Antifungal stewardship in a tertiary hospital

Abstract

Background: The inappropriate use of antifungals is an important health problem related to increasing adverse effects, unnecessary cost and promotion of resistant and emerging fungal infections. Despite its relevance, many health institutions assign few resources to improve prescribing practices.

Aims: To evaluate the efficiency of an antifungal stewardship programme (ASP) centered on restricted antifungal agents.

Methods: The main activity during the eight-month study was to perform a programmed review of restricted antifungals (lipid formulations of amphotericin B, echinocandins and voriconazole) prescribed in hospitalized patients. In the case of amendable antifungal treatment, a recommendation was included in the electronic medical record.

Results: A total of 280 antifungal prescriptions for 262 patients were revised during the study period. The indications were prophylactic in 85 cases (30.4%), pre-emptive in 10 cases (3.5%), empiric in 122 cases (43.6%), and directed in 63 cases (22.5%). A total of 70 prescriptions (25%) in 61 patients were considered to be amendable. In most of these cases, treatment could have been reduced considering the patient's clinical improvement and microbiological results. The most common advice was antifungals change (70%), antifungal withdrawal (21%), removal of one antifungal drug in cases of combined therapy (7%), and switching to oral route (1%). Proposed recommendations were addressed in 28 cases (40%). There was no significant difference in adherence with respect to the type of recommendation (p=0.554). There was a 42% lower use of antifungals during the period of the study compared to that observed during a similar previous period. Mortality among patients who were treated according to the recommendations of the ASP was 17% and in whom treatment was not modified it was 30% (p=0.393).

Conclusions: ASPs centered on hospitalized patients may be an efficient strategy to ameliorate antifungal use in hospitals.

Keywords: Agentes antifúngicos; Anfotericina B liposomal; Antifungal agents; Coste farmacológico; Drug costs; Echinocandins; Equinocandinas; Fluconazol; Fluconazole; Inappropriate prescribing; Liposomal amphotericin B; Prescripción inadecuada.