Evaluation of a stewardship program of antifungal use at a Brazilian tertiary care hospital

Gamarra, Fabiola; Nucci, Márcio; Nouér, Simone Aranha

doi:10.1016/j.bjid.2022.102333

Cited by 5 publications

(7 citation statements)

References 30 publications

(29 reference statements)

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“…Fluconazole was the most prescribed antifungal in this group of patients, which was consistent with findings in the United States by Benedict et al (75.0%) [ 8 ] and reported in Australia by Wang et al (73.5%) [ 9 ]. Similarly, these studies of outpatients were consistent with what was found in studies of hospitalized patients (40.0–80.5%) [ 14 , 15 , 16 , 17 , 18 , 19 ]. When comparing our results with the data of the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) on antifungals prescribed for outpatients in 2020 in 27 countries of the European Union and two countries of the European Economic Area, it was found that, on average, the DHDs (defined daily dose per 1000 inhabitants per day) of terbinafine, voriconazole, and itraconazole were lower, while those of fluconazole and ketoconazole were higher than those found in Europe [ 20 ].…”

Section: Discussionsupporting

confidence: 89%

“…This study found that 29.3% of medications were prescribed in unapproved indications. There are few published studies that address this topic, with only a few on the inappropriate use of systemic antifungals in the hospital environment [ 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. For example, in Greece, researchers found that 25.0% of antifungal prescriptions were inappropriate [ 10 ], similar to that described in Spain (25.0%) [ 11 ] and Oman (25.2%) [ 12 ].…”

Section: Discussionmentioning

confidence: 99%

“…For example, in Greece, researchers found that 25.0% of antifungal prescriptions were inappropriate [ 10 ], similar to that described in Spain (25.0%) [ 11 ] and Oman (25.2%) [ 12 ]. In France, inappropriate use was higher (30.0–40.0%) [ 13 , 14 ], while in Brazil nonadherence to management guidelines was even more worrisome (64.6–80.2%) [ 15 , 16 ]. No studies on the indication prescription of antifungal drugs were found in Colombia, but previously it was reported that 23.5 to 31.3% of patients who received outpatient antibiotics had them prescribed for unapproved uses [ 21 , 22 , 23 ].…”

Section: Discussionmentioning

confidence: 99%

“…In addition, no studies on the use of antifungals could be found to determine their appropriate or inappropriate use in this group of patients. Studies have addressed this topic but involve only hospitalized patients, reflecting that the inappropriate use of these drugs is 25.0% to 80.2% [ 10 , 11 , 12 , 13 , 14 , 15 , 16 ].…”

Section: Introductionmentioning

confidence: 99%

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Study of Prescription-Indication of Outpatient Systemic Anti-Fungals in a Colombian Population. A Cross-Sectional Study

et al. 2022

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The inappropriate use of antifungals is associated with greater antimicrobial resistance, costs, adverse events, and worse clinical outcomes. The aim of this study was to determine prescription patterns and approved and unapproved indications for systemic antifungals in a group of patients in Colombia. This was a cross-sectional study on indications for the use of systemic antifungals in outpatients from a drug dispensing database of approximately 9.2 million people affiliated with the Colombian Health System. Sociodemographic, pharmacological, and clinical variables were considered. Descriptive, bivariate, and multivariate analyses were performed. A total of 74,603 patients with antifungal prescriptions were identified; they had a median age of 36.0 years (interquartile range: 22.0–53.0 years), and 67.3% of patients were women. Fluconazole (66.5%) was the most prescribed antifungal for indications such as vaginitis, vulvitis, and vulvovaginitis (35.0%). A total of 29.3% of the prescriptions were used in unapproved indications. A total of 96.3% of ketoconazole users used the medication in unapproved indications. Men (OR: 1.91; CI95%: 1.79–2.04), <18 years of age (OR: 1.20; CI95%: 1.11–1.31), from the Caribbean region (OR: 1.26; CI95%: 1.18–1.34), with chronic obstructive pulmonary disease (OR: 1.80; CI95%: 1.27–2.54), prescriptions made by a general practitioner (OR: 1.17; CI95%: 1.04–1.31), receiving comedications (OR: 1.58; CI95%: 1.48–1.69), and the concomitant use of other antimicrobials (OR: 1.77; CI95%: 1.66–1.88) were associated with a higher probability that the antifungal was used for unapproved indications; deep mycosis (OR: 0.49; CI95%: 0.41–0.58), prescribing fluconazole (OR: 0.06; CI95%: 0.06–0.06), and having diabetes mellitus (OR: 0.33; CI95%: 0.29–0.37), cancer (OR: 0.13; CI95%: 0.11–0.16), or HIV (OR: 0.07; CI95%: 0.04–0.09) reduced this risk. Systemic antifungals were mostly used for the management of superficial mycoses, especially at the gynecological level. In addition, more than a quarter of patients received these medications in unapproved indications, and there was broad inappropriate use of ketoconazole.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Study of Prescription-Indication of Outpatient Systemic Anti-Fungals in a Colombian Population. A Cross-Sectional Study

et al. 2022

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“…Producing and implementing evidence-based guidelines [42][43][44][45][46][47] are part of a multifaceted approach in AFS. They allow institutions to define best practice in diagnosis and therapy, which can also facilitate assessment of the quality of prescribing [48][49][50] and therefore drive improvement.…”

Section: Afs Strategies: Guidelines/care Bundlesmentioning

confidence: 99%

Antifungal stewardship in solid‐organ transplantation: What is needed?

Whitney¹,

Armstrong‐James

Lyster

et al. 2022

Transplant Infectious Dis

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Background Antifungal stewardship (AFS) lags behind antimicrobial stewardship (AMS) in terms of implementation, evidence base, and workforce experience. Solid‐organ transplantation (SOT) carries a significant risk of invasive fungal infection, with high associated mortality, and is therefore associated with significant opportunities to optimize antifungal use. Methods A literature search for the terms “antifungal stewardship” and “solid‐organ transplant” revealed a small evidence base to support AFS programs in this patient group. Results There is significant overlap in the methodology used in AMS and AFS programs, with notable differences in diagnostics, which are discussed in detail. The primary AFS interventions tested in SOT recipients are implementation of clinical guidelines and care bundles, digital enablers of AFS, and post‐prescription review/audit and feedback. Conclusion There is an urgent need for further research to support effective AFS strategies in this highly susceptible population.

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