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Becker SL, Schneitler S. Antiparasitic stewardship: a call to action. Future Microbiol 2024; 19:5-8. [PMID: 38348569 DOI: 10.2217/fmb-2023-0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Tweetable abstract There is an urgent need to consider antiparasitic drugs in global efforts to achieve and implement equitable and sustainable antimicrobial stewardship initiatives worldwide.
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Affiliation(s)
- Sören L Becker
- Institute of Medical Microbiology & Hygiene, Saarland University, Homburg/Saar, Germany
- Swiss Tropical & Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- Helmholtz Institute for Pharmaceutical Research Saarland, Saarbrücken, Germany
| | - Sophie Schneitler
- Institute of Medical Microbiology & Hygiene, Saarland University, Homburg/Saar, Germany
- Institute of Pneumology at the University of Cologne, Bethanien Hospital, Clinic for Pneumology & Allergology, Centre of Sleep Medicine & Respiratory Care, Solingen, Germany
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2
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Albahar F, Alhamad H, Abu Assab M, Abu-Farha R, Alawi L, Khaleel S. The Impact of Antifungal Stewardship on Clinical and Performance Measures: A Global Systematic Review. Trop Med Infect Dis 2023; 9:8. [PMID: 38251205 PMCID: PMC10820751 DOI: 10.3390/tropicalmed9010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/06/2023] [Accepted: 09/13/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programs (ASP) have been proposed as an opportunity to optimize antifungal use. The antifungal resistance is a significant and emerging threat. The literature on antifungal stewardship (AFS) and its influence on performance and clinical outcome measures is scarce. This study aimed to examine global evidence of the impact of AFS on patients and performance measures. METHODS The "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) was used for the flow of identification, screening, eligibility, and inclusion. PubMed and MEDLINE were searched using the term ''antifungal stewardship'' on 15 February 2023. Search terms included antifungal stewardship, antimicrobial stewardship, candida, candidemia, candiduria, and invasive fungal disease. Of the 1366 records, 1304 were removed since they did not describe an antifungal stewardship intervention. Among the 62 full texts assessed, 21 articles were excluded since they were non-interventional studies and did not include the outcome of interest. Thus, 41 articles were eligible for systematic review. Eligible studies were those that described an AFS program and evaluated clinical or performance measures. RESULTS Of the 41 included studies, the primary performance measure collected was antifungal consumption (22 of 41), and mortality (22 of 41), followed by length of stay (11 of 41) and cost (9 of 41). Most studies were single-center, quasi-experimental, with varying interventions across studies. The principal finding from most of the studies in this systematic review is a reduction in mortality expressed in different units and the use of antifungal agents (13 studies out of 22 reporting mortality). Antifungal consumption was significantly blunted or reduced following stewardship initiation (10 of 22). Comparing studies was impossible due to a lack of standard units, making conducting a meta-analysis unfeasible, which would be a limitation of our study. CONCLUSION It has been shown that AFS interventions may improve antifungal consumption and other performance measures. According to available published studies, antifungal consumption and mortality appear to be the possible performance measures to evaluate the impact of AFS.
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Affiliation(s)
- Fares Albahar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan; (H.A.); (M.A.A.)
| | - Hamza Alhamad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan; (H.A.); (M.A.A.)
| | - Mohammad Abu Assab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Zarqa University, P.O. Box 2000, Zarqa 13110, Jordan; (H.A.); (M.A.A.)
| | - Rana Abu-Farha
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, P.O. Box 541350, Amman 11937, Jordan;
| | - Lina Alawi
- Department of Physiology and Pharmacology, Faculty of Medicine and Health Sciences, An Najah National University, Nablus P.O. Box 7, Palestine;
| | - Sara Khaleel
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Al Zaytoonah University, P.O. Box 130, Amman 11733, Jordan;
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Hennessee IP, Benedict K, Dulski TM, Lipner SR, Gold JAW. Racial disparities, risk factors, and clinical management practices for tinea capitis: An observational cohort study among US children with Medicaid. J Am Acad Dermatol 2023; 89:1261-1264. [PMID: 37549790 PMCID: PMC10683529 DOI: 10.1016/j.jaad.2023.07.1025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/22/2023] [Accepted: 07/05/2023] [Indexed: 08/09/2023]
Affiliation(s)
- Ian P Hennessee
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Kaitlin Benedict
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Theresa M Dulski
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Jeremy A W Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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Hawkins BK, Walker SD, Shorman MA. Missed Opportunities for Antifungal Stewardship during the COVID-19 Era. Antibiotics (Basel) 2023; 12:1352. [PMID: 37760649 PMCID: PMC10526074 DOI: 10.3390/antibiotics12091352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/28/2023] [Accepted: 08/10/2023] [Indexed: 09/29/2023] Open
Abstract
Significant increases in antibacterial use were observed during the COVID-19 pandemic. However, subsequent analyses found this increase in antibiotic use to be excessive in comparison with the relatively low rates of bacterial coinfection. Although patients who are critically ill with COVID-19 may be at an increased risk for pulmonary aspergillosis, antifungal use in these populations remained underreported, particularly in later phases of the pandemic. This single-center, population-level cohort analysis compares the monthly use rates of mold-active antifungal drugs in the medical intensive care unit during April 2019-March 2020 (baseline) with those during April 2020-November 2022. The antifungal drugs included in the analysis were liposomal amphotericin B, anidulafungin, isavuconazonium, posaconazole, and voriconazole. We found that during 2020-2022, the usage of antifungal drugs was not significantly different from baseline for all included agents except isavuconazonium, which was used significantly more (p = 0.009). There were no changes in diagnostic modalities between the two time periods. The reported prevalence of and mortality from COVID-19-associated pulmonary aspergillosis (CAPA) may have resulted in higher rates of prescribing antifungal drugs for critically ill patients with COVID-19. Antimicrobial stewardship programs should develop and apply tools to facilitate more effective and appropriate antifungal use.
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Affiliation(s)
- Brandon K. Hawkins
- College of Pharmacy, University of Tennessee Health Science Center, Knoxville, TN 37920, USA
| | - Samantha D. Walker
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN 37920, USA
| | - Mahmoud A. Shorman
- Division of Infectious Diseases, University of Tennessee Medical Center, Knoxville, TN 37920, USA
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Mudenda S, Chabalenge B, Kasanga M, Mufwambi W, Mfune RL, Daka V, Matafwali SK. Antifungal resistance and stewardship: a call to action in Zambia. Pan Afr Med J 2023; 45:152. [PMID: 37869231 PMCID: PMC10589409 DOI: 10.11604/pamj.2023.45.152.41232] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/06/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Steward Mudenda
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Billy Chabalenge
- Department of Medicines Control, Zambia Medicines Regulatory Authority, Lusaka, Zambia
| | - Maisa Kasanga
- Zhengzhou University, College of Public Health, Zhengzhou, China
| | - Webrod Mufwambi
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Ruth Lindizyani Mfune
- Department of Public Health, Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia
| | - Victor Daka
- Department of Public Health, Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia
| | - Scott Kaba Matafwali
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, United Kingdom
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Al-Obaidi MM, Ostrosky-Zeichner L, Nix DE. Trends of Azole Antifungal Prescription in the United States: Medicare Part D Provider Utilization and Payment Data Analysis. Open Forum Infect Dis 2023; 10:ofad345. [PMID: 37539063 PMCID: PMC10394725 DOI: 10.1093/ofid/ofad345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/06/2023] [Indexed: 08/05/2023] Open
Abstract
Background Invasive fungal infections carry a substantial risk of mortality and morbidity. Azole antifungals are used in the treatment of such infections; however, their extensive use can lead to the emergence of antifungal resistance and increased costs to patients and healthcare systems. The aim of this study is to evaluate trends in these antifungals use and costs. Methods The secular and regional trends of outpatient azole antifungals were analyzed using Medicare Part D Prescriber Public Use Files for the years 2013-2020. The total days supply (TDS), total drug cost (TDC) per 100 000 enrollees, and cost per day (CPD) were evaluated. Results The azole antifungal TDS for Medicare Part D enrollees increased by 12% between 2013 and 2020, and increases were noted for each azole. Southern US regions had the highest TDS, with Arizona having the highest TDS among US states in 2020. Cost analysis showed that TDC of all azoles has increased by 93% over the years, going up from $123 316 in 2013 to $238 336 per 100 000 enrollees in 2020. However, CPD showed an increase only for fluconazole and isavuconazole, with CPD of $1.62 per day and $188.30 per day, respectively. Conclusions Combined azole antifungal prescriptions TDS increased among Medicare Part D enrollees. The trend in CPD was mixed, whereas overall costs consistently increased over the same period. Such findings provide an insight into the impact of azole antifungal prescriptions, and increasing use could foreshadow more antifungal resistance. Continued studies to evaluate different prescribers' trends are warranted.
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Affiliation(s)
- Mohanad M Al-Obaidi
- Division of Infectious Diseases, College of Medicine, University of Arizona, Tucson, Arizona, USA
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, University of Texas Medical School at Houston, USA, Houston, Texas
| | - David E Nix
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona, USA
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Gold JAW, Benedict K, Dulski TM, Lipner SR. Inadequate diagnostic testing and systemic antifungal prescribing for tinea capitis in an observational cohort study of 3.9 million children, United States. J Am Acad Dermatol 2023; 89:133-135. [PMID: 36806646 PMCID: PMC10679877 DOI: 10.1016/j.jaad.2023.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 01/18/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Affiliation(s)
- Jeremy A W Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Kaitlin Benedict
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Theresa M Dulski
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York
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Stemler J, Többen C, Lass-Flörl C, Steinmann J, Ackermann K, Rath PM, Simon M, Cornely OA, Koehler P. Diagnosis and Treatment of Invasive Aspergillosis Caused by Non- fumigatus Aspergillus spp. J Fungi (Basel) 2023; 9:jof9040500. [PMID: 37108955 PMCID: PMC10141595 DOI: 10.3390/jof9040500] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/27/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
With increasing frequency, clinical and laboratory-based mycologists are consulted on invasive fungal diseases caused by rare fungal species. This review aims to give an overview of the management of invasive aspergillosis (IA) caused by non-fumigatus Aspergillus spp.-namely A. flavus, A. terreus, A. niger and A. nidulans-including diagnostic and therapeutic differences and similarities to A. fumigatus. A. flavus is the second most common Aspergillus spp. isolated in patients with IA and the predominant species in subtropical regions. Treatment is complicated by its intrinsic resistance against amphotericin B (AmB) and high minimum inhibitory concentrations (MIC) for voriconazole. A. nidulans has been frequently isolated in patients with long-term immunosuppression, mostly in patients with primary immunodeficiencies such as chronic granulomatous disease. It has been reported to disseminate more often than other Aspergillus spp. Innate resistance against AmB has been suggested but not yet proven, while MICs seem to be elevated. A. niger is more frequently reported in less severe infections such as otomycosis. Triazoles exhibit varying MICs and are therefore not strictly recommended as first-line treatment for IA caused by A. niger, while patient outcome seems to be more favorable when compared to IA due to other Aspergillus species. A. terreus-related infections have been reported increasingly as the cause of acute and chronic aspergillosis. A recent prospective international multicenter surveillance study showed Spain, Austria, and Israel to be the countries with the highest density of A. terreus species complex isolates collected. This species complex seems to cause dissemination more often and is intrinsically resistant to AmB. Non-fumigatus aspergillosis is difficult to manage due to complex patient histories, varying infection sites and potential intrinsic resistances to antifungals. Future investigational efforts should aim at amplifying the knowledge on specific diagnostic measures and their on-site availability, as well as defining optimal treatment strategies and outcomes of non-fumigatus aspergillosis.
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Affiliation(s)
- Jannik Stemler
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50923 Cologne, Germany
| | - Christina Többen
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50923 Cologne, Germany
| | - Cornelia Lass-Flörl
- Institute of Hygiene and Medical Microbiology, European Diamond Excellence Center for Medical Mycology (ECMM), Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Jörg Steinmann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, 90419 Nuremberg, Germany
- Institute of Medical Microbiology, University Hospital Essen, European Diamond Excellence Center for Medical Mycology (ECMM), 45147 Essen, Germany
| | - Katharina Ackermann
- Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Klinikum Nürnberg, 90419 Nuremberg, Germany
| | - Peter-Michael Rath
- Institute of Medical Microbiology, University Hospital Essen, European Diamond Excellence Center for Medical Mycology (ECMM), 45147 Essen, Germany
| | - Michaela Simon
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
| | - Oliver Andreas Cornely
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50923 Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, 50935 Cologne, Germany
| | - Philipp Koehler
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), European Diamond Excellence Center for Medical Mycology (ECMM), Faculty of Medicine, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, 50923 Cologne, Germany
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Gold JAW, Wu K, Jackson BR, Benedict K. Opportunities to improve guideline adherence for the diagnosis and treatment of onychomycosis: Analysis of commercial insurance claims data, United States. J Am Acad Dermatol 2023; 88:683-686. [PMID: 35809801 PMCID: PMC10695165 DOI: 10.1016/j.jaad.2022.06.1201] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/14/2022] [Accepted: 06/30/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Jeremy A W Gold
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Karen Wu
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brendan R Jackson
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kaitlin Benedict
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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Marino A, Calvo M, Trovato L, Scalia G, Gussio M, Consoli U, Ceccarelli M, Nunnari G, Cacopardo B. Mucorales/ Fusarium Mixed Infection in Hematologic Patient with COVID-19 Complications: An Unfortunate Combination. Pathogens 2023; 12:pathogens12020304. [PMID: 36839576 PMCID: PMC9964160 DOI: 10.3390/pathogens12020304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/25/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
Hematological diseases, especially those causing severe neutropenia, represent the main factor in the development of invasive fungal infections (IFIs). Furthermore, COVID-19 has been considerably associated with IFIs due to immunological dysregulation, prolonged hospitalization in intensive care units, and immunomodulatory therapies. Opportunistic molds are correlated with elevated morbidity and mortality rates in these patients, due to immune impairment, diagnostic complexity, and therapeutic challenges. Among opportunistic fungal infections, the Mucorales and Fusarium species are considered particularly aggressive, especially during severe neutropenia. A mixed Mucorales/Fusarium infection has been rarely described in scientific literature. Herein, we report a case of Mucorales and Fusarium co-infection in a patient with acute leukemia whose clinical history was also complicated by COVID-19. Herein, we report a challenging case in order to encourage the clinical suspicion of combined fungal infections in immunosuppressed patients, performing a punctual microbiological diagnosis, and promptly administering the correct empiric and targeted antifungal therapy.
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Affiliation(s)
- Andrea Marino
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95122 Catania, Italy
| | - Maddalena Calvo
- U.O.C. Laboratory Analysis Unit, A.O.U. “Policlinico-Vittorio Emanuele”, Via S. Sofia 78, 95123 Catania, Italy
- Correspondence:
| | - Laura Trovato
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
- U.O.C. Laboratory Analysis Unit, A.O.U. “Policlinico-Vittorio Emanuele”, Via S. Sofia 78, 95123 Catania, Italy
| | - Guido Scalia
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
- U.O.C. Laboratory Analysis Unit, A.O.U. “Policlinico-Vittorio Emanuele”, Via S. Sofia 78, 95123 Catania, Italy
| | - Maria Gussio
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95122 Catania, Italy
| | - Ugo Consoli
- Unità Operativa Complessa (UOC) di Ematologia, ARNAS Garibaldi Hospital, 95122 Catania, Italy
| | - Manuela Ceccarelli
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95122 Catania, Italy
| | - Giuseppe Nunnari
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Messina, 98124 Messina, Italy
| | - Bruno Cacopardo
- Unit of Infectious Diseases, Department of Clinical and Experimental Medicine, ARNAS Garibaldi Hospital, University of Catania, 95122 Catania, Italy
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Chakrabarti A, Mohamed N, Capparella MR, Townsend A, Sung AH, Yura R, Muñoz P. The role of diagnostic tests in antifungal stewardship for treating invasive fungal infections: a plain language summary. Future Microbiol 2023; 18:9-13. [PMID: 36331029 DOI: 10.2217/fmb-2022-0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
WHAT IS THIS SUMMARY ABOUT? This is a summary of an article originally published in the journal Open Forum Infectious Diseases. Invasive fungal infections are caused by fungi. They can spread to deeper parts of the body. Some diagnostic tests are slow and may delay treatment. Better tests help to identify infection early in patients. An antifungal stewardship (shortened to AFS) program is a stepwise process to improve how patients are treated. AFS programs using diagnostic tests may help to manage infections. In this study, researchers wanted to know the impact of such AFS programs. To do so, they looked at the information from 17 previously published studies, which is summarized here. WHAT WERE THE RESULTS? Infections were identified and treated faster in studies with improved diagnostic tests. Treatment cost decreased when infections were identified and treated early. Patients were treated for shorter periods of time. They also spent less time in hospital. Number of deaths were less. WHAT DO THE RESULTS OF THE STUDY MEAN? AFS programs based on diagnostic tests helped patients.
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Affiliation(s)
- Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | | | | | - Andy Townsend
- Pfizer Hospital Medical Affairs, Pfizer, Congleton, UK
| | | | - Renee Yura
- WRD & Medical, Pfizer, Cambridge, MA, USA
| | - Patricia Muñoz
- Clinical Microbiology & Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Hospital Gregorio Marañón, Madrid, Spain.,Medicine Department, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,CIBER Enfermedades Respiratorias - CIBERES (CB06/06/0058), Madrid, Spain
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Abstract
BACKGROUND Antifungal stewardship (AFS) has emerged as an important component of quality in managing invasive fungal infections (IFIs), and cost-benefit calculations suggest regular training in AFS is well worth the effort. METHODS This review will discuss the most common IFIs in solid organ transplantation (SOT)-recipients, how to diagnose them, and current recommendations for antifungal treatment and prophylaxis before demonstrating key takeaway points of AFS in this high-risk population. RESULTS Effective AFS starts before a patient is admitted for SOT, through education and regular interactions of the interdisciplinary clinical team involved in patient management, considering local factors such as epidemiological data and knowledge of diagnostic options including local turnaround times. Understanding the spectrum of antifungal agents, their efficacy and safety profiles, and pharmacokinetics, as well as duration of therapy is hereby essential. The most frequent IFIs in SOT recipients are caused by Candida species, followed by Aspergillus species, both with increasing resistance rates. Diagnosis of IFI can be challenging due to unspecific clinical presentation and difficult interpretation of microbiological findings and biomarkers. Prophylactic strategies, such as those for invasive aspergillosis in lung transplantation or invasive candidiasis (IC) in certain liver transplant settings, as well as the selection of the appropriate therapeutic agents require detailed knowledge on the pharmacokinetics and drug-drug interactions of antifungals. CONCLUSIONS Here in this review, we address what constitutes good AFS in this heterogeneous field of solid organ transplant recipients.
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Affiliation(s)
- Lisa Kriegl
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Johannes Boyer
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria
| | - Matthias Egger
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria,BioTechMed‐GrazGrazAustria
| | - Martin Hoenigl
- Division of Infectious DiseasesDepartment of Internal MedicineMedical University of GrazGrazAustria,BioTechMed‐GrazGrazAustria,Division of Infectious Diseases and Global Public HealthDepartment of MedicineUniversity of California San DiegoSan DiegoCaliforniaUSA
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Avkan-Oğuz V, Irmak Ç, Dağdeviren K, Eren-Kutsoylu O, Nazlı A, Çelik M, Bayrak S. The Effect of the Pandemic on Antifungal Use: What Has Changed? Infect Dis Clin Microbiol 2022; 4:156-162. [PMID: 38633389 PMCID: PMC10985811 DOI: 10.36519/idcm.2022.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/11/2022] [Indexed: 04/19/2024]
Abstract
Objective During the COVID-19 pandemic, antimicrobial and antifungal stewardship programs have lost their priority. Although all parenteral antifungals were used with the recommendations of infectious diseases specialists in the pre-pandemic period, most consultations were delayed during the pandemic because of the workload of infectious diseases specialists. In this period, antifungal treatments in hospitalized patients were managed by mostly primary physicians. Therefore, we aimed to detect the change in the consumption of antifungals during the pandemic. Materials and Methods The data on the antifungal drug use by month and clinics, the number of beds, and the occupancy rate of the clinics were obtained from the hospital information registration system. We defined each drug according to the World Health Organization Anatomical Therapeutic Chemical (WHO ATC) coding system and determined the defined daily dose (DDD). The antifungal consumption (DDD/ 100 bed-days) in pre-pandemic and pandemic periods was compared. Results During the pandemic, the antifungal consumption increased two-fold (2019:7.43; 2020:18.03 DDD/100 bed-days). The highest antifungal consumption rate was in the hematology- oncology-hematopoietic stem cell transplantation (HSCT) clinics with 2.5-fold (2019:39.86; 2020:98.48 DDD/ 100 bed-days) increase. Liposomal amphotericin B consumption made up the majority of this with a four-fold increase in the hematology-oncology-HSCT clinics. Conclusion We detected a dramatic increase in antifungal consumption in both ICUs and inpatient clinics during pandemic. A novel antifungal stewardship approach is urgently needed.
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Affiliation(s)
- Vildan Avkan-Oğuz
- Department of Infectious Diseases and Clinical Microbiology,
Dokuz Eylül University School of Medicine, İzmir, Türkiye
| | - Çaglar Irmak
- Department of Infectious Diseases and Clinical Microbiology,
Dokuz Eylül University School of Medicine, İzmir, Türkiye
| | - Kağan Dağdeviren
- Department of Hospital Pharmacy, Dokuz Eylül University School
of Medicine, İzmir, Türkiye
| | - Oya Eren-Kutsoylu
- Department of Infectious Diseases and Clinical Microbiology,
Dokuz Eylül University School of Medicine, İzmir, Türkiye
| | - Arzu Nazlı
- Department of Infectious Diseases and Clinical Microbiology,
Dokuz Eylül University School of Medicine, İzmir, Türkiye
| | - Muammer Çelik
- Department of Infectious Diseases and Clinical Microbiology,
Dokuz Eylül University School of Medicine, İzmir, Türkiye
| | - Serdar Bayrak
- Department of Cardiovascular Surgery, Dokuz Eylül University
School of Medicine, İzmir, Türkiye
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14
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Moni M, Sidharthan N, Sudhir S, Prabhu B, Nampoothiri V, James J, Philip JM, Thomas J, Antony R, Mohamed ZU, Kumar A, Prasanna P, Edathadathil F, Singh S, Sathyapalan D. A quality improvement initiative to improve the appropriateness of candidemia management by the implementation of a comprehensive candidemia care bundle at a tertiary care hospital in South India: Results of a quasi-experimental study. Medicine (Baltimore) 2022; 101:e28906. [PMID: 35421057 PMCID: PMC9276434 DOI: 10.1097/md.0000000000028906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 02/03/2022] [Indexed: 01/04/2023] Open
Abstract
Management of candidemia in developing countries like India encounters laxity in appropriate clinical management and challenges in terms of healthcare capacity, despite its association with high morbidity and mortality. Our study aims to evaluate the impact of a comprehensive candidemia care bundle implementation on appropriateness of therapy and major clinical outcomes.The single-center, quasi-experimental study conducted at a south Indian tertiary care center included adult patients diagnosed with candidemia. Following a retrospective review of candidemia patients of the pre-implementation period (January 2013-December 2015), the hospital antifungal stewardship team instituted a clinical pharmacist driven comprehensive candidemia care bundle for candidemia patients during the post-implementation period (October 2017-2019) and its impact on appropriateness of antifungal prescriptions and inpatient mortality was evaluated.The study included 175 patients with candidemia, comprising of 103 patients in the pre-implementation period and 72 patients in the post-implementation period. Appropriateness of antifungal prescriptions rose to 65% during post-implementation period from 30% observed in pre-implementation phase (P = .0005). The inhospital mortality rate reduced from 40% in the pre-implementation phase to 36% in the post-implementation phase, recording a 10% reduction over 2 years post-implementation (P = .26). No significant difference was observed in terms length of stay (P = .17).Our study demonstrates the successful implementation of an antifungal stewardship led comprehensive care bundle in a low middle income countries setting. The results of our study will have profound implications in improving the appropriateness of management of candidemia and feasibility of scaling up to wider settings could be explored.
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Affiliation(s)
- Merlin Moni
- Department of General Medicine and Division of Infectious Diseases, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Neeraj Sidharthan
- Department of Hematology, Blood and Marrow Transplantation, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Sangita Sudhir
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Binny Prabhu
- Department of Geriatrics and General Medicine, Epsom and St Heliers NHS trust, UK
| | - Vrinda Nampoothiri
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Jini James
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Jeslyn Mary Philip
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Jisha Thomas
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Remya Antony
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Zubair Umer Mohamed
- Department of Anaesthesia and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Anil Kumar
- Department of Microbiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Preetha Prasanna
- Department of General Medicine and Division of Infectious Diseases, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Fabia Edathadathil
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Sanjeev Singh
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Dipu Sathyapalan
- Department of General Medicine and Division of Infectious Diseases, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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15
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Nwankwo L, Gilmartin D, Matharu S, Nuh A, Donovan J, Armstrong-James D, Shah A. Experience of Isavuconazole as a Salvage Therapy in Chronic Pulmonary Fungal Disease. J Fungi (Basel) 2022; 8. [PMID: 35448593 DOI: 10.3390/jof8040362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/20/2022] [Accepted: 03/27/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Instances of resistant fungal infection are rising in pulmonary disease, with limited therapeutic options. Therapeutic drug monitoring of azole antifungals has been necessary to ensure safety and efficacy but is considered unnecessary for the newest triazole isavuconazole. Aims: To characterise the prevalence of isavuconazole resistance and use in a tertiary respiratory centre. Methods: A retrospective observational analysis (2016−2021) of adult respiratory patients analysing fungal culture, therapeutic drug monitoring, and outcome post-isavuconazole therapy. Results: During the study period, isavuconazole susceptibility testing was performed on 26 Aspergillus spp. isolates. A total of 80.8% of A. fumigatus isolates had isavuconazole (MIC > 1 mg/L, and 73.0% > 2 mg/L) with a good correlation to voriconazole MIC (r = 0.7, p = 0.0002). A total of 54 patients underwent isavuconazole therapy during the study period (median duration 234 days (IQR: 24−499)). A total of 67% of patients tolerated isavuconazole, despite prior azole toxicity in 61.8%, with increased age (rpb = 0.31; p = 0.021) and male sex (φc = 0.30; p = 0.027) being associated with toxicity. A total of 132 isavuconazole levels were performed with 94.8% > 1 mg/L and 72% > 2 mg/L. Dose change from manufacturer’s recommendation was, however, required in 9.3% to achieve a concentration of >2 mg/L. Conclusion: We describe the use of isavuconazole as a salvage therapy in a chronic pulmonary fungal disease setting with a high prevalence of azole resistance. Therapeutic concentrations at standard dosing were high; however, results reinforce antifungal stewardship for optimization.
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16
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van de Peppel RJ, van Grootveld R, Hendriks BJC, van Paassen J, Bernards S, Jolink H, Koopmans JG, von dem Borne PA, van der Beek MT, de Boer MGJ. Implementation of a clinical decision rule for selecting empiric treatment for invasive aspergillosis in a setting with high triazole resistance. Med Mycol 2021; 60:6433628. [PMID: 34878121 PMCID: PMC8653343 DOI: 10.1093/mmy/myab060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/17/2021] [Indexed: 11/14/2022] Open
Abstract
World-wide, emerging triazole resistance increasingly complicates treatment of invasive aspergillosis (IA). In settings with substantial (>10%) prevalence of triazole resistance, empiric combination therapy with both a triazole and liposomal amphotericin B (LAmB) can be considered because of the low yields of susceptibility testing. To avoid toxicity while optimizing outcome, a strategy with monotherapy would be preferable. A newly designed treatment algorithm based on literature and expert consensus provided guidance for empiric monotherapy with either voriconazole or LAmB. Over a four and a half year period, all adult patients in our hospital treated for IA were included and patient data were collected. An independent committee reviewed the attributability of death to IA for each patient. Primary outcomes were 30- and 100-day crude mortality and attributable mortality. In total, 110 patients were treated according to the treatment algorithm. Fifty-six patients (51%) were initially treated with voriconazole and 54 patients (49%) with LAmB. Combined attributable and contributable mortality was 13% within 30 days and 20% within 100 days. Treatment switch to LAmB was made in 24/56 (43%) of patients who were initially treated with voriconazole. Combined contributable and attributable 100-day mortality in this subgroup was 21% and was not increased when compared with patients initially treated with LAmB (P = 0.38). By applying a comprehensive clinical decision algorithm, an antifungal-sparing regime was successfully introduced. Further research is warranted to explore antifungal treatment strategies that account for triazole-resistance. LAY SUMMARY Due to resistance of Aspergillus against triazoles, combination therapy with liposomal amphotericin B (LAmB) is applied more often as primary therapy against invasive aspergillosis. This study presents the results of a decision tool which differentiated between triazole or LAmB monotherapy.
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Affiliation(s)
- Robert J van de Peppel
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Rebecca van Grootveld
- Department of Clinical Microbiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Bart J C Hendriks
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Judith van Paassen
- Department of Intensive Care, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Sandra Bernards
- Department of Clinical Microbiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Hetty Jolink
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Julia G Koopmans
- Department of Pulmonology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Peter A von dem Borne
- Department of Haematology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Martha T van der Beek
- Department of Clinical Microbiology, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, 2333ZA Leiden, the Netherlands
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17
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Helweg-Larsen J, Steensen M, Møller Pedersen F, Bredahl Jensen P, Perch M, Møller K, Riis Olesen B, Søderlund M, Cavling Arendrup M. Intensive Care Antifungal Stewardship Programme Based on T2Candida PCR and Candida Mannan Antigen: A Prospective Study. J Fungi (Basel) 2021; 7:jof7121044. [PMID: 34947026 PMCID: PMC8705527 DOI: 10.3390/jof7121044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 12/17/2022] Open
Abstract
Non-culture-based biomarkers may improve diagnosis and antifungal treatment (AFT) of invasive candidiasis (IC). We evaluated an antifungal stewardship programme (AFSP) in a prospective intensive care unit (ICU) study, which included T2Candida and Candida mannan antigen (MAg) screening of patients with sepsis and a high risk of IC. Patients with non-neutropenic sepsis and a high risk of IC from two large tertiary ICUs were prospectively included, during a one-year period. IC was classified as proven, likely, possible or unlikely. The AFSP, diagnostic values of T2Candida and MAg, and the consumption of antifungals were evaluated. An amount of 219 patients with 504 T2Candida/MAg samples were included. IC was classified as proven in 29 (13.2%), likely in 7 (3.2%) and possible in 10 (5.5%) patients. Sensitivity/specificity/PPV/NPV values, comparing proven/likely versus unlikely IC, were 47%/100%/94%/90% for BC alone, 50%/97%/75%/90% for T2Candida alone, and 39%/96%/67%/88% for MAg alone. For the combination of T2Candida/MAg taken ≤3 days after AFT initiation, sensitivity/specificity/PPV/NPV was 70%/90%/63%/93%. T2Candida/MAg contributed to early (<3 days) AFT initiation in 13%, early AFT discontinuation in 25% and abstaining from AFT in 24% of patients. No reduction in overall use of AFT during the study period compared with the previous year was observed. An AFSP based on T2Candida and MAg screening contributed to a reduction of unnecessary treatment, but not overall AFT use. The diagnostic performance of T2Candida was lower than previously reported, but increased if T2Candida was combined with MAg.
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Affiliation(s)
- Jannik Helweg-Larsen
- Department of Infectious Diseases, Rigshospitalet, 2100 Copenhagen, Denmark;
- Correspondence:
| | - Morten Steensen
- Department of Intensive Care, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Finn Møller Pedersen
- Department of Thoracic Anesthesiology, Rigshospitalet, 2100 Copenhagen, Denmark; (F.M.P.); (P.B.J.)
| | - Pia Bredahl Jensen
- Department of Thoracic Anesthesiology, Rigshospitalet, 2100 Copenhagen, Denmark; (F.M.P.); (P.B.J.)
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Kirsten Møller
- Department of Neuro Anesthesiology, Rigshospitalet, 2100 Copenhagen, Denmark;
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark;
| | | | - Mathias Søderlund
- Department of Infectious Diseases, Rigshospitalet, 2100 Copenhagen, Denmark;
| | - Maiken Cavling Arendrup
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark;
- Unit of Mycology, Statens Serum Institut, 2300 Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
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18
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Hamada Y, Ebihara F, Kikuchi K. A Strategy for Hospital Pharmacists to Control Antimicrobial Resistance (AMR) in Japan. Antibiotics (Basel) 2021; 10:1284. [PMID: 34827222 PMCID: PMC8614892 DOI: 10.3390/antibiotics10111284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 12/21/2022] Open
Abstract
In Japan, there is concern regarding the relation between the inappropriate use of antibiotics and antibiotic resistance (AMR). Increased bacterial resistance is due in part to the inappropriate use of antimicrobial agents. The support of the pharmacist becomes important, and there is growing interest in antimicrobial stewardship to promote the appropriate and safe use of antimicrobials needed for the optimal selection of drugs, doses, durations of therapy, therapeutic drug monitoring (TDM), and implementations of cost containment strategies in Japan. Pharmacists should strive to disseminate the concept of "choosing wisely" in relation to all medicines, implement further interventions, and put them into practice. In this article, we present data for antimicrobial stewardship and Japan's AMR action plan, focusing on how pharmacists should be involved in enabling physicians to choose antimicrobials wisely.
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Affiliation(s)
- Yukihiro Hamada
- Department of Pharmacy, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
| | - Fumiya Ebihara
- Department of Pharmacy, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
| | - Ken Kikuchi
- Department of Infectious Disease, Tokyo Women’s Medical University Hospital, Tokyo 162-8666, Japan;
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19
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Murri R, Lardo S, De Luca A, Posteraro B, Torelli R, De Angelis G, Giovannenze F, Taccari F, Pavan L, Parroni L, Sanguinetti M, Fantoni M. Post-Prescription Audit Plus Beta-D-Glucan Assessment Decrease Echinocandin Use in People with Suspected Invasive Candidiasis. Medicina (Kaunas) 2021; 57:medicina57070656. [PMID: 34206911 PMCID: PMC8306264 DOI: 10.3390/medicina57070656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/13/2021] [Accepted: 06/23/2021] [Indexed: 01/08/2023]
Abstract
Background and Objectives: Overtreatment with antifungal drugs is often observed. Antifungal stewardship (AFS) focuses on optimizing the treatment for invasive fungal diseases. The objective of the present study was to evaluate the utility of a post-prescription audit plus beta-D-glucan (BDG) assessment on reducing echinocandin use in persons with suspected invasive candidiasis. Materials and Methods: This is a prospective, pre-post quasi-experimental study of people starting echinocandins for suspected invasive candidiasis. The intervention of the study included review of each echinocandin prescription and discontinuation of treatment if a very low probability of fungal disease or a negative BDG value were found. Pre-intervention data were compared with the intervention phase. The primary outcome of the study was the duration of echinocandin therapy. Secondary outcomes were length of hospital stay and mortality. Results: Ninety-two echinocandin prescriptions were reviewed, 49 (53.3%) in the pre-intervention phase and 43 (46.7%) in the intervention phase. Discontinuation of antifungal therapy was possible in 21 of the 43 patients in the intervention phase (48.8%). The duration of echinocandin therapy was 7.4 (SD 4.7) in the pre-intervention phase, 4.1 days (SD 2.9) in persons undergoing the intervention, and 8.6 (SD 7.3) in persons in whom the intervention was not feasible (p at ANOVA = 0.016). Length of stay and mortality did not differ between pre-intervention and intervention phases. Conclusions: An intervention based on pre-prescription restriction and post-prescription audit when combined with BDG measurement is effective in optimizing antifungal therapy by significantly reducing excessive treatment duration.
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Affiliation(s)
- Rita Murri
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Infectious Diseases Section, Department of Safety and Bioethics, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Correspondence: ; Tel.: +39-333-456-2124
| | - Sara Lardo
- A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy;
| | - Alessio De Luca
- Pharmacy Complex Operative Unit, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (A.D.L.); (L.P.); (L.P.)
| | - Brunella Posteraro
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Department of Basic Biotechnology, Clinical Intensive Care and Perioperative Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Riccardo Torelli
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Department of Basic Biotechnology, Clinical Intensive Care and Perioperative Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Giulia De Angelis
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Department of Basic Biotechnology, Clinical Intensive Care and Perioperative Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Francesca Giovannenze
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Infectious Diseases Section, Department of Safety and Bioethics, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Francesco Taccari
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
| | - Lucia Pavan
- Pharmacy Complex Operative Unit, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (A.D.L.); (L.P.); (L.P.)
| | - Lucia Parroni
- Pharmacy Complex Operative Unit, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (A.D.L.); (L.P.); (L.P.)
| | - Maurizio Sanguinetti
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Department of Basic Biotechnology, Clinical Intensive Care and Perioperative Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Massimo Fantoni
- Department of Laboratory and Infectious Diseases Sciences, A. Gemelli University Hospital Foundation IRCCS, 00168 Rome, Italy; (B.P.); (R.T.); (G.D.A.); (F.G.); (F.T.); (M.S.); (M.F.)
- Infectious Diseases Section, Department of Safety and Bioethics, Catholic University of the Sacred Heart, 00168 Rome, Italy
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20
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van de Peppel RJ, Schauwvlieghe A, Van Daele R, Spriet I, Van't Wout JW, Brüggemann RJ, Rijnders BJA, Hendriks BJC, de Boer MGJ. Outpatient parenteral antifungal therapy (OPAT) for invasive fungal infections with intermittent dosing of liposomal amphotericin B. Med Mycol 2021; 58:874-880. [PMID: 31965178 PMCID: PMC7527269 DOI: 10.1093/mmy/myz134] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/10/2019] [Accepted: 12/20/2019] [Indexed: 12/27/2022] Open
Abstract
Triazole resistant A. fumigatus has been documented in many parts of the world. In the Netherlands, incidence is now above 10% and results in the need for long-term parenteral therapy with liposomal amphotericin B (LAmB). The long terminal half-life of LAmB suggests that intermittent dosing could be effective, making the application of outpatient antifungal therapy (OPAT) possible. Here, we report our experience with the use of OPAT for Invasive Fungal Infections (IFI). All adult patients treated with LAmB with a 2 or 3 times weekly administration via the outpatient departments in four academic tertiary care centers in the Netherlands and Belgium since January 2010 were included in our analysis. Patient characteristics were collected, as well as information about diagnostics, therapy dose and duration, toxicity, treatment history and outcome of the IFI. In total, 18 patients were included. The most frequently used regimen (67%) was 5 mg/kg 3 times weekly. A partial response to the daily treatment prior to discharge was confirmed by CT-scan in 17 (94%) of patients. A favorable outcome was achieved in 13 (72%) patients. Decrease in renal function occurred in 10 (56%) cases but was reversible in all and was treatment limiting in one patient only. The 100-day mortality and 1-year mortality after initiation of OPAT were 0% and 6%, respectively. In a selected population, and after confirmation of initial response to treatment, our data support the use of OPAT with LAmB for treatment of IFI in an intermittent dosing regimen.
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Affiliation(s)
- Robert J van de Peppel
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexander Schauwvlieghe
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus MC, University Medical Center Rotterdam
| | - Ruth Van Daele
- Pharmacy Department, University Hospitals Leuven and Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven and Department of Pharmaceutical and Pharmacological Sciences, Clinical Pharmacology and Pharmacotherapy, KU Leuven, Belgium
| | - Jan W Van't Wout
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy and Radboud Institute for Health Sciences, Radboud University Medical Center; Center of Expertise in Mycology Radboud / CWZ, Radboud University Medical Center Nijmegen, The Netherlands
| | - Bart J A Rijnders
- Department of Internal Medicine, Section of Infectious Diseases, Erasmus MC, University Medical Center Rotterdam
| | - Bart J C Hendriks
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center
| | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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21
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Alegria W, Patel PK. The Current State of Antifungal Stewardship in Immunocompromised Populations. J Fungi (Basel) 2021; 7:352. [PMID: 33946217 PMCID: PMC8145600 DOI: 10.3390/jof7050352] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 01/05/2023] Open
Abstract
Inappropriate antifungal use is prevalent and can lead to drug-resistant fungi, expose patients to adverse drug events, and increase healthcare costs. While antimicrobial stewardship programs have traditionally focused on antibiotic use, the need for targeted antifungal stewardship (AFS) intervention has garnered interest in recent years. Despite this, data on AFS in immunocompromised patient populations is limited. This paper will review the current state of AFS in this complex population and explore opportunities for multidisciplinary collaboration.
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Affiliation(s)
- William Alegria
- Department of Quality, Patient Safety and Effectiveness, Stanford Health Care, 300 Pasteur Drive, Lane 134 L1C36, Stanford, CA 94305, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford, CA 94305, USA
| | - Payal K. Patel
- Division of Infectious Diseases, Department of Internal Medicine, Ann Arbor VA Medical Center, Ann Arbor, MI 48105, USA;
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, 2215 Fuller Rd, Ann Arbor, MI 48105, USA
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22
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Machado M, Chamorro de Vega E, Martínez-Jiménez MDC, Rodríguez-González CG, Vena A, Navarro R, Zamora-Cintas MI, Agnelli C, Olmedo M, Galar A, Guinea J, Fernández-Cruz A, Alonso R, Bouza E, Muñoz P, Valerio M. Utility of 1,3 β-d-Glucan Assay for Guidance in Antifungal Stewardship Programs for Oncologic Patients and Solid Organ Transplant Recipients. J Fungi (Basel) 2021; 7:jof7010059. [PMID: 33477250 PMCID: PMC7830184 DOI: 10.3390/jof7010059] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/25/2020] [Accepted: 01/11/2021] [Indexed: 11/29/2022] Open
Abstract
The implementation of 1,3 β-d-glucan (BDG) has been proposed as a diagnostic tool in antifungal stewardship programs (ASPs). We aimed to analyze the influence of serum BDG in an ASP for oncologic patients and solid organ transplant (SOT) recipients. We conducted a pre–post study. In the initial period (PRE), the ASP was based on bedside advice, and this was complemented with BDG in the post-period (POST). Performance parameters of the BDG assay were determined. Antifungal (AF) use adequacy was evaluated using a point score. Clinical outcomes and AF costs were also compared before and after the intervention. Overall, 85 patients were included in the PRE-period and 112 in the POST-period. Probable or proven fungal infections were similar in both groups (54.1% vs. 57.1%; p = 0.67). The determination of BDG contributed to improved management in 75 of 112 patients (66.9%). The AF adequacy score improved in the POST-period (mean 7.75 vs. 9.29; p < 0.001). Median days of empiric AF treatment was reduced in the POST-period (9 vs. 5 days, p = 0.04). All-cause mortality (44.7% vs. 34.8%; p = 0.16) was similar in both periods. The cost of AF treatments was reduced in the POST-period with a difference of 779.6 €/patient. Our data suggest that the use of BDG was a cost-effective strategy that contributed to safely improving the results of an ASP for SOT and oncologic patients.
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Affiliation(s)
- Marina Machado
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- Fundación Mutua Madrileña Research Fellowship, 28046 Madrid, Spain
- Correspondence: (M.M.); (M.V.); Tel.: +34-915868453 (M.M. & M.V.)
| | - Esther Chamorro de Vega
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - María del Carmen Martínez-Jiménez
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Fundación Mutua Madrileña Research Fellowship, 28046 Madrid, Spain
| | - Carmen Guadalupe Rodríguez-González
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- Pharmacy Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
| | - Antonio Vena
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - Raquel Navarro
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - María Isabel Zamora-Cintas
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - Caroline Agnelli
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - María Olmedo
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
| | - Alicia Galar
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
| | - Jesús Guinea
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- CIBER Enfermedades Respiratorias, CIBERES (CB06/06/0058), 28029 Madrid, Spain
| | - Ana Fernández-Cruz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
| | - Roberto Alonso
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- CIBER Enfermedades Respiratorias, CIBERES (CB06/06/0058), 28029 Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- CIBER Enfermedades Respiratorias, CIBERES (CB06/06/0058), 28029 Madrid, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Maricela Valerio
- Clinical Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain; (M.d.C.M.-J.); (A.V.); (R.N.); (M.I.Z.-C.); (C.A.); (M.O.); (A.G.); (J.G.); (A.F.-C.); (R.A.); (E.B.); (P.M.)
- Instituto de Investigación Sanitaria Gregorio Marañón, 28007 Madrid, Spain; (E.C.d.V.); (C.G.R.-G.)
- Fundación Mutua Madrileña Research Fellowship, 28046 Madrid, Spain
- Correspondence: (M.M.); (M.V.); Tel.: +34-915868453 (M.M. & M.V.)
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Agnelli C, Bouza E, Del Carmen Martínez-Jiménez M, Navarro R, Valerio M, Machado M, Guinea J, Sánchez-Carrillo C, Alonso R, Muñoz P. Clinical Relevance and Prognostic Value of Persistently Negative (1,3)-β-D-Glucan in Adults With Candidemia: A 5-year Experience in a Tertiary Hospital. Clin Infect Dis 2021; 70:1925-1932. [PMID: 31680136 DOI: 10.1093/cid/ciz555] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 06/25/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The clinical relevance and the potential prognostic role of persistently negative (1,3)-β-D-glucan (BDG) in adults with proven candidemia is unknown. METHODS This retrospective study included all adults diagnosed with candidemia our tertiary university hospital from 2012-2017 who had at least 2 serum BDG determinations throughout the episode of fungemia (Fungitell Assay; positive cut-off ≥80pg/mL). Epidemiology and clinical outcomes were compared between patients with all negative versus any positive BDG tests. Poor clinical outcomes included complications due to candidemia or 30-day all-cause mortality. RESULTS Overall, 26/148 (17.6%) candidemic adults had persistently negative BDG tests. These patients were less likely to present Candida growth in all 3 sets of blood cultures (15.4% vs 45.1%; P = .005) and had less severe clinical presentations (median Pitt score, 0 [interquartile range {IQR} 0-1] vs 1 [IQR 0-2] in patients with any positive BDG test; P = .039). Although adequate treatment was equally provided to both groups (96.2% in persistently negative group vs 93.4 in positive group; P = .599), the persistently negative group had a higher rate of microbiological clearance in the first follow-up blood cultures (92.3% vs 69.7% in positive group; P = .005), fewer complications due to candidemia (7.7% vs 33.6% in positive group; P = .008), a lower 30-day mortality rate (3.8% vs 23.8% in positive group; P = .004), and a shorter in-hospital stay (34 days [IQR 18-55] vs 51 days [IQR 35-91] in positive group; P = .003). In the multivariate analysis, persistently negative BDG tests were independently associated with better prognoses (odds ratio 0.12, 95% confidence interval 0.03-0.49; P = .003). CONCLUSIONS Candidemic patients with persistently negative BDG tests present a better prognosis than the comparative group, probably due to a lower systemic fungal burden. In this context, the appropriate use of persistently negative BDG results could be an aid to individualize therapeutic management in the near future.
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Affiliation(s)
- Caroline Agnelli
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, Division of Infectious Diseases, Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CB06/06/0058), Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - María Del Carmen Martínez-Jiménez
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Raquel Navarro
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Maricela Valerio
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Marina Machado
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - Jesús Guinea
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CB06/06/0058), Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - Carlos Sánchez-Carrillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
| | - Roberto Alonso
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CB06/06/0058), Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Spain
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Niazi-Ali S, Atherton GT, Walczak M, Denning DW. Drug-drug interaction database for safe prescribing of systemic antifungal agents. Ther Adv Infect Dis 2021; 8:20499361211010605. [PMID: 33996073 PMCID: PMC8111513 DOI: 10.1177/20499361211010605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/24/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION A drug-drug interaction (DDI) describes the influence of one drug upon another or the change in a drug's effect on the body when the drug is taken together with a second drug. A DDI can delay, decrease or enhance absorption or metabolism of either drug. Several antifungal agents have a large number of potentially deleterious DDIs. METHODS The antifungal drug interactions database https://antifungalinteractions.org/was first launched in 2012 and is updated regularly. It is available as web and app versions to allow information on potential drug interactions with antifungals with a version for patients and another for health professionals. A new and updated database and interface with apps was created in 2019. This allows clinicians and patients to rapidly check for DDIs. The database is fully referenced to allow the user to access further information if needed. Currently DDIs for fluconazole, itraconazole, voriconazole, posaconazole, isavuconazole, terbinafine, amphotericin B, caspofungin, micafungin and anidulafungin are cross-referenced against 2398 other licensed drugs, a total of nearly 17,000 potential DDIs. RESULTS The database records 541 potentially severe DDIs, 1129 moderate and 1015 mild DDIs, a total of 2685 (15.9%). CONCLUSION As the online database and apps are free to use, we hope that widespread acceptance and usage will reduce medical misadventure and iatrogenic harm from unconsidered DDIs.
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Affiliation(s)
- Saarah Niazi-Ali
- Fungal Infection Trust, PO Box 482, Macclesfield, Cheshire SK10 9AR
| | - Graham T. Atherton
- Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
- National Aspergillosis Centre, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | | | - David W. Denning
- Manchester Fungal Infection Group, The University of Manchester, Manchester, UK
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Abstract
BACKGROUND Case reports and pharmacokinetic data suggest off-label echinocandin dosing may be needed to reach adequate serum concentrations in obese patients. Few outcome studies exist evaluating this population. OBJECTIVES Of this study were to (1) determine the association of body mass index (BMI) with clinical outcomes of candidemia patients on standard doses of anidulafungin and (2) characterize fungal infections by body weight. METHODS A retrospective cohort was conducted to evaluate hospitalized patients treated for candidemia with anidulafungin at Food and Drug Administration-labeled dosing for at least 72 hours from January 1, 2014, through January 31, 2018. Candidemia was diagnosed by blood culture or T2 magnetic resonance (T2MR). Patients were compared according to BMI category. RESULTS One hundred seventy-three patients were included. Candida albicans and Candida glabrata were identified in 58 (33%) and 57 (33%) patients, respectively. Mortality was comparable according to BMI category: 4 (36.4%) underweight, 8 (25.8%) normal weight, 16 (32.0%) overweight, 20 (33.9%) obese, and 7 (31.8%) morbidly obese, P = .976. Variables associated with mortality included: severe sepsis (adjusted odds ratio [OR] = 5.1, 95% CI: 1.7-14.8) and liver disease (adjusted OR = 3.2, 95% CI: 1.1-9.4). Variables that were protective of mortality included: line removal (adjusted OR = 0.05, 95% CI: 0.02-0.2) and receipt of anidulafungin for at least 5 days (adjusted OR = 0.35, 95% CI: 0.15-0.8). CONCLUSION There was no difference detected in mortality among patients with candidemia across BMI category. Larger studies are needed to confirm whether standard doses of anidulafungin are sufficient for candidemia in obese patients.
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Affiliation(s)
- Mary Hutton
- Department of Pharmacy Services, Utah Valley Hospital, Provo, UT, USA
| | - Rachel M Kenney
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, USA
| | - Jose A Vazquez
- Department of Medicine, Augusta University, Medical College of Georgia, Augusta, GA, USA
| | - Susan L Davis
- Department of Pharmacy Practice, Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences, Detroit, MI, USA
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Hamada Y, Ueda T, Miyazaki Y, Nakajima K, Fukunaga K, Miyazaki T, Nakada-Motokawa N, Nagao M, Kawamura H, Shigemi A, Ebihara F, Kimura T, Ikegame K, Uchino M, Ikeuchi H, Takesue Y. Effects of antifungal stewardship using therapeutic drug monitoring in voriconazole therapy on the prevention and control of hepatotoxicity and visual symptoms: A multicentre study conducted in Japan. Mycoses 2020; 63:779-786. [PMID: 32510723 PMCID: PMC7496238 DOI: 10.1111/myc.13129] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 11/25/2022]
Abstract
Background Hepatotoxicity and visual symptoms are common adverse effects (AEs) of voriconazole therapy. Objective To retrospectively evaluate the effects of treatment modification based on therapeutic drug monitoring on AEs in patients undergoing voriconazole therapy. Methods The target voriconazole trough concentration (Cmin) was 1‐5 µg/mL. Receiver operating characteristic curves were used to determine Cmin cut‐offs for AEs. Results A total of 401 patients were included. Among 108 patients with high initial Cmin, voriconazole was discontinued in 32 and the dose was reduced in 71. Among 44 patients with low initial Cmin, voriconazole was discontinued in 4 and the dose was increased in 19. Hepatotoxicity occurred in 6.0% of patients, after a median of 10 days. Visual symptoms were evident in 9.5% of patients after a median of 4 days. Initial Cmin was significantly associated with visual symptoms but not hepatotoxicity, which suggested the effect of treatment modification on hepatotoxicity. However, both hepatotoxicity and visual symptoms were significantly correlated with Cmin at the onset of AEs, and the Cmin cut‐offs were 3.5 μg/mL for hepatotoxicity and 4.2 μg/mL for visual symptoms. Voriconazole was discontinued after the occurrence of AEs in 62.5% of patients with hepatotoxicity but only 26.3% of patients with visual symptoms. With dose adjustment, treatment was completed in 8/9 patients with hepatotoxicity and 27/28 patients with visual symptoms. Conclusions A significant preventive effect was demonstrated on hepatotoxicity, but not on visual symptoms because of earlier occurrence. With treatment modification after the occurrence of AEs, most patients completed therapy.
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Affiliation(s)
- Yukihiro Hamada
- Department of Pharmacy, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Takashi Ueda
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshitsugu Miyazaki
- Department of Chemotherapy and Mycoses, National Institute of Infectious Diseases, Tokyo, Japan
| | - Kazuhiko Nakajima
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
| | - Keiko Fukunaga
- Department of Hematology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Taiga Miyazaki
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Nana Nakada-Motokawa
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Miki Nagao
- Department of Infection Control and Prevention, Kyoto University Hospital, Kyoto, Japan
| | - Hideki Kawamura
- Division of Medical and Environmental Safety, Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - Akari Shigemi
- Division of Medical and Environmental Safety, Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - Fumiya Ebihara
- Department of Pharmacy, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Toshimi Kimura
- Department of Pharmacy, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Kazuhiro Ikegame
- Department of Hematology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Motoi Uchino
- Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Ikeuchi
- Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention, Hyogo College of Medicine, Nishinomiya, Japan
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Ananda-Rajah MR, Fitchett S, Ayton D, Peleg AY, Fleming S, Watson E, Cairns K, Peel T. Ushering in Antifungal Stewardship: Perspectives of the Hematology Multidisciplinary Team Navigating Competing Demands, Constraints, and Uncertainty. Open Forum Infect Dis 2020; 7:ofaa168. [PMID: 32577425 PMCID: PMC7299525 DOI: 10.1093/ofid/ofaa168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/12/2020] [Indexed: 11/14/2022] Open
Abstract
Background The social, contextual, and behavioral determinants that influence care in patients at risk for invasive fungal diseases (IFD) are poorly understood. This knowledge gap is a barrier to the implementation of emerging antifungal stewardship (AFS) programs. We aimed to understand the barriers and enablers to AFS, opportunities for improvement, and perspectives of AFS for hematology patients at a major medical center in Australia. Methods Semistructured, face-to-face interviews were conducted with 35 clinicians from 6 specialties (hematology, infectious diseases, pharmacy, nursing, radiology, respiratory), followed by thematic analysis mapped to a behavioral change framework. Results Access to fungal diagnostics including bronchoscopy was identified as the key barrier to rational prescribing. Collective decision making was the norm, aided by an embedded stewardship model with on-demand access to infectious diseases expertise. Poor self-efficacy/knowledge among prescribers was actually an enabler of AFS, because clinicians willingly deferred to infectious diseases for advice. A growing outpatient population characterized by frequent care transitions was seen as an opportunity for AFS but neglected by an inpatient focused model, as was keeping pace with emerging fungal risks. Ad hoc surveillance, audit, and feedback practices frustrated population-level quality improvement for all actors. Antifungal stewardship was perceived as a specialized area that should be integrated within antimicrobial stewardship but aligned with the cultural expectations of hematologists. Conclusions Antifungal stewardship is multifaceted, with fungal diagnostics a critical gap and outpatients a neglected area. Formal surveillance, audit, and feedback mechanisms are essential for population-level quality improvement. Resourcing is the next challenge because complex immunocompromised patients require personalized attention and audit of clinical outcomes including IFD is difficult.
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Affiliation(s)
- Michelle R Ananda-Rajah
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia.,General Medical Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Samuel Fitchett
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Darshini Ayton
- Monash Partners Academic Health Science Centre, Clayton, Victoria, Australia
| | - Anton Y Peleg
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
| | - Shaun Fleming
- Clinical Haematology, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Eliza Watson
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kelly Cairns
- Department of Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - Trisha Peel
- Department of Infectious Diseases, Alfred Health and Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Mularoni A, Adamoli L, Polidori P, Ragonese B, Gioè SM, Pietrosi A, Tuzzolino F, Guadagnino G, Monaco F, Grossi PA, Conaldi PG, Luca A, Mikulska M. How can we optimise antifungal use in a solid organ transplant centre? Local epidemiology and antifungal stewardship implementation: A single-centre study. Mycoses 2020; 63:746-754. [PMID: 32358860 DOI: 10.1111/myc.13098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 04/15/2020] [Accepted: 04/27/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE We aimed to implement and to assess the impact of the antifungal stewardship programme (AFSp) on prescription appropriateness of antifungals, management and outcomes of candidaemia patients, and antifungal consumption and costs at our solid organ transplant (SOT) institute. METHODS Local epidemiology of invasive fungal infections (IFIs) from 2009 to 2017 was analysed in order to prepare an effective AFSp, implemented in January 2018. It included suspension of empirical antifungal prescriptions after 72 hours (antifungal time-out), automated alert and infectious disease (ID) consult for empirical prescriptions and for every patient with IFI, and indication for step-down to oral fluconazole when possible. We used process measures and results measures to assess the effects of the implemented programme. RESULTS The ASFp led to significant improvements in selection of the appropriate antifungal (40.5% in pre-AFS vs 78.6% in post-AFS), correct dosing (51.2% vs 79.8%), correct length of treatment (55.9% vs 75%) and better management of patients with candidaemia. Analysis of prescribed empirical antifungal revealed that defined daily doses (DDDs) per 100 patient days decreased by 36.7% in 2018 compared to the average of pre-AFSp period, with important savings in costs. CONCLUSION This AFSp led to a better use of antifungal drugs in terms of appropriateness and consumption, with stable clinical and microbiological outcomes in patients with IFI.
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Affiliation(s)
- Alessandra Mularoni
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Lucia Adamoli
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Piera Polidori
- Clinical Pharmacy Service, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Barbara Ragonese
- Department of Accreditation and Quality, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Santi Mauro Gioè
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Astrid Pietrosi
- Department of Management Control and Decision Support, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Fabio Tuzzolino
- Research Office, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Giuliana Guadagnino
- Department of Infectious and Tropical Diseases, St. Annunziata Hospital, Cosenza, Italy
| | - Francesco Monaco
- Laboratory of Clinical Pathology, Microbiology, and Virology, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Paolo Antonio Grossi
- Clinica delle Malattie Infettive e Tropicali, Università degli Studi dell'Insubria, Varese, Italy
| | - Pier Giulio Conaldi
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Angelo Luca
- IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Malgorzata Mikulska
- Division of Infectious Diseases, University of Genoa (DISSAL) and Ospedale Policlinico San Martino, Genoa, Italy
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Bal AM, McGill M. Rapid species identification of Candida directly from blood culture broths by Sepsityper-MALDI-TOF mass spectrometry: impact on antifungal therapy. J R Coll Physicians Edinb 2019; 48:114-119. [PMID: 29992199 DOI: 10.4997/jrcpe.2018.203] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Rapid identification of Candida species facilitates pathogen-directed therapy with either fluconazole or an echinocandin. METHOD We applied Sepsityper matrix-assisted laser desorption ionisation time of flight mass spectrometry (MALDI-TOF-MS) technology on positive blood culture broths for rapid species identification. RESULTS Of the 74 patients with candidaemia, 25 had the species identified on the day of the positive blood culture directly from the broth (rapid identification group) while the remaining 49 had the species identified from culture (conventional identification group). Three (13.6%) out of 22 treated patients in the rapid identification group received echinocandin compared to 20/45 (44.4%) in the conventional identification group. The appropriateness of therapy was 90.9% in the rapid identification group and 62.2% in the conventional identification group (p = 0.01). Cost savings were more than £10,000 in the first three days of treatment. CONCLUSION Sepsityper-MALDI-TOF-MS is a useful tool in supporting antifungal stewardship programmes.
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Affiliation(s)
- A M Bal
- Department of Microbiology, University Hospital, Crosshouse, Kilmarnock KA2 0BE, UK,
| | - M McGill
- Department of Microbiology, University Hospital Crosshouse, Kilmarnock, UK
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Bouza E, Almirante B, García Rodríguez J, Garnacho-Montero J, Salavert M, Muñoz P, Sanguinetti M. Biomarkers of fungal infection: Expert opinion on the current situation. Rev Esp Quimioter 2019. [PMID: 31729203 PMCID: PMC6987620 DOI: 10.37201/req/2260.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The introduction of non-culture-based diagnostic techniques is revolutionizing the world of microbiological diagnosis and infection assessment. Fungi are no exception, and the introduction of biomarkers has opened up enormous expectations for better management of these entities. Biomarkers are diverse, their targets are also diverse and their evaluation has been done preferably in an individualized use and with deficient designs. Less is known about the value of the combined use of biomarkers and the impact of the negativity of two or more biomarkers on antifungal treatment decisions has been poorly studied. Given the paucity of prospective, randomized and definitive studies, we have convened experts from different fields, with an interest in invasive fungal infections, to answer some questions about the current relevant use of fungal biomarkers. This document summarizes the answers of these experts to the different questions.
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Affiliation(s)
- E Bouza
- Emilio Bouza, Instituto de Investigación Sanitaria Gregorio Marañón, Servicio de Microbiología Clínica y E. Infecciosas, C/ Dr. Esquerdo, 46, 28007 Madrid, Spain.
| | | | | | | | | | - P Muñoz
- Patricia Muñoz, Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquerdo, 46, 28007 Madrid, Spain.
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Baggio D, Peel T, Peleg AY, Avery S, Prayaga M, Foo M, Haffari G, Liu M, Bergmeir C, Ananda-Rajah M. Closing the Gap in Surveillance and Audit of Invasive Mold Diseases for Antifungal Stewardship Using Machine Learning. J Clin Med 2019; 8:E1390. [PMID: 31491944 DOI: 10.3390/jcm8091390] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 08/30/2019] [Accepted: 09/02/2019] [Indexed: 12/22/2022] Open
Abstract
Clinical audit of invasive mold disease (IMD) in hematology patients is inefficient due to the difficulties of case finding. This results in antifungal stewardship (AFS) programs preferentially reporting drug cost and consumption rather than measures that actually reflect quality of care. We used machine learning-based natural language processing (NLP) to non-selectively screen chest tomography (CT) reports for pulmonary IMD, verified by clinical review against international definitions and benchmarked against key AFS measures. NLP screened 3014 reports from 1 September 2008 to 31 December 2017, generating 784 positives that after review, identified 205 IMD episodes (44% probable-proven) in 185 patients from 50,303 admissions. Breakthrough-probable/proven-IMD on antifungal prophylaxis accounted for 60% of episodes with serum monitoring of voriconazole or posaconazole in the 2 weeks prior performed in only 53% and 69% of episodes, respectively. Fiberoptic bronchoscopy within 2 days of CT scan occurred in only 54% of episodes. The average turnaround of send-away bronchoalveolar galactomannan of 12 days (range 7–22) was associated with high empiric liposomal amphotericin consumption. A random audit of 10% negative reports revealed two clinically significant misses (0.9%, 2/223). This is the first successful use of applied machine learning for institutional IMD surveillance across an entire hematology population describing process and outcome measures relevant to AFS. Compared to current methods of clinical audit, semi-automated surveillance using NLP is more efficient and inclusive by avoiding restrictions based on any underlying hematologic condition, and has the added advantage of being potentially scalable.
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Bassetti M, Giacobbe DR, Vena A, Brink A. Challenges and research priorities to progress the impact of antimicrobial stewardship. Drugs Context 2019; 8:212600. [PMID: 31516534 PMCID: PMC6726362 DOI: 10.7573/dic.212600] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 07/16/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial stewardship programmes have been playing an important role in patient care and hospital policies. These programmes are now recognised as formal strategies for curbing the upward trend in antibiotic resistance and for improving the appropriate antimicrobial and antifungal use. The role of such programs in the era of antimicrobial resistance presents several unique challenges and opportunities, most notably in the diagnostic and therapeutic setting. Controversies remain regarding the most effective interventions and the appropriate design to evaluate their impact. In this review, based on rounds of discussion, we explain the most important challenges faced by antibiotic stewardship and antifungal stewardship programmes. We also try to suggest areas for further research.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Department of Medicine, University of Udine, Italy.,Infectious Diseases Unit, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Largo R. Benzi, 10, 16132, Genoa, Italy.,Department of Health Sciences, DISSAL, University of Genoa, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Largo R. Benzi, 10, 16132, Genoa, Italy.,Department of Health Sciences, DISSAL, University of Genoa, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Clinic, Department of Medicine, University of Udine, Italy
| | - Adrian Brink
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Ito-Takeichi S, Niwa T, Fujibayashi A, Suzuki K, Ohta H, Niwa A, Tsuchiya M, Yamamoto M, Hatakeyama D, Suzuki A, Baba H, Murakami N, Itoh Y. The impact of implementing an antifungal stewardship with monitoring of 1-3, β-D-glucan values on antifungal consumption and clinical outcomes. J Clin Pharm Ther 2019; 44:454-462. [PMID: 30723924 DOI: 10.1111/jcpt.12809] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 12/26/2018] [Accepted: 01/10/2019] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Implementation of an antifungal stewardship programme is a recognized need. However, there is insufficient information to confirm the impact of antifungal stewardship interventions. Further, few studies have evaluated the clinical effects of an antifungal stewardship intervention using 1-3, β-D-glucan (βDG) testing. The aim of the present study was to evaluate the impact of implementing an antifungal stewardship with monitoring of βDG values on antifungal use and clinical outcomes. METHODS A single institutional prospective cohort study was conducted to evaluate the impact of implementing daily reviews of antifungal agents and monitoring patients who measured βDG values since August 2013. Antifungal consumption and clinical outcomes in patients with Candida bloodstream infection were compared before and after the intervention. RESULTS After implementation of the programme, parental antifungal use was significantly reduced compared to that before intervention (P = 0.006). In the after-intervention group, the rate of 60-day clinical failure in patients with Candida bloodstream infection was significantly reduced, from 80.0% (28/35) to 36.4% (8/22) (P < 0.001), and the rate of 60-day mortality associated with Candida bloodstream infection tended to be reduced, from 42.9% (15/35) to 18.2% (4/22) (P = 0.081) compared to the before-intervention group. The incidence of adverse events associated with antifungal agents was significantly lower in the after-intervention group than in the before-intervention group (51.4% [18/35] vs 13.6% [3/22], P = 0.004). WHAT IS NEW AND CONCLUSION Our findings suggest that daily review of the use of antifungal agents and monitoring of measured βDG values was highly effective in reducing antifungal consumption and improving the clinical outcomes of patients with Candida bloodstream infection.
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Affiliation(s)
- Syuri Ito-Takeichi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan.,Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Takashi Niwa
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan.,Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Ayasa Fujibayashi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan.,Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Keiko Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan.,Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Hirotoshi Ohta
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Ayumi Niwa
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Mayumi Tsuchiya
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Masayo Yamamoto
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Daijiro Hatakeyama
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Hisashi Baba
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Nobuo Murakami
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Yoshinori Itoh
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
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Stanzani M, Lewis RE. Development and Applications of Prognostic Risk Models in the Management of Invasive Mold Disease. J Fungi (Basel) 2018; 4:E141. [PMID: 30572637 DOI: 10.3390/jof4040141] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 12/10/2018] [Accepted: 12/14/2018] [Indexed: 12/15/2022] Open
Abstract
Prognostic models or risk scores are frequently used to aid individualize risk assessment for diseases with multiple, complex risk factors and diagnostic challenges. However, relatively little attention has been paid to the development of risk models for invasive mold diseases encountered in patients with hematological malignancies, despite a large body of epidemiological research. Herein we review recent studies that have described the development of prognostic models for mold disease, summarize our experience with the development and clinical use of one such model (BOSCORE), and discuss the potential impact of prognostic risk scores for individualized therapy, diagnostic and antifungal stewardship, as well as clinical and epidemiological research.
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Hirano R, Sakamoto Y, Kitazawa J, Yamamoto S, Kayaba H. Epidemiology, practice patterns, and prognostic factors for candidemia; and characteristics of fourteen patients with breakthrough Candida bloodstream infections: a single tertiary hospital experience in Japan. Infect Drug Resist 2018; 11:821-833. [PMID: 29910625 PMCID: PMC5987783 DOI: 10.2147/idr.s156633] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Candidemia is associated with high mortality, and its prognostic factors need to be examined in more detail in order to improve its management. A case of breakthrough (BT) candidemia is defined as the development of candidemia during antifungal therapy. The microbiological characteristics of and appropriate clinical practices for BT candidemia remain unclear. Objectives The primary objective of the present study was to identify the prognostic factors of candidemia, while the secondary objective was to elucidate the microbiological characteristics of patients with BT candidemia. Materials and methods A total of 121 patients diagnosed with candidemia between January 2007 and December 2016 were enrolled in this study. The primary outcome was the 30-day mortality rate. Results The overall incidence of candidemia was 0.056 cases/1000 inpatients. Among the 126 Candida isolated, C. albicans accounted for 36%, C. parapsilosis 26%, C. glabrata 12%, C. guilliermondii 14%, C. tropicalis 3%, C. pelliculos 1%, and other unidentifiable Candida species 8%. The 30-day mortality rate was 33%. In a multivariate Cox hazard analysis, C. albicans, the absence of antifungal therapy, age, lung disease, and mechanical ventilation were associated with a high mortality rate, whereas C. parapsilosis, the removal of a central venous catheter, and surgical wards were associated with a lower mortality rate. Fourteen patients had BT candidemia. A significant difference was observed in the proportion of C. guilliermondii and other Candida species exhibiting resistance to fluconazole and voriconazole, between patients with and without BT candidemia. Resistance to fluconazole was prominent in patients that developed candidemia with a history of azole antifungal agents. Conclusion The prompt initiation of antifungal therapy and removal of central venous catheter were essential for better outcomes. A class switch to other antifungal agents needs to be considered in empirical antifungal therapy for BT candidemia with a history of exposure to azole antifungal agents.
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Affiliation(s)
- Ryuichi Hirano
- Department of Pharmacy, Aomori Prefectural Central Hospital, Aomori, Japan.,Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuichi Sakamoto
- Department of Laboratory Medicine, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Junichi Kitazawa
- Department of Laboratory Medicine, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Shoji Yamamoto
- Department of Pharmacy, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Hiroyuki Kayaba
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Carr A, Colley P, Berhe M, Nguyen HL. Evaluating predictors of invasive candidiasis in patients with and without candidemia on micafungin. Proc (Bayl Univ Med Cent) 2018; 31:30-34. [PMID: 29686548 DOI: 10.1080/08998280.2017.1396164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Numerous risk factors have been linked to invasive candidiasis; however, they are nonspecific and often trigger empiric antifungal therapy in a large number of patients. Identification of more precise predictors could promote judicious use of empiric echinocandins. In this retrospective review, 127 patients with blood cultures positive for Candida spp. were compared to a randomly selected cohort of 134 patients on empiric micafungin for ≥3 days and with blood cultures negative for Candida spp. Factors associated with candidemia included total parenteral nutrition (TPN; 26.0% vs 15.7%, P = 0.040), multifocal Candida colonization (23.6% vs 3.0%, P < 0.001), and positive 1,3-β-d-glucan assay (95.0% vs 35.0%, P < 0.001). Patients without candidemia on empiric micafungin were more likely to receive antibiotic therapy in the previous 10 days (55.9% vs 79.9%, P < 0.001) and to be taking immunosuppressive medications (11.0% vs 30.6%, P < 0.001). Receipt of TPN (odds ratio [OR] = 2.07, 95% confidence interval [CI], 1.02-4.21), severe sepsis (OR = 2.20, 95% CI, 1.00-4.83), and multifocal Candida colonization (OR = 13.87, 95% CI, 4.43-43.37) were independently associated with candidemia in the multivariable logistic regression model. Therefore, the absence of these risk factors, especially in conjunction with a negative 1,3-β-d-glucan assay, may be used to recommend de-escalation of empiric micafungin therapy.
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Affiliation(s)
- Amy Carr
- Department of Pharmacy, Seton Healthcare Family, Austin, Texas
| | - Peter Colley
- Department of Pharmacy, Baylor University Medical Center, Dallas, Texas
| | - Mezgebe Berhe
- Department of Medicine, Division of Infectious Diseases, Baylor University Medical Center, Dallas, Texas
| | - Hoa L Nguyen
- Department of Quantitative Sciences, Baylor Scott and White Health, Dallas, Texas
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Abstract
INTRODUCTION Fungemia presents high morbi-mortality and thus rapid microbiological diagnosis may contribute to appropriate patient management. In the last decade, kits based on molecular technologies have become available and health care institutes are increasingly facing critical investment choices. Although all these tools aim to achieve rapid fungal detection and species identification, they display different inherent characteristics. Areas covered: Considering technologies allowing detection and identification of fungal species in a sepsis context, the market proposes either tests on positive blood culture or tests on patient's whole blood. In this review, the authors describe and compare the ePlex® Blood Culture Identification Fungal Pathogen (BCID-FP) test, a fully automated one-step single-use cartridge assay that has been designed to detect identify frequent or rare but emerging, fungal species, from positive blood culture. A comparison with the competing kits is provided. Expert commentaries: The ePlex BCID-FP test provides a diversified and rather relevant panel. Its easy-to-use cartridges allow flexible use around the clock. Nevertheless, prospective clinical studies assessing the time-to-result benefit on antifungal stewardship and on hospital length of stay are not available yet. New tools aim to benefit clinicians and patients, but they should be accompanied by supervision of result interpretation and adaptation of antifungal stewardship.
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Affiliation(s)
- Danièle Maubon
- a Univsité Grenoble Alpes, CNRS, Grenoble INP*, TIMC-IMAG , Grenoble , France.,b Parasitology-Mycology Laboratory, Infectious Agents Department , CHU Grenoble-Alpes , Grenoble , France
| | - Céline Dard
- b Parasitology-Mycology Laboratory, Infectious Agents Department , CHU Grenoble-Alpes , Grenoble , France
| | - Cécile Garnaud
- a Univsité Grenoble Alpes, CNRS, Grenoble INP*, TIMC-IMAG , Grenoble , France.,b Parasitology-Mycology Laboratory, Infectious Agents Department , CHU Grenoble-Alpes , Grenoble , France
| | - Muriel Cornet
- a Univsité Grenoble Alpes, CNRS, Grenoble INP*, TIMC-IMAG , Grenoble , France.,b Parasitology-Mycology Laboratory, Infectious Agents Department , CHU Grenoble-Alpes , Grenoble , France
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Rac H, Wagner JL, King ST, Barber KE, Stover KR. Impact of an antifungal stewardship intervention on optimization of candidemia management. Ther Adv Infect Dis 2017; 5:3-10. [PMID: 29344355 DOI: 10.1177/2049936117745267] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Candidemia represents a leading cause of healthcare-associated bloodstream infections with significant morbidity and mortality. Previous studies have demonstrated that comprehensive care bundles improve candidemia management but are time-consuming. Objective To determine the impact of a one-time targeted candidemia intervention on time to initiation of adequate therapy compared to standard of care. Methods This Institutional Review Board (IRB)-approved, quasi-experiment evaluated a targeted candidemia intervention involving a single phone call to the primary team providing recommendations for care. Daily follow-up was provided by the infectious diseases (ID) consult service. Two time periods were evaluated: pre-intervention (01 August 2012 to 31 July 2014) and post-intervention (01 October 2014 to 30 September 2016). The primary endpoint was time to adequate antifungal therapy (TTx) in the business hours (6 a.m. to 6 p.m. Monday through Friday) population (BHP). Secondary endpoints were TTx in the total population as well as infection-related length of stay (IF-LOS) and compliance with quality indicators (composite endpoint: ophthalmology (OPH) consult, repeat cultures, and ⩾14 days of adequate therapy). Results In all, 117 patients were included (pre-intervention = 50, post-intervention = 67, BHP = 51). TTx decreased from 2 h 57 m to 2 h 12 m (p = 0.094) in the BHP and 3 h 30 m to 2 h 9 m (p = 0.021) in the total population. There was no difference in IF-LOS (p = 0.797), compliance with quality indicators (p = 0.343), or in-hospital mortality (p = 0.761). Post-intervention, there were more ID and OPH consults (p < 0.001). Conclusions Our one-time candidemia intervention did not statistically decrease time to adequate therapy in the BHP, but did in the total population. No differences were found for other clinical outcomes, except increases in ID and OPH consults. Further studies are needed to examine whether a one-time intervention is non-inferior to a more comprehensive care bundle.
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Affiliation(s)
- Hana Rac
- Department of Pharmacy, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jamie L Wagner
- Department of Pharmacy Practice, School of Pharmacy, University of Mississippi, Jackson, MS, USA
| | - S Travis King
- Department of Pharmacy Practice, School of Pharmacy, University of Mississippi, Jackson, MS, USA
| | - Katie E Barber
- Department of Pharmacy Practice, School of Pharmacy, University of Mississippi, Jackson, MS, USA
| | - Kayla R Stover
- Department of Pharmacy Practice, School of Pharmacy, University of Mississippi; Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
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Micallef C, Ashiru-Oredope D, Hansraj S, Denning DW, Agrawal SG, Manuel RJ, Schelenz S, Guy R, Muller-Pebody B, Patel R, Howard P, Hopkins S, Johnson E, Enoch DA. An investigation of antifungal stewardship programmes in England. J Med Microbiol 2017; 66:1581-1589. [PMID: 29068278 DOI: 10.1099/jmm.0.000612] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
PURPOSE We sought to explore the current status of antifungal stewardship (AFS) initiatives across National Health Service (NHS) Trusts within England, the challenges and barriers, as well as ways to improve current AFS programmes. METHODOLOGY An electronic survey was sent to all 155 acute NHS Trusts in England. A total of 47 Trusts, corresponding to 30 % of English acute Trusts, responded to the the survey; 46 Trusts (98 %) had an antimicrobial stewardship (AMS) programme but only 5 (11 %) had a dedicated AFS programme. Overall, 20 (43 %) Trusts said they included AFS as part of their AMS programmes. From those conducting AFS programmes, 7 (28 %) have an AFS/management team, 16 (64 %) monitor and report on antifungal usage, 5 (20 %) have dedicated AFS ward rounds and 12 (48 %) are directly involved in the management of invasive fungal infections.Results/Key findings. Altogether, 13 acute Trusts (52 %) started their AFS programme to manage costs, whilst 12 (48 %) commenced the programme due to clinical need; 27 (73 %) declared that they would increase their AFS initiatives if they could. Of those without an AFS programme, 14 (67 %) responded that this was due to lack of resources/staff time. Overall, 12 Trusts (57 %) responded that the availability of rapid diagnostics and clinical support would enable them to conduct AFS activities. CONCLUSION Although a minority of Trusts conduct dedicated AFS programmes, nearly half include AFS as part of routine AMS activities. Cost issues are the main driver for AFS, followed by clinical need. The availability of rapid diagnostics and clinical support could help increase AFS initiatives.
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Affiliation(s)
- Christianne Micallef
- Pharmacy Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital Biomedical Campus, Hills Road, Cambridge CB2 0QQ, UK
| | - Diane Ashiru-Oredope
- Antimicrobial Resistance Programme, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Sejal Hansraj
- Antimicrobial Resistance Programme, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - David W Denning
- National Aspergillosis Centre, University Hospital of South Manchester, The University of Manchester and Manchester Academic Health Science Centre, Manchester, UK
| | - Samir G Agrawal
- Bart's Health NHS Trust and Blizard Institute, Queen Mary University of London, London, UK
| | - Rohini J Manuel
- National Infection Service, Public Health England, Public Health Laboratory London, London, UK
| | - Silke Schelenz
- Royal Brompton Hospital & Harefield Hospitals NHS FT, Sydney Street, London SW3 6NP, UK
| | - Rebecca Guy
- Healthcare Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Berit Muller-Pebody
- Healthcare Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Rakhee Patel
- Pharmacy Department, Darent Valley Hospital, Dartford and Gravesham NHS Trust, Darenth Wood Road, Dartford, Kent DA2 8DA, UK
| | - Philip Howard
- Pharmacy Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Susan Hopkins
- Healthcare Associated Infection and Antimicrobial Resistance Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Elizabeth Johnson
- Public Health England South West Laboratory, Myrtle Road, Kingsdown, Bristol BS2 8EL, UK
| | - David A Enoch
- National Infection Service, Public Health England, Microbiology Laboratory, Addenbrook's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Abstract
Improved understanding of basic mycological, pharmacological, and immunological processes has led to important advances in the diagnosis and treatment of invasive fungal infections. However, the rise of fungi that are resistant to existing antifungal agents poses a substantial threat to human health. Addressing this expanding problem is an urgent priority for the international research community. In this article, we highlight important diagnostic and therapeutic advances that address the rise of resistant fungi as well as new public health initiatives that warrant further investigation to help curb the spread of these potentially lethal organisms.
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Affiliation(s)
| | - David W Denning
- University Hospital of South Manchester, University of Manchester, Manchester Academic Health Science Centre, United Kingdom
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases Program, Weill Cornell Medicine, New York, New York
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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: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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42
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Abstract
Report from the 26th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID 2016), 9-12 April Amsterdam, The Netherlands Invasive fungal infections are a major threat to the lives of the increasing number of immunocompromized patients, but neutropenic hemato-oncology patients are at especially high risk. Since effective antifungal treatment and prophylaxis are critical to improve survival in these patients, the emergence of antifungal drug resistance has become an increasing cause of concern. Mortality from invasive fungal infection also remains high even when patients receive appropriate and timely antifungal therapy. These important topics were among those discussed by the over 11,600 clinical microbiologists and infectious disease physicians from more than 120 countries attending the 26th European Congress of Clinical Microbiology and Infectious Diseases.
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Affiliation(s)
- Paul Verweij
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sue Lyon
- Freelance Medical Writer, London, UK
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43
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Pfaller MA, Castanheira M. Nosocomial Candidiasis: Antifungal Stewardship and the Importance of Rapid Diagnosis. Med Mycol 2015; 54:1-22. [PMID: 26385381 DOI: 10.1093/mmy/myv076] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 07/20/2015] [Indexed: 01/12/2023] Open
Abstract
Candidemia and other forms of candidiasis are associated with considerable excess mortality and costs. Despite the addition of several new antifungal agents with improved spectrum and potency, the frequency of Candida infection and associated mortality have not decreased in the past two decades. The lack of rapid and sensitive diagnostic tests has led to considerable overuse of antifungal agents resulting in increased costs, selection pressure for resistance, unnecessary drug toxicity, and adverse drug interactions. Both the lack of timely diagnostic tests and emergence of antifungal resistance pose considerable problems for antifungal stewardship. Whereas antifungal stewardship with a focus on nosocomial candidiasis should be able to improve the administration of antifungal therapy in terms of drug selection, proper dose and duration, source control and de-escalation therapy, an important parameter, timeliness of antifungal therapy, remains a victim of slow and insensitive diagnostic tests. Fortunately, new proteomic and molecular diagnostic tools are improving the time to species identification and detection. In this review we will describe the potential impact that rapid diagnostic testing and antifungal stewardship can have on the management of nosocomial candidiasis.
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Affiliation(s)
- Michael A Pfaller
- T2Biosystems, Lexington, Massachusetts JMI Laboratories, North Liberty, Iowa University of Iowa College of Medicine College of Public Health, Iowa City, Iowa
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44
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Chang CC, Ananda-Rajah M, Belcastro A, McMullan B, Reid A, Dempsey K, Athan E, Cheng AC, Slavin MA. Consensus guidelines for implementation of quality processes to prevent invasive fungal disease and enhanced surveillance measures during hospital building works, 2014. Intern Med J 2015; 44:1389-97. [PMID: 25482747 DOI: 10.1111/imj.12601] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Healthcare-associated fungal outbreaks impose a substantial economic burden on the health system and typically result in high patient morbidity and mortality, particularly in the immunocompromised host. As the population at risk of invasive fungal infection continues to grow due to the increased burden of cancer and related factors, the need for hospitals to employ preventative measures has become increasingly important. These guidelines outline the standard quality processes hospitals need to accommodate into everyday practice and at times of healthcare-associated outbreak, including the role of antifungal stewardship programmes and best practice environmental sampling. Specific recommendations are also provided to help guide the planning and implementation of quality processes and enhanced surveillance before, during and after high-risk activities, such as hospital building works. Areas in which information is still lacking and further research is required are also highlighted.
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Affiliation(s)
- C C Chang
- Department of Infectious Diseases, Alfred Health and Monash University, Prahran, Victoria; Centre for Biomedical Research, Burnet Institute, Victoria; Lewin-Cameron Laboratory, The Doherty Institute for Infection and Immunity, Parkville, Victoria
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45
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van de Peppel RJ, Dekkers OM, von dem Borne PA, de Boer MGJ. Relapsed and secondary disease drive the risk profile for invasive aspergillosis prior to stem cell transplantation in patients with acute myeloid leukemia or myelodysplastic syndrome. Med Mycol 2014; 52:699-705. [PMID: 25049037 DOI: 10.1093/mmy/myu036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) are at risk for invasive aspergillosis (IA) even prior to the introduction of stem cell transplantation (SCT). In times of increasing triazole resistance and changing use of antifungal prophylaxis, insight into the risk factors for IA is needed to improve strategies for preventing IA in this population. Consecutive patients who received remission-induction therapy for AML or MDS at the Leiden Academic Medical Centre were included. Instead of standard antifungal prophylaxis, an assertive protocol for diagnosis of suspected fungal infection was in place. IA was classified according to the revised European Organization for Research and Treatment of Cancer criteria. Potential predisposing characteristics for IA were compared by uni- and multivariate analyses. In 45 (25%) of 184 included episodes (167 patients), IA was diagnosed prior to SCT. A multivariate Cox regression model demonstrated that relapsed AML (hazard ratio [HR] 2.4; 95% confidence interval [CI], 1.1-5.1; P = 0.02), secondary AML (HR, 5.2; 95% CI, 2.3-11.8; P < 0.001), and prolonged duration of neutropenia (HR, 2.2; 95% CI, 1.2-4.0; P = 0.01) were independently associated with IA. Use of granulocyte-colony-stimulating factor showed a trend toward a protective effect (HR, 0.37; 95% CI, 0.1-31.0; P = 0.06). Relapsed AML, secondary AML, and duration of neutropenia were independent factors for determining the risk for development of IA prior to SCT. The results provide further guidance for antifungal stewardship programs when integrating individual patient tailored decision making in antifungal prophylaxis strategies.
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Affiliation(s)
- Robert J van de Peppel
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Mark G J de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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