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Chorafa E, Iosifidis E, Oletto A, Warris A, Castagnola E, Bruggemann R, Groll AH, Lehrnbecher T, Ferreras Antolin L, Mesini A, Agakidou E, Controzzi T, De Luca M, Dimitriou G, Emonts M, Esposito S, Fernàndez-Polo A, Ghimenton-Walters E, Gkentzi D, Grasa C, Hatzidaki E, Jõgi P, Kildonaviciute K, Kontou A, Leibold-Aguinarte A, Manzanares A, Mendoza-Palomar N, Metsvaht T, Noni M, Paulus S, Perrone S, Rincón-López E, Romani L, Sánchez L, Cetin BS, Spoulou V, Strenger V, Vergadi E, Villaverde S, Vuerich M, Zamora-Flores E, Roilides E. Antifungal Drug Usage in European Neonatal Units: A Multicenter Weekly Point Prevalence Study. Pediatr Infect Dis J 2024:00006454-990000000-00920. [PMID: 38917027 DOI: 10.1097/inf.0000000000004445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
BACKGROUND Data on antifungal prescribing in neonatal patients are limited to either single-center or single-country studies or to 1-day recording. Therefore, we assessed antifungal longitudinal usage in neonatal units (NUs) within Europe. METHODS CALYPSO, a prospective weekly point prevalence study on antifungal drug usage in NUs in 18 hospitals (8 European countries), was conducted in 2020 during a 12-week period. All patients receiving systemic antifungals were included. Ward demographics were collected at the beginning; ward and patient data including indication, risk factors and antifungal regimen were weekly collected prospectively. RESULTS Among 27 participating NUs, 15 (56%) practiced antifungal prophylaxis for neonates with birth weight <1000 g or <1500 g and additional risk factors. In total, 174 patients received antifungals with a median frequency per week of 10.5% ranging from 6.9% to 12.6%. Indication for antifungal prescribing was prophylaxis in 135/174 (78%) courses and treatment in 22% [39 courses (69% empirical, 10% preemptive, 21% targeted)]. Fluconazole was the most frequent systemic agent used both for prophylaxis (133/135) and treatment (15/39, 39%). Among neonates receiving prophylaxis, the most common risk factors were prematurity (119/135, 88%), mechanical ventilation (109/135, 81%) and central vascular catheters (89/135, 66%). However, gestational age <28 weeks was only recorded in 55/135 (41%) courses and birth weight <1000 g in 48/135 (35%). Most common reason for empirical treatment was late-onset sepsis; all 8 targeted courses were prescribed for invasive candidiasis. CONCLUSION Antifungal usage in European NUs is driven by prophylaxis and empirical treatment with fluconazole being the most prescribed agent for both indications.
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Affiliation(s)
- Elisavet Chorafa
- From the Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University School of Medicine, Hippokration Hospital, Thessaloniki, Greece
| | - Elias Iosifidis
- From the Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University School of Medicine, Hippokration Hospital, Thessaloniki, Greece
| | | | - Adilia Warris
- Medical Research Council Center for Medical Mycology, University of Exeter, Exeter, United Kingdom
- European Pediatric Mycology Network
| | - Elio Castagnola
- European Pediatric Mycology Network
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Roger Bruggemann
- European Pediatric Mycology Network
- Department of Pharmacy, Centre of Expertise in Mycology Radboudumc/Canisius-Wilhelmina Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Andreas H Groll
- European Pediatric Mycology Network
- Infectious Disease Research Program, Center for Bone Marrow Transplantation, Department of Pediatric Hematology/Oncology, University Children's Hospital, Muenster, Germany
| | - Thomas Lehrnbecher
- European Pediatric Mycology Network
- Division of Hematology, Oncology and Hemostaseology, Department of Pediatrics, Goethe University Frankfurt, Frankfurt/Main, Germany
| | - Laura Ferreras Antolin
- Medical Research Council Center for Medical Mycology, University of Exeter, Exeter, United Kingdom
- European Pediatric Mycology Network
- Pediatric Infectious Diseases and Immunology Unit, St George's University Hospitals, NHS Foundation Trust, London, United Kingdom
| | - Alessio Mesini
- European Pediatric Mycology Network
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Eleni Agakidou
- 1st Department of Neonatology and Intensive Care Unit, Aristotle University School of Medicine, Hippokration Hospital, Thessaloniki, Greece
| | - Tiziana Controzzi
- Pediatric Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maia De Luca
- Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Gabriel Dimitriou
- Department of Pediatrics, University General Hospital of Patras, Medical School, University of Patras, Rio, Greece
| | - Marieke Emonts
- Paediatric Immunology, Infectious Diseases & Allergy Department Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Susanna Esposito
- Pediatric Department, Azienda Ospedaliera-Universitaria di Parma, Parma, Italy
| | - Aurora Fernàndez-Polo
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Elisabetta Ghimenton-Walters
- Paediatric Immunology, Infectious Diseases & Allergy Department Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Despoina Gkentzi
- Department of Pediatrics, University General Hospital of Patras, Medical School, University of Patras, Rio, Greece
| | - Carlos Grasa
- Pediatric Department, Hospital Universitario La Paz, IdiPAZ. CIBERINFEC, Madrid, Spain
| | - Eleftheria Hatzidaki
- Pediatric Department, University General Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Piia Jõgi
- Neonatology Department, Tartu University Hospital, Tartu, Estonia
| | | | - Angeliki Kontou
- 1st Department of Neonatology and Intensive Care Unit, Aristotle University School of Medicine, Hippokration Hospital, Thessaloniki, Greece
| | - Alessa Leibold-Aguinarte
- Division of Hematology, Oncology and Hemostaseology, Department of Pediatrics, Goethe University Frankfurt, Frankfurt/Main, Germany
| | | | - Natalia Mendoza-Palomar
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Tuuli Metsvaht
- Neonatology Department, Tartu University Hospital, Tartu, Estonia
| | - Maria Noni
- 1st Department of Pediatrics, National and Kapodistrian University of Athens, "Agia Sophia" Children's Hospital, Athens, Greece
| | - Stéphane Paulus
- Pediatric Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Serafina Perrone
- Pediatric Department, Azienda Ospedaliera-Universitaria di Parma, Parma, Italy
| | - Elena Rincón-López
- Neonatology Department, Hospital Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Lorenza Romani
- Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Laura Sánchez
- Pediatric Department, Hospital Universitario La Paz, IdiPAZ. CIBERINFEC, Madrid, Spain
| | - Benhur Sirvan Cetin
- Department of Pediatric Infectious Diseases, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Vana Spoulou
- 1st Department of Pediatrics, National and Kapodistrian University of Athens, "Agia Sophia" Children's Hospital, Athens, Greece
| | | | - Eleni Vergadi
- Pediatric Department, University General Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | | | - Marco Vuerich
- Pediatric Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Emmanuel Roilides
- From the Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University School of Medicine, Hippokration Hospital, Thessaloniki, Greece
- 1st Department of Neonatology and Intensive Care Unit, Aristotle University School of Medicine, Hippokration Hospital, Thessaloniki, Greece
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Wang H, Li D, Jiang Y, Liang J, Yu Q, Kuang L, Huang Y, Qin D, Li P, He J, Xu F, Li X, Wang F, Wei Y, Li X. Population pharmacokinetics of fluconazole for prevention or treatment of invasive candidiasis in Chinese young infants. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03184-7. [PMID: 38850301 DOI: 10.1007/s00210-024-03184-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/24/2024] [Indexed: 06/10/2024]
Abstract
The dosing of fluconazole for young infants remains empirical because of the limited pharmacokinetic (PK) data. We aimed to establish a population PK model and assess the systematic exposure-response of commonly used regimens of fluconazole in Chinese infants. We included infants with a postnatal age of less than 120 days and received intravenous fluconazole. Both scheduled and scavenged plasma samples were collected, and fluconzaole concentration was determined by a validated ultra-performance liquid chromatography-tandem mass spectrometry assay. Population PK analysis was conducted using Phoenix NLME, and then Monte Carlo simulation was conducted to predict the probability of target attainment (PTA) of empirically used regimens of both prophylactic and therapeutic purposes. Based on 304 plasma samples from 183 young infants, fluconazole concentration data was best described by a one-compartment model with first-order elimination. Gestational Age (GA), postnatal age (PNA), and body weight (BW) were included in the final model as CL = 0.02*(GA/214)2.77*(PNA/13)0.24*exp(nCL); V = 1.56*(BW/1435)0.90*exp(nV). Model validation revealed the final model had qualified stability and acceptable predictive properties. Monte Carlo simulation indicated that under the same minimum inhibitory concentration (MIC) value and administration regimen, PTA decreased with GA and PNA. The commonly used prophylactic regimens can meet the clinical need, while higher doses might be needed for treatment of invasive candidiasis. This population PK model of fluconazole discriminated the impact of GA and PNA on CL and BW on V. Dosing adjustment was needed according to the GA and PNA of infants to achieve targeted exposures.
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Affiliation(s)
- Honghong Wang
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University,, Beijing, China
| | - Yongjiang Jiang
- Department of Neonatology, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Jing Liang
- Department of Neonatology, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Qiaoai Yu
- Department of Laboratory, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Linghong Kuang
- School of Computer Science and Mathematics, Fujian University of Technology, Fuzhou, Fujian, China
| | - Yuling Huang
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Dongjie Qin
- Pharmaceutical Division, Liuzhou Quality Inspection and Testing Research Center, Liuzhou, Guangxi, China
| | - Ping Li
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Jing He
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Feng Xu
- Department of Pharmacy, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Xueli Li
- Department of Laboratory, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Fei Wang
- Department of Pharmacy, Fujian Provincial Geriatric Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yanfei Wei
- Department of Neonatology, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China.
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University,, Beijing, China.
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de Barros Fernandes T, Ramos SF, Leitzke LRF, Júnior RGA, de Araújo JM, de Souza Júnior AS, da Silva ARO, Heineck I, de França Fonteles MM, Bracken LE, Peak M, de Lyra Junior DP, Osorio-de-Castro CGS, Lima EC. Use of antimicrobials in pediatric wards of five Brazilian hospitals. BMC Pediatr 2024; 24:177. [PMID: 38481225 PMCID: PMC10936065 DOI: 10.1186/s12887-024-04655-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 02/19/2024] [Indexed: 03/17/2024] Open
Abstract
The use of antimicrobials (AMs) in pediatric infections is common practice and use may be inappropriate leading to antimicrobial resistance. Off-label AM use is also common in this group and can result in drug-related problems. There is lack of DUR data in Brazil and in Latin America, specially for AM pediatric use. The aim of this study was to describe the utilization of AMs in hospitalized children in five hospitals in Brazil. We conducted an observational study of the utilization of AMs in pediatric wards in hospitals in the states of Ceará (CE), Sergipe (SE), Rio de Janeiro (RJ), Rio Grande do Sul (RS) and the Federal District (DF). Data derived from patient medical records and prescriptions were collected over a six-month period in each hospital. The number of AMs used by each patient was recorded, and AM use was assessed using Days of therapy (DOT) and Length of therapy (LOT) per 1000 patient days according to different patient characteristics. Off-label (OL) use was described according to age. The study analyzed data from 1020 patients. The sex and age distributions were similar across the five hospitals. However, differences were found for comorbidities, history of ICU admission and length of hospital stay. The most common diseases were respiratory tract infections. There were wide variations in DOT/1000PD (278-517) and LOT/1000PD (265-390). AM utilization was highest in the hospital in SE. The consumption of second-generation penicillins and cephalosporins was high. The prevalence of OL use of AMs was higher for patients in the RJ hospital, in infants, in patients who underwent prolonged hospital stays, and in patients who used multiple AMs. The AM that showed the highest prevalence of OL use was azithromycin, in both oral and parenteral formulations. Overall AM use was high and showed differences in each setting, possibly influenced by local characteristics and by prescribing standards adopted by pediatricians.
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Affiliation(s)
- Thais de Barros Fernandes
- Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, 21041-210, Brazil.
| | - Sheila Feitosa Ramos
- Center for Biological and Health Sciences, Federal University of Western Bahia, Barreiras, Brazil
| | - Luísa Rodrigues Furtado Leitzke
- Postgraduate Program in Pharmaceutical Services, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | | | | | - Isabela Heineck
- Postgraduate Program in Pharmaceutical Services, Faculty of Pharmacy, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Louise E Bracken
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Matthew Peak
- Paediatric Medicines Research Unit, Institute in the Park, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Divaldo Pereira de Lyra Junior
- Health Sciences Graduate Program, Social Pharmacy Teaching and Research Laboratory (LEPFS), Federal University of Sergipe, São Cristóvão, Brazil
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Otto WR, Arendrup MC, Fisher BT. A Practical Guide to Antifungal Susceptibility Testing. J Pediatric Infect Dis Soc 2023; 12:214-221. [PMID: 36882026 PMCID: PMC10305799 DOI: 10.1093/jpids/piad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 03/06/2023] [Indexed: 03/09/2023]
Abstract
We review antifungal susceptibility testing and the development of clinical breakpoints, and detail an approach to using antifungal susceptibility results when breakpoints have not been defined. This information may prove helpful when selecting therapy for invasive fungal infections in children.
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Affiliation(s)
- William R Otto
- Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, Cincinnati Children’s Hospital and Medical Center, Cincinnati, Ohio, USA
| | - Maiken Cavling Arendrup
- Unit of Mycology, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Brian T Fisher
- Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Study of Prescription-Indication of Outpatient Systemic Anti-Fungals in a Colombian Population. A Cross-Sectional Study. Antibiotics (Basel) 2022; 11:antibiotics11121805. [PMID: 36551462 PMCID: PMC9774786 DOI: 10.3390/antibiotics11121805] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022] Open
Abstract
The inappropriate use of antifungals is associated with greater antimicrobial resistance, costs, adverse events, and worse clinical outcomes. The aim of this study was to determine prescription patterns and approved and unapproved indications for systemic antifungals in a group of patients in Colombia. This was a cross-sectional study on indications for the use of systemic antifungals in outpatients from a drug dispensing database of approximately 9.2 million people affiliated with the Colombian Health System. Sociodemographic, pharmacological, and clinical variables were considered. Descriptive, bivariate, and multivariate analyses were performed. A total of 74,603 patients with antifungal prescriptions were identified; they had a median age of 36.0 years (interquartile range: 22.0−53.0 years), and 67.3% of patients were women. Fluconazole (66.5%) was the most prescribed antifungal for indications such as vaginitis, vulvitis, and vulvovaginitis (35.0%). A total of 29.3% of the prescriptions were used in unapproved indications. A total of 96.3% of ketoconazole users used the medication in unapproved indications. Men (OR: 1.91; CI95%: 1.79−2.04), <18 years of age (OR: 1.20; CI95%: 1.11−1.31), from the Caribbean region (OR: 1.26; CI95%: 1.18−1.34), with chronic obstructive pulmonary disease (OR: 1.80; CI95%: 1.27−2.54), prescriptions made by a general practitioner (OR: 1.17; CI95%: 1.04−1.31), receiving comedications (OR: 1.58; CI95%: 1.48−1.69), and the concomitant use of other antimicrobials (OR: 1.77; CI95%: 1.66−1.88) were associated with a higher probability that the antifungal was used for unapproved indications; deep mycosis (OR: 0.49; CI95%: 0.41−0.58), prescribing fluconazole (OR: 0.06; CI95%: 0.06−0.06), and having diabetes mellitus (OR: 0.33; CI95%: 0.29−0.37), cancer (OR: 0.13; CI95%: 0.11−0.16), or HIV (OR: 0.07; CI95%: 0.04−0.09) reduced this risk. Systemic antifungals were mostly used for the management of superficial mycoses, especially at the gynecological level. In addition, more than a quarter of patients received these medications in unapproved indications, and there was broad inappropriate use of ketoconazole.
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Characteristics of antifungal utilization for hospitalized children in the United States. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e190. [PMID: 36505943 PMCID: PMC9726632 DOI: 10.1017/ash.2022.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 12/05/2022]
Abstract
Objective To characterize antifungal prescribing patterns, including the indication for antifungal use, in hospitalized children across the United States. Design We analyzed antifungal prescribing data from 32 hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a cross-sectional point-prevalence survey conducted between June 2016 and December 2017. Methods Inpatients aged <18 years with an active systemic antifungal order were included in the analysis. We classified antifungal prescribing by indication (ie, prophylaxis, empiric, targeted), and we compared the proportion of patients in each category based on patient and antifungal characteristics. Results Among 34,927 surveyed patients, 2,095 (6%) received at least 1 systemic antifungal and there were 2,207 antifungal prescriptions. Most patients had an underlying oncology or bone marrow transplant diagnosis (57%) or were premature (13%). The most prescribed antifungal was fluconazole (48%) and the most common indication for antifungal use was prophylaxis (64%). Of 2,095 patients receiving antifungals, 79 (4%) were prescribed >1 antifungal, most often as targeted therapy (48%). The antifungal prescribing rate ranged from 13.6 to 131.2 antifungals per 1,000 patients across hospitals (P < .001). Conclusions Most antifungal use in hospitalized children was for prophylaxis, and the rate of antifungal prescribing varied significantly across hospitals. Potential targets for antifungal stewardship efforts include high-risk, high-utilization populations, such as oncology and bone marrow transplant patients, and specific patterns of utilization, including prophylactic and combination antifungal therapy.
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Kaur H, Krishnamoorthi S, Dhaliwal N, Biswal M, Singh S, Muthu V, Rudramurthy SM, Agarwal R, Ghoshal S, Singh S, Malhotra P, Jain S, Samujh R, Ghosh A, Chakrabarti A. Antifungal prescription practices and consumption in a tertiary care hospital of a developing country. Mycoses 2022; 65:935-945. [PMID: 35934811 DOI: 10.1111/myc.13514] [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: 04/11/2022] [Revised: 07/12/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antifungal stewardship is a less explored component of antimicrobial stewardship programmes, especially in developing countries. OBJECTIVE We aimed to determine antifungal prescription practices in a tertiary centre of a developing country to identify the challenges for antifungal stewardship programmes. METHODS Four single-day point prevalent surveys were performed in inpatient units and data were collected from medical records. Antifungal use was recorded in terms of consumption, therapeutic strategies and appropriateness. RESULTS We found a 2.42%-point prevalence of antifungal prescriptions. Antifungal use was higher in children than adults (4.1% vs. 2.03%), medical than surgical units (3.7% vs. 1.24%) and ICUs than general wards (5.8% vs. 1.9%). The highest antifungal use was observed in the haematology-oncology units (29.3%) followed by emergency (16.2%) and gastroenterology units (11.6%). Among 215 prescriptions, amphotericin B was the most commonly prescribed (50.2%) followed by fluconazole (31.6%). The targeted antifungal therapy was practised more commonly (31.5%) than empiric (29.1%), pre-emptive (22.6%) and prophylactic (16.8%) therapy. Amphotericin B was commonly used for pre-emptive (p = .001) and targeted (p = .049) therapy, while fluconazole (p = .001) and voriconazole (p = .011) for prophylaxis. The prescriptions were inappropriate in 25.1% due to the wrong choice of antifungal (44.4%), indication (27.7%) and dosage (24%). The overall mean antifungal consumption was 2.71 DDD/1000 PD and 8.96 DOT/1000 PD. CONCLUSIONS We report here the low prevalence of antifungal use at a tertiary care centre in a developing country. Though training for antifungal use would be important for antifungal stewardship, the challenge would remain with the affordability of antifungals.
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Affiliation(s)
- Harsimran Kaur
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Navneet Dhaliwal
- Department of Hospital Administration, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manisha Biswal
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shreya Singh
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sushmita Ghoshal
- Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Department of Paediatric Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology & Medical Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ram Samujh
- Department of Paediatric Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anup Ghosh
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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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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Keighley C, Cooley L, Morris AJ, Ritchie D, Clark JE, Boan P, Worth LJ. Consensus guidelines for the diagnosis and management of invasive candidiasis in haematology, oncology and intensive care settings, 2021. Intern Med J 2021; 51 Suppl 7:89-117. [DOI: 10.1111/imj.15589] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Caitlin Keighley
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney Camperdown New South Wales Australia
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, New South Wales Health Pathology Westmead New South Wales Australia
- Southern IML Pathology, Sonic Healthcare Coniston New South Wales Australia
| | - Louise Cooley
- Department of Microbiology and Infectious Diseases Royal Hobart Hospital Hobart Tasmania Australia
- University of Tasmania Hobart Tasmania Australia
| | - Arthur J. Morris
- LabPLUS, Clinical Microbiology Laboratory Auckland City Hospital Auckland New Zealand
| | - David Ritchie
- Department of Clinical Haematology Peter MacCallum Cancer Centre and Royal Melbourne Hospital Melbourne Victoria Australia
| | - Julia E. Clark
- Department of Infection Management Queensland Children's Hospital, Children's Health Queensland Brisbane Queensland Australia
- Child Health Research Centre The University of Queensland Brisbane Queensland Australia
| | - Peter Boan
- PathWest Laboratory Medicine WA, Department of Microbiology Fiona Stanley Fremantle Hospitals Group Murdoch Western Australia Australia
- Department of Infectious Diseases Fiona Stanley Fremantle Hospitals Group Murdoch Western Australia Australia
| | - Leon J. Worth
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne Victoria Australia
- Department of Infectious Diseases Peter MacCallum Cancer Centre Melbourne Victoria Australia
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McMullan BJ, Hall L, James R, Mostaghim M, Jones CA, Konecny P, Blyth CC, Thursky KA. Antibiotic appropriateness and guideline adherence in hospitalized children: results of a nationwide study. J Antimicrob Chemother 2021; 75:738-746. [PMID: 31697335 DOI: 10.1093/jac/dkz474] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 10/01/2019] [Accepted: 10/16/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Information on the nature and appropriateness of antibiotic prescribing for children in hospitals is important, but scarce. OBJECTIVES To analyse antimicrobial prescribing and appropriateness, and guideline adherence, in hospitalized children across Australia. PATIENTS AND METHODS We analysed data from the National Antimicrobial Prescribing Survey (NAPS) from 2014 to 2017. Surveys were performed in hospital facilities of all types (public and private; major city, regional and remote). Participants were admitted children <18 years old. Risk factors associated with inappropriate prescribing were explored using logistic regression models. RESULTS Among 6219 prescriptions for 3715 children in 253 facilities, 19.6% of prescriptions were deemed inappropriate. Risk factors for inappropriate prescribing included non-tertiary paediatric hospital admission [OR 1.37 (95% CI 1.20-1.55)] and non-major city hospital location [OR 1.52 (95% CI 1.30-1.77)]. Prescriptions for neonates, immunocompromised children and those admitted to an ICU were less frequently inappropriate. If a restricted antimicrobial was prescribed and not approved, the prescription was more likely to be inappropriate [OR 12.9 (95% CI 8.4-19.8)]. Surgical prophylaxis was inappropriate in 59% of prescriptions. CONCLUSIONS Inappropriate antimicrobial prescribing in children was linked to specific risk factors identified here, presenting opportunities for targeted interventions to improve prescribing. This information, using a NAPS dataset, allows for analysis of antimicrobial prescribing among different groups of hospitalized children. Further exploration of barriers to appropriate prescribing and facilitators of best practice in this population is recommended.
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Affiliation(s)
- Brendan J McMullan
- National Centre for Infections in Cancer, University of Melbourne, Melbourne, Australia.,Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Lisa Hall
- School of Public Health, University of Queensland, Brisbane, Australia
| | - Rodney James
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Mona Mostaghim
- Department of Pharmacy, Sydney Children's Hospital, Randwick, Sydney, Australia
| | - Cheryl A Jones
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Pamela Konecny
- Department of Infectious Diseases, Immunology & Sexual Health, St George Hospital, Kogarah, Sydney, Australia.,St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
| | - Christopher C Blyth
- School of Medicine, University of Western Australia, Perth, Australia.,Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia.,Department of Paediatric Infectious Diseases, Perth Children's Hospital, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Perth, Australia
| | - Karin A Thursky
- National Centre for Antimicrobial Stewardship, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
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11
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Ferreras-Antolin L, Bielicki J, Warris A, Sharland M, Hsia Y. Global Divergence of Antifungal Prescribing Patterns: Data From the Global Antimicrobial Resistance, Prescribing, and Efficacy in Neonates and Children Surveys. Pediatr Infect Dis J 2021; 40:327-332. [PMID: 33710977 DOI: 10.1097/inf.0000000000002983] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Globally, invasive fungal diseases (IFDs) have a significant impact in human health. With an increasing pediatric population at risk of IFD, effective antifungal drugs access and affordability should be ensured universally. The aim of our study was to characterize the global antifungal drug use in neonates and children and its variability between countries in different income groups. METHODS Data were extracted from the Global Antimicrobial Resistance, Prescribing and Efficacy in Neonates and Children Point Prevalence Survey project, consisting in 1 pilot and four 1-day Point Prevalence Survey between 2015 and 2017. The data had been entered through a study-specific web-based data collection tool. RESULTS From a total of 13,410 children included, 7.8% (1048/13,410) received at least 1 systemic antifungal drug: 9.5% (95% confidence interval: 8.9%-10.1%) in high income countries (HIC) versus 5.0% (95% confidence interval: 4.4%-5.6%) in low-middle income countries (LMIC) (P < 0.01). A significant proportion of patients on antifungals belonged to high-risk group for IFD (67.4%; 706/1048); most of these were managed in HIC (72.8%, P < 0.01). The likelihood of receiving antifungals being in high-risk group was higher in HIC compared with LMIC (ratio of 5.8 vs. 3.4, P < 0.01). Antifungal prophylaxis was more likely prescribed in HIC (67.2% vs. 30.4%, P < 0.01). Fluconazole was the most frequently prescribed drug. The proportional use of fluconazole was higher in LMIC compared with HIC. CONCLUSIONS A significant variability of antifungal prescribing patterns was observed. The proportional use of systemic antifungals was twice as high in HIC compared with LMIC. More detailed data on access and antifungal use in limited-resource settings should be explored.
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Affiliation(s)
- Laura Ferreras-Antolin
- From the Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, United Kingdom
- MRC Centre for Medical Mycology, University of Exeter, United Kingdom
| | - Julia Bielicki
- From the Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, United Kingdom
- Paediatric Pharmacology Group, University of Basel Children's Hospital, Basel, Switzerland
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, United Kingdom
- Paediatric Infectious Diseases, Great Ormond Street Hospital, London, United Kingdom
| | - Mike Sharland
- From the Paediatric Infectious Diseases Research Group, Infection and Immunity, St George's University of London, London, United Kingdom
| | - Yingfen Hsia
- MRC Centre for Medical Mycology, University of Exeter, United Kingdom
- School of Pharmacy, Queens' University Belfast, Belfast, United Kingdom
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Antifungal stewardship in a tertiary care paediatric hospital: the PROAFUNGI study. BMC Infect Dis 2021; 21:100. [PMID: 33482749 PMCID: PMC7821674 DOI: 10.1186/s12879-021-05774-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/06/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The increasing use of antifungal drugs (AF) in children and the concern for related adverse events and costs has led to the development of specific AF stewardship programmes (AFS). Studies in adult patients have shown improvements in AF prescription and usage after implementation, but paediatric data are scant. The aim of this PROAFUNGI study was to describe the use and appropriateness of AF in a high complexity paediatric centre. METHODS Observational, prospective, single-centre, modified point-prevalence study (11 surveys, July-October 2018), including paediatric (< 18 years) patients receiving at least one systemic AF. Prescriptions were evaluated by the AFS team. RESULTS The study included 119 prescriptions in 55 patients (53% males, median age 8.7 years [IQR 2.4-13.8]). The main underlying condition was cancer (45.5% of patients; HSCT in 60% of them); and the first indication for AF was prophylaxis (75 prescriptions, 63.2%). Liposomal amphotericin B was used most commonly (46% prescriptions), mainly as prophylaxis (75%). Among the 219 evaluations, 195 (89%) were considered optimal. The reason for non-optimal prescriptions was mostly lack of indication (14/24), especially in critical patients with ventricular assist devices. The use of AF without paediatric approval accounted for 8/24 inappropriate prescriptions. CONCLUSIONS A high rate of AF appropriateness was found for the children's hospital as a whole, in relation with a well-established AFS. Nonetheless, the identification of specific areas of improvement should guide future actions of the AFS team, which will focus mainly on prophylaxis in critically ill patients receiving circulatory assistance and the use of non-approved drugs in children.
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The current state of antifungal stewardship among pediatric antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2020; 41:1279-1284. [PMID: 32662383 DOI: 10.1017/ice.2020.306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To characterize the current state of antifungal stewardship practices and perceptions of antifungal use among pediatric antimicrobial stewardship programs (ASPs). DESIGN We developed and distributed an electronic survey, which included 17 closed-ended questions about institutional antifungal stewardship practices and perceptions, among pediatric ASPs. PARTICIPANTS ASP physicians and pharmacists of 74 hospitals participating in the multicenter Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative. RESULTS We sent surveys to 74 hospitals and received 68 unique responses, for a response rate of 92%. Overall, 63 of 68 the respondent ASPs (93%) reported that they conduct 1 or more antifungal stewardship activities. Of these 68 hospital ASPs, 43 (63%) perform prospective audit and feedback (PAF) of antifungals. The most common reasons reported for not performing PAF of antifungals were not enough time or resources (19 of 25, 76%) and minimal institutional antifungal use (6 of 25, 24%). Also, 52 hospitals (76%) require preauthorization for 1 or more antifungal agents. The most commonly restricted antifungals were isavuconazole (42 of 52 hospitals, 80%) and posaconazole (39 of 52 hospitals, 75%). Furthermore, 33 ASPs (48%) agreed or strongly agreed that antifungals are inappropriately used at their institution, and only 25 of 68 (37%) of ASPs felt very confident making recommendations about antifungals. CONCLUSIONS Most pediatric ASPs steward antifungals, but the strategies employed are highly variable across surveyed institutions. Although nearly half of respondents identified inappropriate antifungal use as a problem at their institution, most ASPs do not feel confident making recommendations about antifungals. Future studies are needed to determine the rate of inappropriate antifungal use and the best antifungal stewardship strategies.
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Santiago-García B, Rincón-López EM, Ponce Salas B, Aguilar de la Red Y, Garrido Colino C, Martínez Fernández-Llamazares C, Saavedra-Lozano J, Hernández-Sampelayo Matos T. Effect of an intervention to improve the prescription of antifungals in pediatric hematology-oncology. Pediatr Blood Cancer 2020; 67:e27963. [PMID: 31407514 DOI: 10.1002/pbc.27963] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The use of antifungals has expanded in pediatric hematology-oncology, and the need to develop pediatric-based surveillance and education activities is becoming crucial. The aims of this study were to evaluate the impact of a multidisciplinary protocol on the adequacy of antifungal prescription in a pediatric hematology-oncology unit and to assess the effect of an educational intervention to improve the knowledge of prescribing pediatricians over time. METHODS A multidisciplinary team established a protocol for the management of invasive fungal disease (IFD). The use of antifungals before (January 2012-May 2013) and after the protocol (June 2013-December 2015) was evaluated. Prescribing pediatricians attended a training course on IFD and were evaluated before 0, 6, and 12 months after the intervention. RESULTS During the study period, antifungal agents were used in 185 episodes (56 children, 39.3% females), and were administered as prophylaxis (58.9%), empiric (34.6%), or targeted therapy (6.5%). Antifungal prescriptions were inadequate in 7% of the episodes, related to drug selection (53.8%), dosage (38.5%) and route of administration (7.7%). After protocol implementation, inadequate prescriptions decreased 9.9% (15.2% vs 5.3%; P = .04). Following the educational activity, the percentage of adequate responses to the questionnaire improved significantly compared to baseline, and persisted over time (19.7% improvement at 0 months [P < .0001]; 21.1% at 6 months [P < .0001]; 16.6% at 12 months [P = .002]). CONCLUSIONS The establishment of multidisciplinary protocols and education activities improved the quality of antifungal prescription and the knowledge of prescribers regarding antifungal therapy. Therefore, these activities may be important for the implementation of antifungal stewardship programs in pediatrics.
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Affiliation(s)
- Begoña Santiago-García
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Elena María Rincón-López
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
| | | | | | - Carmen Garrido Colino
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, Gregorio Marañón Hospital, Madrid, Spain
| | | | - Jesús Saavedra-Lozano
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Teresa Hernández-Sampelayo Matos
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
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- Pediatric Infectious Diseases Unit, Department of Pediatrics, Gregorio Marañón Hospital, Gregorio Marañón Health Research Institute, Madrid, Spain
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15
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Abstract
Abstract
Infections belong to the most serious health problems in neonates. Invasive candidiases are one of the leading causes of mortality and morbidity in Neonatal intensive care units (NICUs). A more cautious approach is adequate when dealing with fungal infections in premature neonates. Sometimes it is necessary to cure an infection at the very beginning just before manifestation of clinical symptoms. Neonatal colonization due to Candida albicans or non-albicans Candidae predisposes to invasive candidiasis. Pregnancies complicated by preterm delivery should be considered for screening and treatment of maternal Candida colonization to decrease the occurrence of neonatal fungal colonization and its consequences. It is important to prevent infection to spread among patients and avoid complications. Prophylaxis in neonates must be safe and effective. Most authors prefer selective prophylaxis. Fluconazole is the drug of choice for prophylaxis in extremely low birth weight (ELBW) neonates. The prophylaxis is beneficial especially in NICUs with high rates of invasive candidiases. The authors describe benefits and trends in prophylaxis. They also summarize evidence on timing, dosing, and effect of fluconazole prophylaxis.
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Neonatal Antifungal Consumption Is Dominated by Prophylactic Use; Outcomes From The Pediatric Antifungal Stewardship: Optimizing Antifungal Prescription Study. Pediatr Infect Dis J 2019; 38:1219-1223. [PMID: 31568253 DOI: 10.1097/inf.0000000000002463] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Diagnostic challenges combined with the vulnerability of neonates to develop invasive candidiasis (IC) may lead to antifungal administration in the absence of IC. A modified point-prevalence study was performed to obtain an improved insight and understanding of antifungal prescribing in this specific patient population. METHODS Neonates and infants ≤90 days of age receiving systemic antifungals from 12 centers in England were included. Data were collected prospectively during 26 consecutive weeks and entered into an online REDCap database. RESULTS Two hundred eighty neonates and infants were included, the majority ≤1 month of age (68.2%). Prematurity was the commonest underlying condition (68.9%). Antifungals were prescribed for prophylactic reason in 79.6%; of those, 64.6% and 76.3% were extreme low birth weight infants and prematurely born neonates, respectively. Additional risk factors were present in almost all patients, but only 44.7% had ≥3 risk factors rendering them more susceptible to develop IC. Nonpremature and non extremely low birth weight premature infants only scored ≥3 risk factors in 32.6% and 15%, respectively. Fluconazole was the most common antifungal used (76.7% of all prescriptions), and commonly underdosed as treatment. The number of microbiologic proven IC was low, 5.4%. CONCLUSIONS Neonatal antifungal prophylaxis is commonly prescribed outside the recommendations based on known risk profiles. Fluconazole is the main antifungal prescribed in neonates and infants, with underdosing frequently observed when prescribed for treatment. Number of proven IC was very low. These observations should be taken into consideration to develop a national pediatric Antifungal Stewardship program aiming to guide rational prescribing.
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Muldaeva G, Beisenayeva A, Arystan L, Baymanova A, Haydargaliyeva L, Beisenayeva A. The Point Prevalence Survey Research of Antibacterial Drugs' Prescription for Outpatient Treatment of Urinary System Infections. Open Access Maced J Med Sci 2019; 7:2551-2555. [PMID: 31666863 PMCID: PMC6814458 DOI: 10.3889/oamjms.2019.622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/14/2019] [Accepted: 07/15/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND: Antibiotic resistance of microorganisms is the subject of numerous discussions and initiatives, it has a well-defined tendency to increase which is largely related to a big number of errors when prescribing antibacterial drugs at the outpatient stage of treatment and disease prevention, as well as a lack of information and data on the quantity and quality of antimicrobial therapy. One of the elements aimed at reducing antibiotic resistance growth is audit and analysis of application practice. AIM: To assess qualitative and quantitative characteristics for urinary tract infections treatment using antimicrobial drugs by general physicians at the outpatient level. MATERIALS AND METHODS: The Point Prevalence Survey (PPS) analysis of antimicrobial drugs prescription was conducted by general physicians of No. 1, 4, 5 Hospitals of Karaganda city. There was carried out a daily prospectively data collecting on antibacterial drugs prescription by Doctor of Medical institutions, which was performed during patients’ visit. For each person who was prescribed the AD, there was filled a special questionnaire developed by the European Center for Disease Prevention and Control, including passport data, data on disease and prescription of antibacterial drugs. There were considered 200 cases of antibiotic prescription. The study included patients of both sexes, all age groups, who were prescribed the antibiotic therapy for the UTI treatment. RESULTS: When selecting antimicrobial therapy, the Protocols for diagnosis and treatment indicate the need for a microbiological study to determine sensitivity to antibacterial drugs, that was not performed in 100% of cases, and initial treatment was empirically prescribed, namely, in 34% of cases there were used drugs from the cephalosporin group (Ceftriaxone), nitrofurans (Furazidin)-42%, fluoroquinolones (Levofloxacin)-24%. In treating acute cystitis, in most cases, alternative medications were prescribed, though according to current recommendations, first-line therapy includes fosfomycin trometamol, pivmecillins and nitrofurantoin macrocrystals, which according to the results of this study were not used at all. CONCLUSION: In most cases (71%), alternative antibacterial drugs were prescribed for initial treatment of urinary tract infections. In majority cases, the dosage regimen of antibacterial drugs, dosage frequency, treatment course did not meet current recommendations.
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Affiliation(s)
- Gulmira Muldaeva
- Department of General Medical Practice No. 2, Non-Profit Joint-Stock Company "Karaganda Medical University", Karaganda, Kazakhstan
| | - Aizhan Beisenayeva
- Department of General Medical Practice No. 2, Non-Profit Joint-Stock Company "Karaganda Medical University", Karaganda, Kazakhstan
| | - Leila Arystan
- Department of General Medical Practice No. 2, Non-Profit Joint-Stock Company "Karaganda Medical University", Karaganda, Kazakhstan
| | - Aliya Baymanova
- Department of General Medical Practice No. 2, Non-Profit Joint-Stock Company "Karaganda Medical University", Karaganda, Kazakhstan
| | - Leila Haydargaliyeva
- Department of General Medical Practice No. 2, Non-Profit Joint-Stock Company "Karaganda Medical University", Karaganda, Kazakhstan
| | - Anel Beisenayeva
- Department of Oncology and Radiology, Non-Profit Joint-Stock Company "Karaganda Medical University", Karaganda, Kazakhstan
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Abstract
Invasive fungal diseases (IFD) are an important cause of morbidity and mortality in premature neonates and immunocompromised pediatric patients. Their diagnostic and therapeutic management remains a challenge. A nationwide survey was conducted among 13 of the largest pediatric units in the United Kingdom, to obtain insight in the current management of IFD in neonates and children. All responding centers were tertiary teaching centers. The use of fungal diagnostic tools and imaging modalities varied among centers. Antifungal prophylaxis was prescribed in most centers for extreme-low birth weight (LBW) infants and high-risk hemato-oncologic patients, but with a huge variety in antifungals given. An empirical treatment was favored by most centers in case of febrile neutropenia. First line therapy for candidemia consists of either fluconazole or liposomal amphotericin B, with voriconazole being first-line therapy for invasive aspergillosis. Disseminated invasive aspergillosis was most often mentioned as a reason to prescribe combination antifungal therapy. In conclusion, this survey reinforces the fact that there are still important aspects in the management of pediatric IFD which should ideally be addressed in pediatric clinical trials. Attention needs to be given the knowledge gaps as observed in the results of our survey to optimize the management of IFD in children and neonates.
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Affiliation(s)
- Laura Ferreras-Antolín
- From the MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Paediatric Infectious Diseases Research Group, St. George's Hospital, St. George´s University London, University of London, London, United Kingdom
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St. George's Hospital, St. George´s University London, University of London, London, United Kingdom
| | - Adilia Warris
- From the MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Royal Aberdeen Children's Hospital, Aberdeen, United Kingdom
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Pfaller MA, Diekema DJ, Turnidge JD, Castanheira M, Jones RN. Twenty Years of the SENTRY Antifungal Surveillance Program: Results for Candida Species From 1997-2016. Open Forum Infect Dis 2019; 6:S79-S94. [PMID: 30895218 PMCID: PMC6419901 DOI: 10.1093/ofid/ofy358] [Citation(s) in RCA: 418] [Impact Index Per Article: 83.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background The emergence of antifungal resistance threatens effective treatment of invasive fungal infection (IFI). Invasive candidiasis is the most common health care–associated IFI. We evaluated the activity of fluconazole (FLU) against 20 788 invasive isolates of Candida (37 species) collected from 135 medical centers in 39 countries (1997–2016). The activity of anidulafungin, caspofungin, and micafungin (MCF) was evaluated against 15 308 isolates worldwide (2006–2016). Methods Species identification was accomplished using phenotypic (1997–2001), genotypic, and proteomic methods (2006–2016). All isolates were tested using reference methods and clinical breakpoints published in the Clinical and Laboratory Standards Institute documents. Results A decrease in the isolation of Candida albicans and an increase in the isolation of Candida glabrata and Candida parapsilosis were observed over time. Candida glabrata was the most common non–C. albicans species detected in all geographic regions except for Latin America, where C. parapsilosis and Candida tropicalis were more common. Six Candida auris isolates were detected: 1 each in 2009, 2013, 2014, and 2015 and 2 in 2016; all were from nosocomial bloodstream infections and were FLU-resistant (R). The highest rates of FLU-R isolates were seen in C. glabrata from North America (NA; 10.6%) and in C. tropicalis from the Asia-Pacific region (9.2%). A steady increase in isolation of C. glabrata and resistance to FLU was detected over 20 years in the United States. Echinocandin-R (EC-R) ranged from 3.5% for C. glabrata to 0.1% for C. albicans and C. parapsilosis. Resistance to MCF was highest among C. glabrata (2.8%) and C. tropicalis (1.3%) from NA. Mutations on FKS hot spot (HS) regions were detected among 70 EC-R isolates (51/70 were C. glabrata). Most isolates harboring FKS HS mutations were resistant to 2 or more ECs. Conclusions EC-R and FLU-R remain uncommon among contemporary Candida isolates; however, a slow and steady emergence of resistance to both antifungal classes was observed in C. glabrata and C. tropicalis isolates.
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Affiliation(s)
- Michael A Pfaller
- JMI Laboratories, North Liberty, Iowa.,University of Iowa College of Medicine, Iowa City, Iowa
| | | | - John D Turnidge
- Departments of Pathology and Molecular and Cellular Biology, University of Adelaide, Adelaide, SA, Australia
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Invasive Aspergillosis in Pediatric Leukemia Patients: Prevention and Treatment. J Fungi (Basel) 2019; 5:jof5010014. [PMID: 30754630 PMCID: PMC6463058 DOI: 10.3390/jof5010014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 12/16/2022] Open
Abstract
The purpose of this article is to review and update the strategies for prevention and treatment of invasive aspergillosis (IA) in pediatric patients with leukemia and in patients with hematopoietic stem cell transplantation. The major risk factors associated with IA will be described since their recognition constitutes the first step of prevention. The latter is further analyzed into chemoprophylaxis and non-pharmacologic approaches. Triazoles are the mainstay of anti-fungal prophylaxis while the other measures revolve around reducing exposure to mold spores. Three levels of treatment have been identified: (a) empiric, (b) pre-emptive, and (c) targeted treatment. Empiric is initiated in febrile neutropenic patients and uses mainly caspofungin and liposomal amphotericin B (LAMB). Pre-emptive is a diagnostic driven approach attempting to reduce unnecessary use of anti-fungals. Treatment targeted at proven or probable IA is age-dependent, with voriconazole and LAMB being the cornerstones in >2yrs and <2yrs age groups, respectively.
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Najmi A, Sadasivam B, Jhaj R, Atal S, Kumar S, Santenna C. A pilot point prevalence study of antimicrobial drugs in indoor patients of a teaching hospital in Central India. J Family Med Prim Care 2019; 8:2212-2217. [PMID: 31463232 PMCID: PMC6691475 DOI: 10.4103/jfmpc.jfmpc_430_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Aim To evaluate the point prevalence of antimicrobial drug use by using point prevalence survey method. Methodology A cross-sectional point prevalence study was done on patients admitted in AIIMS Bhopal hospital. This study included all inpatients receiving an antimicrobial that were on the ward at 8 AM on a specific day in May 2018. Information regarding age, gender, occupation, income group, diagnosis, patient's present/past medical history, treatment, any adverse drug reactions, and investigations are recorded in a pro forma. Results A total of 77 patients (31.95%) were included out of total 241 patients who received at least one antimicrobial. Of patients who received at least one antimicrobial, diagnosis was mentioned in 83.11% of prescriptions. Targeted treatment was given to 10.38% of patients. Reasons for antimicrobial were recorded in 12.98% of patients. Most common healthcare infection recorded was catheter-associated urinary tract infections followed by postoperative surgical site infections. Penicillin with beta lactamase inhibitors was most commonly prescribed antibiotic group followed by third generation cephalosporins and fluoroquinolones. Stop or review date was recorded in 19.48% of patients. Parenteral administration was given to 30.55% of patients. Compliance to guidelines was followed in 64.11% of patients. Local antibiotic guideline and antibiogram were available in hospital. Biomarkers were utilized in 9.77% of patients to guide the choice of therapy. Conclusion Availability of antibiotic policy, antibiogram, local antibiotic guidelines, drugs, and therapeutic committee were some of the encouraging findings. Diagnosis was mentioned in majority of prescriptions. Most patients were prescribed oral antimicrobial drugs, which can reduce complications with parenteral route. Underutilizations of microbiological facilities, prolonged use of antibiotics for surgical prophylaxis, and polypharmacy were areas of concern.
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Affiliation(s)
- Ahmad Najmi
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Balakrishnan Sadasivam
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Ratinder Jhaj
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Shubham Atal
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Sunil Kumar
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - C Santenna
- Department of Pharmacology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Antifungal Treatment and Outcome in Very Low Birth Weight Infants: A Population-based Observational Study of the German Neonatal Network. Pediatr Infect Dis J 2018; 37:1165-1171. [PMID: 29601449 DOI: 10.1097/inf.0000000000002001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The diagnostic proof of fungal infection in preterm infants is difficult. Antifungal treatment (AFT) is often initiated empirically when infants with suspected infection do not improve despite broad-spectrum antibiotic therapy. It was the aim of our study to determine the rate of exposure to empirical AFT in a large cohort of very low birth weight infants (VLBWI) of the German Neonatal Network and to address associated risks and outcomes. METHODS The epidemiologic database consisted of n = 13,343 VLBWI born in 54 German Neonatal Network centers between 2009 and 2015. AFT was defined as number of neonates who got any dose of at least one of the following antifungal drugs: fluconazole, amphotericin B, voriconazole and caspofungin (denominator: number of infants enrolled in German Neonatal Network) for treatment (not prophylaxis) of (suspected) fungal infection. Univariate and logistic regression analyses were used to identify risk factors for exposure to AFT and associated short-term morbidities and long-term outcomes at 5-year follow-up. RESULTS In our cohort, 724 out of 13,343 (5.4%) VLBWI were exposed to empiric AFT and had a mean gestational age of 25.7 (±2.1) weeks. Forty-four out of 13,343 (0.3%) had proven bloodstream infection with Candida spp. The main risk factors for exposure to AFT were gestational age, postnatal steroid treatment, need for abdominal surgery and use of carbapenems. Notably, AFT was associated with adverse outcomes such as bronchopulmonary dysplasia [adjusted odds ratio (OR): 1.9; 95% confidence interval (CI): 1.6-2.3; P < 0.001) and retinopathy of prematurity requiring intervention (adjusted OR: 1.69; 95% CI: 1.3-2.3; P <0.001) but not mortality. In the subgroup of infants available for 5-year follow-up (n = 895), exposure to AFT was associated with a risk for cerebral palsy (adjusted OR: 2.79; 95% CI: 1.11-7.04; P = 0.04) and intelligence quotient < 85 (adjusted OR: 2.07; 95% CI: 1.01-4.28; P = 0.049). CONCLUSIONS A significant proportion of VLBWI is exposed to AFT, specifically those born <26 weeks. Exposed infants were found to have a higher risk for adverse outcomes, which may reflect their significant vulnerability in general. Given the observational design of our study, it remains unclear whether potential side effects of empirical or target AFT itself contribute to adverse outcome. Future studies need to include risk-based strategies and stewardship programs to restrict the use of antifungal management in VLBWI.
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Iosifidis E, Papachristou S, Roilides E. Advances in the Treatment of Mycoses in Pediatric Patients. J Fungi (Basel) 2018; 4:E115. [PMID: 30314389 PMCID: PMC6308938 DOI: 10.3390/jof4040115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/05/2018] [Accepted: 10/07/2018] [Indexed: 12/16/2022] Open
Abstract
The main indications for antifungal drug administration in pediatrics are reviewed as well as an update of the data of antifungal agents and antifungal policies performed. Specifically, antifungal therapy in three main areas is updated as follows: a) Prophylaxis of premature neonates against invasive candidiasis; b) management of candidemia and meningoencephalitis in neonates; and c) prophylaxis, empiric therapy, and targeted antifungal therapy in children with primary or secondary immunodeficiencies. Fluconazole remains the most frequent antifungal prophylactic agent given to high-risk neonates and children. However, the emergence of fluconazole resistance, particularly in non-albicans Candida species, should be considered during preventive or empiric therapy. In very-low birth-weight neonates, although fluconazole is used as antifungal prophylaxis in neonatal intensive care units (NICU's) with relatively high incidence of invasive candidiasis (IC), its role is under continuous debate. Amphotericin B, primarily in its liposomal formulation, remains the mainstay of therapy for treating neonatal and pediatric yeast and mold infections. Voriconazole is indicated for mold infections except for mucormycosis in children >2 years. Newer triazoles-such as posaconazole and isavuconazole-as well as echinocandins, are either licensed or under study for first-line or salvage therapy, whereas combination therapy is kept for refractory cases.
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Affiliation(s)
- Elias Iosifidis
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
| | - Savvas Papachristou
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Faculty of Medicine, Aristotle University School of Health Sciences, Konstantinoupoleos 49, 54642, Thessaloniki, Greece.
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Stultz JS, Kohinke R, Pakyz AL. Variability in antifungal utilization among neonatal, pediatric, and adult inpatients in academic medical centers throughout the United States of America. BMC Infect Dis 2018; 18:501. [PMID: 30285738 PMCID: PMC6171307 DOI: 10.1186/s12879-018-3410-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/23/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Identification of factors associated with antifungal utilization in neonatal, pediatric, and adult patient groups is needed to guide antifungal stewardship initiatives in academic medical centers. METHODS For this hospital-level analysis, we analyzed antifungal use in hospitals across the United States of America, excluding centers only providing care for hematology/oncology patients. Analysis of variance was used to compare antifungal use between patient groups. Three multivariable linear regression models were used to determine independent factors associated with antifungal use in the neonatal, pediatric, and adult patient groups. RESULTS For the neonatal, pediatric, and adult patient groups, 54, 44, and 60 hospitals were included, respectively. Total antifungal use was significantly lower in the neonatal patient group (14 days of therapy (DOT)/1000 patient days (PDs) versus 76 in pediatrics and 74 in adults, p < 0.05). There were no significant associations identified with total antifungal DOT/1000 PDs in the neonatal patient group (model R2 = 0.11). In the pediatric patient group (model R2 = 0.55), admission to immunosuppressed service lines and total broad-spectrum antibiotic use were positively associated with total antifungal use (coefficients of 1.95 and 0.41, both p < 0.05). In the adult patient group (model R2 = 0.79), admission to immunosuppressed service lines, total invasive fungal infections, and total broad-spectrum antibiotic use were positively associated with total antifungal use (coefficients of 5.08, 5.17, and 0.137, all p < 0.05). CONCLUSIONS Variability in antifungal use in the neonatal group could not be explained well, whereas factors were associated with antifungal use in the adult and pediatric patient groups. These data can help guide antifungal stewardship initiatives.
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Affiliation(s)
- Jeremy S. Stultz
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, The University of Tennessee Health Science Center, 881 Madison Avenue, Room 223, Memphis, TN 38163 USA
| | - Rose Kohinke
- Carilion Roanoke Memorial Hospital, Roanoke, VA USA
| | - Amy L. Pakyz
- School of Pharmacy, Virginia Commonwealth University, Richmond, VA USA
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25
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Çağlar İ, Devrim İ, Özdemir H, Şahbudak Z, Sönmez G, Buyukcam A, Gulhan B, Kara A, Aygun DF, Bayram N, Celebi S, Çetin B, Nepesov MI, Yilmaz AT, Kepenekli E, Çiftdogan DY, Acar MK, Yayla BC, Okumuş C, Ecevit Z, Hatipoglu N, Kuyucu N, Kosker M, Sen S, Karbuz A, Sutcu M, Duramaz BB, Özen M, Çiftçi E, Alabaz D, Kurugol Z, Kara A, Kanik S, Kilic O, Oncel S, Somer A, Tapisiz A, Belet N, Akcan ÖM, Türel Ö, Ozkaya A, Tezer H, Cengiz AB, İnce E, Camcioglu Y, Kocabas E, Arisoy ES, Salman N. Antifungal consumption, indications and selection of antifungal drugs in paediatric tertiary hospitals in Turkey: Results from the first national point prevalence survey. J Glob Antimicrob Resist 2018; 15:232-238. [PMID: 30121343 DOI: 10.1016/j.jgar.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The aim of this point prevalence survey was to evaluate the consumption, indications and strategies of antifungal therapy in the paediatric population in Turkey. METHODS A point prevalence study was performed at 25 hospitals. In addition to general data on paediatric units of the institutes, the generic name and indication of antifungal drugs, the presence of fungal isolation and susceptibility patterns, and the presence of galactomannan test and high-resolution computed tomography (HRCT) results were reviewed. RESULTS A total of 3338 hospitalised patients were evaluated. The number of antifungal drugs prescribed was 314 in 301 patients (9.0%). Antifungal drugs were mostly prescribed in paediatric haematology and oncology (PHO) units (35.2%), followed by neonatal ICUs (NICUs) (19.6%), paediatric services (18.3%), paediatric ICUs (PICUs) (14.6%) and haematopoietic stem cell transplantation (HSCT) units (7.3%). Antifungals were used for prophylaxis in 147 patients (48.8%) and for treatment in 154 patients (50.0%). The antifungal treatment strategy in 154 patients was empirical in 77 (50.0%), diagnostic-driven in 29 (18.8%) and targeted in 48 (31.2%). At the point of decision-making for diagnostic-driven antifungal therapy in 29 patients, HRCT had not been performed in 1 patient (3.4%) and galactomannan test results were not available in 12 patients (41.4%). Thirteen patients (8.4%) were receiving eight different antifungal combination therapies. CONCLUSION The majority of antifungal drugs for treatment and prophylaxis were prescribed in PHO and HSCT units (42.5%), followed by ICUs. Thus, antifungal stewardship programmes should mainly focus on these patients within the availability of diagnostic tests of each hospital.
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Affiliation(s)
- İlknur Çağlar
- Dr. Behçet Uz Children's Hospital, Department of Pediatric Infectious Diseases, İzmir, Turkey
| | - İlker Devrim
- Dr. Behçet Uz Children's Hospital, Department of Pediatric Infectious Diseases, İzmir, Turkey.
| | - Halil Özdemir
- Ankara University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Zümrüt Şahbudak
- Ege University, Faculty of Medicine, Department of Pediatric Infectious Diseases, İzmir, Turkey
| | - Gülsüm Sönmez
- Çukurova University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Adana, Turkey
| | - Ayse Buyukcam
- Hacettepe University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Belgin Gulhan
- Ankara Children's Hematology Oncology Training and Research Hospital, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Ahu Kara
- Dr. Behçet Uz Children's Hospital, Department of Pediatric Infectious Diseases, İzmir, Turkey
| | - Deniz F Aygun
- Cerrahpaşa Medical Faculty, Department of Pediatric Infectious Diseases, İstanbul, Turkey
| | - Nuri Bayram
- Dr. Behçet Uz Children's Hospital, Department of Pediatric Infectious Diseases, İzmir, Turkey
| | - Solmaz Celebi
- Uludağ University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Bursa, Turkey
| | - Benhur Çetin
- Gaziantep Cengiz Gokcek Children's Hospital, Department of Pediatric Infectious Diseases, Gaziantep, Turkey
| | - Merve I Nepesov
- Eskişehir Osmangazi University, Faculty of Medicine, Clinic of Pediatric Infectious Diseases, Eskişehir, Turkey
| | - Ayşe T Yilmaz
- Kocaeli University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Infectious Diseases, Kocaeli, Turkey
| | - Eda Kepenekli
- Marmara University Pendik Training and Research Hospital, Department of Pediatric Infectious Diseases, İstanbul, Turkey
| | - Dilek Yilmaz Çiftdogan
- İzmir Katip Çelebi University, Faculty of Medicine & İzmir Tepecik Training and Research Hospital, Department of Pediatric Infectious Diseases, İzmir, Turkey
| | - Manolya K Acar
- Istanbul University, Faculty of Medicine, Department of Pediatric Infectious Diseases, İstanbul, Turkey
| | - Burcu Cura Yayla
- Gazi University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Canan Okumuş
- Dokuz Eylül University, Faculty of Medicine, Department of Pediatric Infectious Diseases, İzmir, Turkey
| | - Zafer Ecevit
- Başkent University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Nevin Hatipoglu
- Bakırköy Dr. Sadi Konuk Research and Training Hospital, Pediatric Infectious Diseases Clinic, İstanbul, Turkey
| | - Necdet Kuyucu
- Mersin University, Faculty of Medicine, Department of Pediatrics, Mersin, Turkey
| | - Muhammed Kosker
- Diyarbakır Children's Hospital, Pediatric Infectious Diseases Clinic, Diyarbakır, Turkey
| | - Semra Sen
- Manisa Celal Bayar University, Faculty of Medicine, Pediatric Infectious Diseases Unit, Manisa, Turkey
| | - Adem Karbuz
- Okmeydanı Training and Research Hospital, Pediatric Infectious Diseases Unit, İstanbul, Turkey
| | | | - Burcu Bursal Duramaz
- Bezmialem Vakıf University, Faculty of Medicine, Department of Pediatric İnfectious Diseases, İstanbul, Turkey
| | - Metehan Özen
- Acıbadem University, Faculty of Medicine, Department of Pediatrics, İstanbul, Turkey
| | - Ergin Çiftçi
- Ankara University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Derya Alabaz
- Çukurova University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Adana, Turkey
| | - Zafer Kurugol
- Ege University, Faculty of Medicine, Department of Pediatric Infectious Diseases, İzmir, Turkey
| | - Ateş Kara
- Hacettepe University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Saliha Kanik
- Ankara Children's Hematology Oncology Training and Research Hospital, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Omer Kilic
- Eskişehir Osmangazi University, Faculty of Medicine, Clinic of Pediatric Infectious Diseases, Eskişehir, Turkey
| | - Selim Oncel
- Kocaeli University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Infectious Diseases, Kocaeli, Turkey
| | - Ayper Somer
- Istanbul University, Faculty of Medicine, Department of Pediatric Infectious Diseases, İstanbul, Turkey
| | - Anil Tapisiz
- Gazi University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Nursen Belet
- Dokuz Eylül University, Faculty of Medicine, Department of Pediatric Infectious Diseases, İzmir, Turkey
| | | | - Özden Türel
- Bezmialem Vakıf University, Faculty of Medicine, Department of Pediatric İnfectious Diseases, İstanbul, Turkey
| | - Aslinur Ozkaya
- Ankara Children's Hematology Oncology Training and Research Hospital, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Hasan Tezer
- Gazi University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Ali Bulent Cengiz
- Hacettepe University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Erdal İnce
- Ankara University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Ankara, Turkey
| | - Yıldız Camcioglu
- Istanbul University, Cerrahpaşa Medical Faculty, Department of Pediatric Infectious Diseases and Clinical Immunology and Allergy, İstanbul, Turkey
| | - Emine Kocabas
- Çukurova University, Faculty of Medicine, Department of Pediatric Infectious Diseases, Adana, Turkey
| | - Emin S Arisoy
- Kocaeli University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Infectious Diseases, Kocaeli, Turkey
| | - Nuran Salman
- Istanbul University, Faculty of Medicine, Department of Pediatric Infectious Diseases, İstanbul, Turkey
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Yusuf E, Versporten A, Goossens H. Is there any difference in quality of prescribing between antibacterials and antifungals? Results from the first global point prevalence study (Global PPS) of antimicrobial consumption and resistance from 53 countries. J Antimicrob Chemother 2018; 72:2906-2909. [PMID: 29091210 DOI: 10.1093/jac/dkx236] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/13/2017] [Indexed: 01/05/2023] Open
Abstract
Objectives To compare the quality of antibacterial with antifungal prescribing in the world. Methods Data from the global point prevalence study (Global PPS) were used. The Global PPS took place on any one day between February and June 2015 in 335 participating hospitals from 53 countries. It collected demographic data on patients treated with antimicrobials and data on prescription characteristics of the antimicrobials. For the present study, the quality of antibiotic prescription was compared with antifungal prescription using logistic regression analysis. The following indicators were compared: the presence of the reason for prescription and stop/review date in notes, and compliance with a local guideline. Results There were 48565 antimicrobial prescriptions for 34731 patients [median age 63 years (range 0-106); 52.6% male] in the Global PPS. Among these antimicrobials, 43513 (89.6%) were antibacterials and 2062 were antifungals for systematic use, and these data were used in this study. Reasons for prescriptions [77.7% versus 71.8%, OR 1.4 (95% CI 1.2-1.5)] and stop/review dates [38.3% versus 31.9%, OR 1.3 (1.2-1.5)] were found more often in notes for antibacterials than for antifungals. Antibacterials were prescribed less often according to local guidelines than antifungals [57.0% versus 71.0%, OR 0.6 (0.5-0.6)]. Conclusions There are differences in the quality of antibacterial and antifungal prescribing and we identified opportunities that can be used to improve the quality of antimicrobial prescribing.
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Affiliation(s)
- Erlangga Yusuf
- Laboratory of Medical Microbiology, Antwerp University Hospital (UZA), Belgium.,Laboratory of Medical Microbiology, VAXINFECTIO, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Ann Versporten
- Laboratory of Medical Microbiology, VAXINFECTIO, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Antwerp University Hospital (UZA), Belgium.,Laboratory of Medical Microbiology, VAXINFECTIO, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
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Antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: results of an internet-based global point prevalence survey. LANCET GLOBAL HEALTH 2018; 6:e619-e629. [PMID: 29681513 DOI: 10.1016/s2214-109x(18)30186-4] [Citation(s) in RCA: 360] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 02/20/2018] [Accepted: 03/06/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND The Global Point Prevalence Survey (Global-PPS) established an international network of hospitals to measure antimicrobial prescribing and resistance worldwide. We aimed to assess antimicrobial prescribing and resistance in hospital inpatients. METHODS We used a standardised surveillance method to collect detailed data about antimicrobial prescribing and resistance from hospitals worldwide, which were grouped by UN region. The internet-based survey included all inpatients (adults, children, and neonates) receiving an antimicrobial who were on the ward at 0800 h on one specific day between January and September, 2015. Hospitals were classified as primary, secondary, tertiary (including infectious diseases hospitals), and paediatric hospitals. Five main ward types were defined: medical wards, surgical wards, intensive-care units, haematology oncology wards, and medical transplantation (bone marrow or solid transplants) wards. Data recorded included patient characteristics, antimicrobials received, diagnosis, therapeutic indication according to predefined lists, and markers of prescribing quality (eg, whether a stop or review date were recorded, and whether local prescribing guidelines existed and were adhered to). We report findings for adult inpatients. FINDINGS The Global-PPS for 2015 included adult data from 303 hospitals in 53 countries, including eight lower-middle-income and 17 upper-middle-income countries. 86 776 inpatients were admitted to 3315 adult wards, of whom 29 891 (34·4%) received at least one antimicrobial. 41 213 antimicrobial prescriptions were issued, of which 36 792 (89·3%) were antibacterial agents for systemic use. The top three antibiotics prescribed worldwide were penicillins with β-lactamase inhibitors, third-generation cephalosporins, and fluoroquinolones. Carbapenems were most frequently prescribed in Latin America and west and central Asia. Of patients who received at least one antimicrobial, 5926 (19·8%) received a targeted antibacterial treatment for systemic use, and 1769 (5·9%) received a treatment targeting at least one multidrug-resistant organism. The frequency of health-care-associated infections was highest in Latin America (1518 [11·9%]) and east and south Asia (5363 [10·1%]). Overall, the reason for treatment was recorded in 31 694 (76·9%) of antimicrobial prescriptions, and a stop or review date in 15 778 (38·3%). Local antibiotic guidelines were missing for 7050 (19·2%) of the 36 792 antibiotic prescriptions, and guideline compliance was 77·4%. INTERPRETATION The Global-PPS showed that worldwide surveillance can be accomplished with voluntary participation. It provided quantifiable measures to assess and compare the quantity and quality of antibiotic prescribing and resistance in hospital patients worldwide. These data will help to improve the quality of antibiotic prescribing through education and practice changes, particularly in low-income and middle-income countries that have no tools to monitor antibiotic prescribing in hospitals. FUNDING bioMérieux.
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Hamdy RF, Zaoutis TE, Seo SK. Antifungal stewardship considerations for adults and pediatrics. Virulence 2017; 8:658-672. [PMID: 27588344 PMCID: PMC5626349 DOI: 10.1080/21505594.2016.1226721] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 08/05/2016] [Accepted: 08/11/2016] [Indexed: 10/21/2022] Open
Abstract
Antifungal stewardship refers to coordinated interventions to monitor and direct the appropriate use of antifungal agents in order to achieve the best clinical outcomes and minimize selective pressure and adverse events. Antifungal utilization has steadily risen over time in concert with the increase in number of immunocompromised adults and children at risk for invasive fungal infections (IFI). Challenges in diagnosing IFI often lead to delays in treatment and poorer outcomes. There are also emerging data linking prior antifungal exposure and suboptimal dosing to the emergence of antifungal resistance, particularly for Candida. Antimicrobial stewardship programs can take a multi-pronged bundle approach to ensure suitable prescribing of antifungals via post-prescription review and feedback and/or prior authorization. Institutional guidelines can also be developed to guide diagnostic testing in at-risk populations; appropriate choice, dose, and duration of antifungal agent; therapeutic drug monitoring; and opportunities for de-escalation and intravenous-to-oral conversion.
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Affiliation(s)
- Rana F. Hamdy
- Division of Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Theoklis E. Zaoutis
- Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan K. Seo
- Department of Medicine, Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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29
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Agrawal S, Barnes R, Brüggemann RJ, Rautemaa-Richardson R, Warris A. The role of the multidisciplinary team in antifungal stewardship. J Antimicrob Chemother 2017; 71:ii37-ii42. [PMID: 27880668 DOI: 10.1093/jac/dkw395] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
There are a variety of challenges faced in the management of invasive fungal diseases (IFD), including high case-fatality rates, high cost of antifungal drugs and development of antifungal resistance. The diagnostic challenges and poor outcomes associated with IFD have resulted in excessive empirical use of antifungals in various hospital settings, exposing many patients without IFD to potential drug toxicities as well as causing spiralling antifungal drug costs. Further complexity arises as different patient groups show marked variation in their risk for IFD, fungal epidemiology, sensitivity and specificity of diagnostic tests and the pharmacokinetics and pharmacodynamics of antifungal drugs. To address these issues and to ensure optimal management of IFD, specialist knowledge and experience from a range of backgrounds is required, which extends beyond the remit of most antibiotic stewardship programmes. The first step in the development of any antifungal stewardship (AFS) programme is to build a multidisciplinary team encompassing the necessary expertise in the management of IFD to develop and implement the AFS programme. The specific roles of the key individuals within the AFS team and the importance of collaboration are discussed in this article.
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Affiliation(s)
- Samir Agrawal
- Division of Haemato-Oncology, St Bartholomew's Hospital and Blizard Institute, Queen Mary University, London, UK
| | - Rosemary Barnes
- Department of Medical Microbiology and Infectious Diseases, Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Roger J Brüggemann
- Department of Pharmacy and Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Riina Rautemaa-Richardson
- Manchester Academic Health Science Centre, Institute of Inflammation and Repair, University of Manchester, Manchester, UK.,University Hospital of South Manchester, Wythenshawe Hospital, Manchester, UK
| | - Adilia Warris
- Aberdeen Fungal Group, MRC Centre for Medical Mycology, Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
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30
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Grzybowski A, Brona P, Kim SJ. Microbial flora and resistance in ophthalmology: a review. Graefes Arch Clin Exp Ophthalmol 2017; 255:851-862. [PMID: 28229218 PMCID: PMC5394129 DOI: 10.1007/s00417-017-3608-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 01/11/2017] [Accepted: 02/06/2017] [Indexed: 02/03/2023] Open
Abstract
Antibiotic resistance in systemic infection is well-researched and well-publicized. Much less information is available on the resistance of normal ocular microbiome and that of ophthalmic infections. An understanding of the distribution of ocular microorganisms may help us in tailoring our empiric treatment, as well as in choosing effective pre-, peri- and postoperative management, to achieve the best results for patients. This study aims to summarize and review the available literature on the subject of normal ocular flora and its resistance, as well as the broader topic of antibiotic resistance in ophthalmology.
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Affiliation(s)
- Andrzej Grzybowski
- Department of Ophthalmology, Poznan City Hospital, Ul. Szwajcarska 3, 60-285, Poznan, Poland.
- Department of Ophthalmology, University of Warmia and Mazury, Olsztyn, Poland.
| | - Piotr Brona
- Department of Ophthalmology, Poznan City Hospital, Ul. Szwajcarska 3, 60-285, Poznan, Poland
| | - Stephen Jae Kim
- Department of Ophthalmology, Vanderbilt University, Nashville, TN, USA
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31
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Variability in Antifungal and Antiviral Use in Hospitalized Children. Infect Control Hosp Epidemiol 2017; 38:743-746. [PMID: 28294077 DOI: 10.1017/ice.2017.40] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We analyzed antifungal and antiviral prescribing among high-risk children across freestanding children's hospitals. Antifungal and antiviral days of therapy varied across hospitals. Benchmarking antifungal and antiviral use and developing antimicrobial stewardship strategies to optimize use of these high cost agents is needed. Infect Control Hosp Epidemiol 2017;38:743-746.
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Prospective Biomarker Screening for Diagnosis of Invasive Aspergillosis in High-Risk Pediatric Patients. J Clin Microbiol 2016; 55:101-109. [PMID: 27795339 DOI: 10.1128/jcm.01682-16] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/12/2016] [Indexed: 11/20/2022] Open
Abstract
Combined biomarker screening is increasingly used to diagnose invasive aspergillosis (IA) in high-risk patients. In adults, the combination of galactomannan (GM) and fungal DNA detection has proven to be beneficial in the diagnosis of IA. Data in purely pediatric cohorts are scarce. Here, we monitored 39 children shortly before and after allogeneic stem cell transplantation twice weekly by use of a commercial GM enzyme-linked immunosorbent assay (ELISA) and a PCR assay based on amplification of the pan-Aspergillus ITS1/5.8S ribosomal operon. In addition, clinical data were recorded and classification of IA was performed according to the European Organization for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria. Among the 39 high-risk children, we identified 4 patients (10.3%) with probable and 2 (5.1%) with possible IA. All patients with probable IA were repeatedly positive for both tests (means of 9.5 and 6.8 positive GM and PCR samples, respectively), whereas both possible IA cases were detected by PCR. The sensitivity and specificity were, respectively, 67% and 89% for GM and 100% and 63% for PCR. Positive and negative predictive values were, respectively, 50% and 100% for GM and 27% and 100% for PCR. For the combined testing approach, both values were 100%. The number of positive samples seemed to be lower in patients undergoing antifungal therapy. Sporadically positive tests occurred in 12% (GM) and 42% (PCR) of unclassified patients. In summary, our data show that combined monitoring for GM and fungal DNA also results in a high diagnostic accuracy in pediatric patients. Future studies have to determine whether combined testing is suitable for early detection of subclinical disease and how antifungal prophylaxis impacts assay performance.
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33
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Gharbi M, Doerholt K, Vergnano S, Bielicki JA, Paulus S, Menson E, Riordan A, Lyall H, Patel SV, Bernatoniene J, Versporten A, Heginbothom M, Goossens H, Sharland M. Using a simple point-prevalence survey to define appropriate antibiotic prescribing in hospitalised children across the UK. BMJ Open 2016; 6:e012675. [PMID: 27810974 PMCID: PMC5129034 DOI: 10.1136/bmjopen-2016-012675] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The National Health Service England, Commissioning for Quality and Innovation for Antimicrobial Resistance (CQUIN AMR) aims to reduce the total antibiotic consumption and the use of certain broad-spectrum antibiotics in secondary care. However, robust baseline antibiotic use data are lacking for hospitalised children. In this study, we aim to describe, compare and explain the prescription patterns of antibiotics within and between paediatric units in the UK and to provide a baseline for antibiotic prescribing for future improvement using CQUIN AMR guidance. METHODS We conducted a cross-sectional study using a point prevalence survey (PPS) in 61 paediatric units across the UK. The standardised study protocol from the Antibiotic Resistance and Prescribing in European Children (ARPEC) project was used. All inpatients under 18 years of age present in the participating hospital on the day of the study were included except neonates. RESULTS A total of 1247 (40.9%) of 3047 children hospitalised on the day of the PPS were on antibiotics. The proportion of children receiving antibiotics showed a wide variation between both district general and tertiary hospitals, with 36.4% ( 95% CI 33.4% to 39.4%) and 43.0% (95% CI 40.9% to 45.1%) of children prescribed antibiotics, respectively. About a quarter of children on antibiotic therapy received either a medical or surgical prophylaxis with parenteral administration being the main prescribed route for antibiotics (>60% of the prescriptions for both types of hospitals). General paediatrics units were surprisingly high prescribers of critical broad-spectrum antibiotics, that is, carbapenems and piperacillin-tazobactam. CONCLUSIONS We provide a robust baseline for antibiotic prescribing in hospitalised children in relation to current national stewardship efforts in the UK. Repeated PPS with further linkage to resistance data needs to be part of the antibiotic stewardship strategy to tackle the issue of suboptimal antibiotic use in hospitalised children.
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Affiliation(s)
- Myriam Gharbi
- NIHR Health Protection Research Unit Antimicrobial Resistance and Healthcare Associated Infection—Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Katja Doerholt
- Paediatric Infection Diseases, St George's Hospital NHS Trust, London, UK
| | - Stefania Vergnano
- Institute for Infection and Immunity—Paediatric Infectious Diseases Research Group, St. George's University of London, London, UK
| | - Julia Anna Bielicki
- Institute for Infection and Immunity—Paediatric Infectious Diseases Research Group, St. George's University of London, London, UK
| | - Stéphane Paulus
- Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Esse Menson
- Department of General Paediatrics, Evelina London Children's Hospital, London, UK
| | - Andrew Riordan
- Paediatric Infectious Diseases and Immunology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Hermione Lyall
- Department of Infectious Diseases, St Mary's Hospital Imperial College Healthcare NHS Trust, London, UK
| | - Sanjay Valabh Patel
- Paediatric Infectious Diseases and Immunology, Southampton Children's Hospital, Southampton, UK
| | - Jolanta Bernatoniene
- Paediatric Infectious Disease and Immunology, University Hospitals Bristol NHS Foundation Trust, Bristol Royal Hospital for Children, Bristol, UK
| | - Ann Versporten
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO) University of Antwerp, Antwerp, Belgium
| | | | - Herman Goossens
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO) University of Antwerp, Antwerp, Belgium
| | - Mike Sharland
- Paediatric Infection Diseases, St George's Hospital NHS Trust, London, UK
- Institute for Infection and Immunity—Paediatric Infectious Diseases Research Group, St. George's University of London, London, UK
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34
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The European Paediatric Mycology Network (EPMyN): Towards a Better Understanding and Management of Fungal Infections in Children. CURRENT FUNGAL INFECTION REPORTS 2016; 10:7-9. [PMID: 27127543 PMCID: PMC4794521 DOI: 10.1007/s12281-016-0252-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The European Paediatric Mycology Network (EPMyN) was launched in 2014 to create a European platform for research and education in the field of paediatric mycology. The EPMyN aims to address the lack of paediatric specific evidence and knowledge needed to (1) improve the management and outcome of invasive fungal infections in children and neonates and to (2) enhance and develop paediatric antifungal stewardship programmes.
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35
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Vij A, Sood A, Piliang M, Mesinkovska NA. Infection or allergy? The multifaceted nature of vulvar dermatoses. Int J Womens Dermatol 2015; 1:170-172. [PMID: 28491984 PMCID: PMC5419826 DOI: 10.1016/j.ijwd.2015.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/04/2015] [Accepted: 08/17/2015] [Indexed: 12/01/2022] Open
Abstract
Chronic dermatitis or pruritus affecting the female genital and perianal skin can be challenging to properly diagnose and manage. The differential diagnosis generally includes allergic, inflammatory, infectious, and neoplastic conditions. We report the case of a 52-year-old woman with a 6-month history of a progressive, debilitating vulvar and perianal rash that highlights the multifaceted nature of female genital dermatoses.
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Affiliation(s)
- Alok Vij
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH
| | - Apra Sood
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH
| | - Melissa Piliang
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH.,Department of Dermatopathology, Cleveland Clinic Foundation, Cleveland, OH
| | - Natasha Atanaskova Mesinkovska
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH.,Department of Dermatopathology, Cleveland Clinic Foundation, Cleveland, OH
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36
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Metsvaht T, Nellis G, Varendi H, Nunn AJ, Graham S, Rieutord A, Storme T, McElnay J, Mulla H, Turner MA, Lutsar I. High variability in the dosing of commonly used antibiotics revealed by a Europe-wide point prevalence study: implications for research and dissemination. BMC Pediatr 2015; 15:41. [PMID: 25880733 PMCID: PMC4407781 DOI: 10.1186/s12887-015-0359-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic dosing in neonates varies between countries and centres, suggesting suboptimal exposures for some neonates. We aimed to describe variations and factors influencing the variability in the dosing of frequently used antibiotics in European NICUs to help define strategies for improvement. METHODS A sub-analysis of the European Study of Neonatal Exposure to Excipients point prevalence study was undertaken. Demographic data of neonates receiving any antibiotic on the study day within one of three two-week periods from January to June 2012, the dose, dosing interval and route of administration of each prescription were recorded. The British National Formulary for Children (BNFC) and Neofax were used as reference sources. Risk factors for deviations exceeding ±25% of the relevant BNFC dosage recommendation were identified by multivariate logistic regression analysis. RESULTS In 89 NICUs from 21 countries, 586 antibiotic prescriptions for 342 infants were reported. The twelve most frequently used antibiotics - gentamicin, penicillin G, ampicillin, vancomycin, amikacin, cefotaxime, ceftazidime, meropenem, amoxicillin, metronidazole, teicoplanin and flucloxacillin - covered 92% of systemic prescriptions. Glycopeptide class, GA <32 weeks, 5(th) minute Apgar score <5 and geographical region were associated with deviation from the BNFC dosage recommendation. While the doses of penicillins exceeded recommendations, antibiotics with safety concerns followed (gentamicin) or were dosed below (vancomycin) recommendations. CONCLUSIONS The current lack of compliance with existing dosing recommendations for neonates needs to be overcome through the conduct of well-designed clinical trials with a limited number of antibiotics to define pharmacokinetics/pharmacodynamics, efficacy and safety in this population and by efficient dissemination of the results.
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Affiliation(s)
- Tuuli Metsvaht
- Institute of Microbiology, Tartu University, Tartu, Estonia. .,Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
| | - Georgi Nellis
- Institute of Microbiology, Tartu University, Tartu, Estonia. .,Children's Clinic, Tartu University Hospital, Tartu, Estonia.
| | - Heili Varendi
- Children's Clinic, Tartu University Hospital, Tartu, Estonia.
| | - Anthony J Nunn
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - Susan Graham
- Research and Development, Liverpool women's NHS Foundation Trust, Liverpool, UK.
| | - Andre Rieutord
- Pharmacy Department, Hospital Antoine Beclère, Paris, France.
| | - Thomas Storme
- Pharmacy Department, APHP, Hospital Robert Debré, Paris, France.
| | - James McElnay
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK.
| | - Hussain Mulla
- Department of Pharmacy, University Hospitals of Leicester, Leicester, UK.
| | - Mark A Turner
- Department of Women's and Children's Health, Institute of Translational Medicine, Liverpool Women's NHS Foundation Trust, University of Liverpool, Liverpool, UK.
| | - Irja Lutsar
- Institute of Microbiology, Tartu University, Tartu, Estonia.
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