Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Riccardo Torelli
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Department of Basic Biotechnology, Clinical Intensive Care and Perioperative Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Giulia De Angelis
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Department of Basic Biotechnology, Clinical Intensive Care and Perioperative Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Francesca Giovannenze
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Infectious Diseases Section, Department of Safety and Bioethics, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Francesco Taccari
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
| | - Lucia Pavan
- Pharmacy Complex Operative Unit, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (A.D.L.); (L.P.); (L.P.)
| | - Lucia Parroni
- Pharmacy Complex Operative Unit, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (A.D.L.); (L.P.); (L.P.)
| | - Maurizio Sanguinetti
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Department of Basic Biotechnology, Clinical Intensive Care and Perioperative Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Massimo Fantoni
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Infectious Diseases Section, Department of Safety and Bioethics, Catholic University of the Sacred Heart, 00168 Rome, Italy
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Machado M, Chamorro de Vega E, Martínez-Jiménez MDC, Rodríguez-González CG, Vena A, Navarro R, Zamora-Cintas MI, Agnelli C, Olmedo M, Galar A, Guinea J, Fernández-Cruz A, Alonso R, Bouza E, Muñoz P, Valerio M. Utility of 1,3 β-d-Glucan Assay for Guidance in Antifungal Stewardship Programs for Oncologic Patients and Solid Organ Transplant Recipients. J Fungi (Basel) 2021; 7:59. [PMID: 33477250 PMCID: PMC7830184 DOI: 10.3390/jof7010059] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/25/2020] [Accepted: 01/11/2021] [Indexed: 11/29/2022] Open
Abstract
The implementation of 1,3 β-d-glucan (BDG) has been proposed as a diagnostic tool in antifungal stewardship programs (ASPs). We aimed to analyze the influence of serum BDG in an ASP for oncologic patients and solid organ transplant (SOT) recipients. We conducted a pre-post study. In the initial period (PRE), the ASP was based on bedside advice, and this was complemented with BDG in the post-period (POST). Performance parameters of the BDG assay were determined. Antifungal (AF) use adequacy was evaluated using a point score. Clinical outcomes and AF costs were also compared before and after the intervention. Overall, 85 patients were included in the PRE-period and 112 in the POST-period. Probable or proven fungal infections were similar in both groups (54.1% vs. 57.1%; p = 0.67). The determination of BDG contributed to improved management in 75 of 112 patients (66.9%). The AF adequacy score improved in the POST-period (mean 7.75 vs. 9.29; p < 0.001). Median days of empiric AF treatment was reduced in the POST-period (9 vs. 5 days, p = 0.04). All-cause mortality (44.7% vs. 34.8%; p = 0.16) was similar in both periods. The cost of AF treatments was reduced in the POST-period with a difference of 779.6 €/patient. Our data suggest that the use of BDG was a cost-effective strategy that contributed to safely improving the results of an ASP for SOT and oncologic patients.
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Affiliation(s)
- Marina Machado
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- Fundación Mutua Madrileña Research Fellowship, 28046 Madrid, Spain
| | - Esther Chamorro de Vega
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - María del Carmen Martínez-Jiménez
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Fundación Mutua Madrileña Research Fellowship, 28046 Madrid, Spain
| | - Carmen Guadalupe Rodríguez-González
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Antonio Vena
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - Raquel Navarro
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - María Isabel Zamora-Cintas
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - Caroline Agnelli
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - María Olmedo
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
| | - Alicia Galar
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
| | - Jesús Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- CIBER Enfermedades Respiratorias, CIBERES (CB06/06/0058), 28029 Madrid, Spain
| | - Ana Fernández-Cruz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - Roberto Alonso
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- CIBER Enfermedades Respiratorias, CIBERES (CB06/06/0058), 28029 Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- CIBER Enfermedades Respiratorias, CIBERES (CB06/06/0058), 28029 Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- Fundación Mutua Madrileña Research Fellowship, 28046 Madrid, Spain
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Markogiannakis A, Korantanis K, Gamaletsou MN, Samarkos M, Psichogiou M, Daikos G, Sipsas NV. Impact of a non-compulsory antifungal stewardship program on overuse and misuse of antifungal agents in a tertiary care hospital. Int J Antimicrob Agents 2020; 57:106255. [PMID: 33279582 DOI: 10.1016/j.ijantimicag.2020.106255] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 11/02/2020] [Accepted: 11/28/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To assess the impact of an antifungal stewardship (AFS) program on appropriate use, consumption and acquisition costs of antifungals, and on clinical outcomes (in-hospital-mortality, in-hospital-length-of-stay). METHODS The study was conducted at a 535-bed tertiary-care hospital and had three consecutive periods. A) Observational period (10 months): all antifungal prescriptions were prospectively evaluated. B) Educational intervention to increase the awareness on proper antifungals use. C) Implementation of a non-compulsory AFS program (10 months) based on prospective audit and feedback. Interrupted time series analysis has been used to assess the impact of the intervention. RESULTS During the pre-interventional period 198 AF prescriptions for 147 patients, have been evaluated compared to 181 prescriptions in 138 patients during the AFS period. Statistical analysis showed a significant immediate drop of inappropriate prescriptions after intervention with a significantly declining trend thereafter, and a significant drop of the total consumption of antifungals immediately after the intervention with a significant declining trend thereafter. All-cause, in-hospital- mortality was stable during the pre-intervention period with a significant declining trend after the AFS program implementation, although no immediate intervention effect could be established. Comparison of pre-and post-interventional periods showed significant reduction in acquisition costs (-26.8%, p<0.001) but no difference regarding the total number of bed-days (107,654 vs. 102,382), and mean length of hospital-stay (5.19 vs. 4.96 days, p=NS). CONCLUSIONS The implementation of a non-compulsory AFS program resulted in significant improvement in the quality of prescriptions and reduction in antifungals consumption and acquisitions costs, without affecting the overall in-hospital-mortality and mean in-hospital-length-of-stay.
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Affiliation(s)
| | - Konstantinos Korantanis
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, and General Hospital of Athens Laiko, Athens, Greece
| | - Maria N Gamaletsou
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, and General Hospital of Athens Laiko, Athens, Greece
| | - Michael Samarkos
- First Department of Medicine, School of Medicine, National and Kapodistrian University of Athens and General Hospital of Athens Laiko, Athens, Greece
| | - Mina Psichogiou
- First Department of Medicine, School of Medicine, National and Kapodistrian University of Athens and General Hospital of Athens Laiko, Athens, Greece
| | - George Daikos
- First Department of Medicine, School of Medicine, National and Kapodistrian University of Athens and General Hospital of Athens Laiko, Athens, Greece
| | - Nikolaos V Sipsas
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, and General Hospital of Athens Laiko, Athens, Greece
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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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Martín-Gutiérrez G, Peñalva G, Ruiz-Pérez de Pipaón M, Aguilar M, Gil-Navarro MV, Pérez-Blanco JL, Pérez-Moreno MA, Amaya-Villar R, Ferrándiz-Millón C, Gascón ML, Goycochea-Valdivia WA, Jiménez-Mejías ME, Navarro MD, Lepe JA, Alvarez-Marín R, Neth O, Guisado-Gil AB, Infante-Domínguez C, Molina J, Cisneros JM. Efficacy and safety of a comprehensive educational antimicrobial stewardship program focused on antifungal use. J Infect 2020; 80:342-349. [PMID: 31954101 DOI: 10.1016/j.jinf.2020.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 01/04/2020] [Accepted: 01/08/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Few data exist regarding the impact of antimicrobial stewardship programs on antifungal use. We evaluated the efficacy and safety of a comprehensive long-term antimicrobial stewardship program (ASP) focused on antifungal use. METHODS During a 9-year period, we quarterly assessed antifungal consumption, incidence density of hospital-acquired candidemia, Candida spp. distribution, antifungal resistance, and crude death rate per 1000 occupied bed days (OBDs) of hospital-acquired candidemia. We performed segmented regression analysis of interrupted time series. RESULTS A significant change in trend was observed for antifungal consumption, with a sustained reduction of -0.87% per quarter (95% confidence interval [CI], -1.36 -0.38, p < 0.001), accounting for a final reduction of -38.4%. The main reduction was produced in fluconazole, with a sustained reduction of -1.37% per quarter (95%CI, -1.96 -0.68, p<0.001). The incidence density of hospital-acquired candidemia decreased, with a change in slope of -5.06% cases per 1000 OBDs per year (95%CI, -8.23 -1.77, p = 0.009). The 14-day crude death rate per 1000 OBDs dropped from 0.044 to 0.017 (-6.36% deaths per 1000 OBDs per year; 95%CI, -13.45 -1.31, p = 0.09). CONCLUSIONS This ASP has succeeded in optimizing the use of antifungal with a long-lasting reduction without increasing the incidence, neither the mortality, of hospital-acquired candidemia.
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Affiliation(s)
- Guillermo Martín-Gutiérrez
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | - Germán Peñalva
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | - Maite Ruiz-Pérez de Pipaón
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | - Manuela Aguilar
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | | | | | - María Antonia Pérez-Moreno
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | | | | | - María L Gascón
- Intensive Care Department, University Hospital Virgen del Rocío, Seville, Spain
| | - Walter A Goycochea-Valdivia
- Pediatric Infectious Diseases and Immunodeficiency, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain
| | - Manuel E Jiménez-Mejías
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | - María Dolores Navarro
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | - José A Lepe
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | - Rocío Alvarez-Marín
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | - Olaf Neth
- Pediatric Infectious Diseases and Immunodeficiency, Institute of Biomedicine of Seville, University Hospital Virgen del Rocío, Spanish National Research Council, University of Seville, Spain
| | - Ana B Guisado-Gil
- Clinical Pharmacy Service, University Hospital Virgen del Rocío, Seville, Spain
| | - Carmen Infante-Domínguez
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | - José Molina
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain
| | - José M Cisneros
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, Seville, Spain.
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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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25
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So M. Antimicrobial Stewardship in Patients with Hematological Malignancies: Key Considerations. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-00189-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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