Mucormycosis in pediatric oncology patients is a rare invasive fungal infection associated with significant morbidity and mortality. We describe five patients diagnosed with mucormycosis during induction chemotherapy for acute lymphoblastic leukemia at our institution. All of the patients in our series survived, some in spite of having disseminated disease. Most of the patients’ chemotherapy was modified with the aim of controlling their leukemia while minimizing immunosuppression until their fungal infection was under control. Although mucormycosis is frequently fatal, rapid diagnosis and a multidisciplinary approach can lead to excellent outcomes, even in patients undergoing intensive chemotherapy.
LS is a rare form of labyrinthitis characterized by centrifugal destruction of the otic capsule. The current index case highlights the importance of combined medical and surgical treatment and describes for the first time in the literature the fibrous ossification of the otic capsule following disease resolution.
Objective: To characterize the current state of antifungal stewardship practices and perceptions of antifungal use among pediatric antimicrobial stewardship programs (ASPs). Design: We developed and distributed an electronic survey, which included 17 closed-ended questions about institutional antifungal stewardship practices and perceptions, among pediatric ASPs. Participants: ASP physicians and pharmacists of 74 hospitals participating in the multicenter Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) Collaborative. Results: We sent surveys to 74 hospitals and received 68 unique responses, for a response rate of 92%. Overall, 63 of 68 the respondent ASPs (93%) reported that they conduct 1 or more antifungal stewardship activities. Of these 68 hospital ASPs, 43 (63%) perform prospective audit and feedback (PAF) of antifungals. The most common reasons reported for not performing PAF of antifungals were not enough time or resources (19 of 25, 76%) and minimal institutional antifungal use (6 of 25, 24%). Also, 52 hospitals (76%) require preauthorization for 1 or more antifungal agents. The most commonly restricted antifungals were isavuconazole (42 of 52 hospitals, 80%) and posaconazole (39 of 52 hospitals, 75%). Furthermore, 33 ASPs (48%) agreed or strongly agreed that antifungals are inappropriately used at their institution, and only 25 of 68 (37%) of ASPs felt very confident making recommendations about antifungals. Conclusions: Most pediatric ASPs steward antifungals, but the strategies employed are highly variable across surveyed institutions. Although nearly half of respondents identified inappropriate antifungal use as a problem at their institution, most ASPs do not feel confident making recommendations about antifungals. Future studies are needed to determine the rate of inappropriate antifungal use and the best antifungal stewardship strategies.
Objective: To characterize antifungal prescribing patterns, including the indication for antifungal use, in hospitalized children across the United States. Design: We analyzed antifungal prescribing data from 32 hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a cross-sectional point-prevalence survey conducted between June 2016 and December 2017. Methods: Inpatients aged <18 years with an active systemic antifungal order were included in the analysis. We classified antifungal prescribing by indication (ie, prophylaxis, empiric, targeted), and we compared the proportion of patients in each category based on patient and antifungal characteristics. Results: Among 34,927 surveyed patients, 2,095 (6%) received at least 1 systemic antifungal and there were 2,207 antifungal prescriptions. Most patients had an underlying oncology or bone marrow transplant diagnosis (57%) or were premature (13%). The most prescribed antifungal was fluconazole (48%) and the most common indication for antifungal use was prophylaxis (64%). Of 2,095 patients receiving antifungals, 79 (4%) were prescribed >1 antifungal, most often as targeted therapy (48%). The antifungal prescribing rate ranged from 13.6 to 131.2 antifungals per 1,000 patients across hospitals (P < .001). Conclusions: Most antifungal use in hospitalized children was for prophylaxis, and the rate of antifungal prescribing varied significantly across hospitals. Potential targets for antifungal stewardship efforts include high-risk, high-utilization populations, such as oncology and bone marrow transplant patients, and specific patterns of utilization, including prophylactic and combination antifungal therapy.
BackgroundAntifungal stewardship may help reduce the toxicity, cost, and emergence of resistance related to inappropriate antifungal use. A better understanding of antifungal prescribing patterns, particularly in high-risk, high-utilization populations, is needed to guide appropriate stewardship interventions. We analyzed antifungal prescribing characteristics, including the indications for use and differences between oncology/bone marrow transplant (Onc/BMT) and non-Onc/BMT patients, using a multi-center national cohort of hospitalized children.MethodsWe analyzed antifungal prescribing data from 32 hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a point prevalence survey conducted quarterly between June 2016 and December 2017. We included inpatients <18 years of age with an active order for a systemic antifungal agent and evaluated the patient and antifungal characteristics. In the Onc/BMT group, we classified antifungal prescribing by indication and compared the proportion of antifungal prescriptions in each category based on antifungal class, route of administration, and use of combination therapy.ResultsSix percent (2,095/34,927) of patients received a total of 2,207 antifungal prescriptions. Fifty-eight percent (1,291/2,207) of antifungal prescriptions were for Onc/BMT patients. Among patients prescribed an antifungal, those with an Onc/BMT diagnosis were older, received broader-spectrum agents, and were more likely to receive combination therapy (Table 1). The majority of antifungal use in the Onc/BMT group was for prophylaxis, with significant variation in the rate and choice of prophylactic antifungal prescribing across hospitals (Figure 1). Combination antifungal use was common among Onc/BMT patients receiving targeted therapy (Table 2).ConclusionThe majority of antifungal use among hospitalized children is for patients with an Onc/BMT diagnosis and the patterns of antifungal utilization in this population appear to differ significantly from non-Onc/BMT patients. Based on the variation observed in this nationwide cohort, potential stewardship targets include the rate and type of antifungal prophylaxis and the use of combination therapy in Onc/BMT patients. Disclosures All authors: No reported disclosures.
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