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The Time for Antifungal Stewardship Programs Is Now

Invasive fungal infections are a significant cause of mortality and morbidity, particularly in immunocompromised patients with hematologic malignancies and hematopoietic stem cell recipients, as well as solid organ transplant recipients. In the United States, Candida accounts for the majority of cases of health care-associated bloodstream infections.1,2 Even in light of newly available antifungal agents, the costs of antifungals are substantial, while the mortality for invasive aspergillosis and invasive candidiasis remains high.3-7 Retrospective studies report that 30% to 50% of overall antifungal prescriptions were not optimized or inappropriate.8,9 The rate of inappropriate antifungal prescribing is similar to that for antibiotics, demonstrating the alarming need for antifungal stewardship.1 The role of stewardship may offer value to optimizing clinical outcomes while minimizing antifungal overuse and costs, therefore also controlling resistance developed from selection pressure. Other challenges of treating invasive fungal infections include rising drug resistance and delayed initiation of therapy due to the lack of rapid and accurate diagnostic tools.

The extent of knowledge and understanding about antimycotic resistance and drug-resistant fungal infections is still unclear. Particularly, infections caused by Candida auris are of recent serious concern because of the inherent multidrug resistance of the fungi pathogen, limiting therapeutic options.10 According to the Centers for Disease Control and Prevention (CDC) surveillance data, approximately 7% of all Candida bloodstream isolates were fluconazole resistant and mostly identified as Candida glabrata.11,12 Additionally, echinocandin resistance in C. glabrata isolates has doubled from 4% in 2008 to 8% in 2014.13 Not only is antifungal resistance emerging with Candida species but it is also, more recently, increasing with Aspergillus species. Reported widespread azole resistance is also increasing in Aspergillus fumigatus, which was first documented in the Netherlands and is now seen in various regions of the world.14 Recent surveillance studies have identified azole resistance as a result of widespread environmental fungicide use.15,16

Compared with antibiotic stewardship, published experience focusing on antifungal stewardship, as well as drug-resistant fungal pathogens, is sparse and limited but emerging. Nevertheless, rising bacterial and fungal resistance is an internationally recognized and public threat, leading to the increasing need for the implementation of antimicrobial stewardship as addressed by the newly effective Joint Commission standard for hospitals.17

Additionally, the CDC offers support that complements other existing guidelines pertaining to antimicrobial stewardship, such as the recent 2016 guidelines by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America.18,19 The IDSA guideline recommendations regarding interventions for optimal antifungal use focus on immunocompromised patients, including those with hematologic malignancy or solid organ transplant.

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