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The Time for Antifungal Stewardship Programs Is Now

Implementation and Impact of Antifungal Stewardship Programs 

In parallel with the CDC core elements of antimicrobial stewardship, Muñoz and colleagues described 7 essential elements for antifungal stewardship.18,20 Although limited studies exist, there are some that highlight an overall positive impact of antifungal stewardship and interventions. A 12-month prospective study in a British tertiary referral hospital either discontinued or changed nearly half of amphotericin B and echinocandin treatments after implementation of an antifungal stewardship on high-cost antifungals, leading to significant health care cost savings.21 Alternatively, a different stewardship approach may include interventions made on positive fungal cultures, which have shown various results on the impact on clinical outcomes, which may improve time to effective therapy,22 increase proportion of patients who receive an ophthalmologic examination,23 or reduce 30-day mortality.24

Challenges and Barriers to Antifungal Stewardship Programs 

There are numerous challenges in early diagnosis and treatment of invasive fungal infections, requiring the expertise of a collaborative group of trained infectious diseases specialists, clinical microbiologists, and other specialists in main prescribing departments such as hematology and oncology.19 Microbiology labs at institutions may not be able to readily test and determine susceptibilities for fungal isolates. Therefore, clinicians are limited in distinguishing drug-resistant infections based only on clinical suspicion or comfort with de-escalating to narrower spectrum antifungals.

Within the IDSA guidelines, recommendations related to antifungal stewardship include interventions that incorporate nonculture-based fungal markers, candidemia-care bundles, and prospective audit and feedback, similar to antibiotic stewardship.19 Utilization of galactomannan, (1-3)-b-D-glucan, or fungal polymerase chain reaction has demonstrated effective and safe reductions in antifungal treatment in high-risk patients with hematological malignancies. In addition, b-D-glucan is currently being studied to assist stewardships in de-escalation of broad-spectrum antifungals in patients with severe sepsis or septic shock receiving treatment in a multicenter, prospective, open-label, randomized trial.25 An example of other stewardship interventions includes implementation of candidemia-care bundles, which was associated with improved care such as increasing use of appropriate antifungal therapy and rates of ophthalmologic examinations.26

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