A systematic review of the impact of antifungal stewardship interventions in the United States

Abstract

Background Antimicrobial resistance is a widely recognized public health threat, and stewardship interventions to combat this problem are well described. Less is known about antifungal stewardship (AFS) initiatives and their influence within the United States. The purpose of this study was to evaluate evidence on the impact of AFS interventions on clinical and performance measures. Methods A systematic review of English language studies identified in the PubMed and EMBASE databases was performed through November 2017. The review was conducted in accordance with PRISMA. Search terms included antifungal stewardship, antimicrobial stewardship, Candida , candidemia, candiduria, and invasive fungal disease. Eligible studies were those that described an AFS program or intervention occurring in the US and evaluated clinical or performance measures. Results Fifty-four articles were identified and 13 were included. Five studies evaluated AFS interventions and reported clinical outcomes (mortality and length of stay) and performance measures (appropriate antifungal choice and time to therapy). The remaining eight studies evaluated general stewardship interventions and reported data on antifungal consumption. All studies were single center, quasi-experimental with varying interventions across studies. AFS programs had no impact on mortality (3 of 3 studies), with an overall rate of 27% in the intervention group and 23% in the non-intervention group. Length of stay (5 of 5) was also similar between groups (range, 9–25 vs. 11–22). Time to antifungal therapy improved in 2 of 5 studies, and appropriate choice of antifungal increased in 2 of 2 studies. Antifungal consumption was significantly blunted or reduced following stewardship initiation (8 of 8), although a direct comparison between studies was not possible due to a lack of common units. Conclusion The available evidence suggests that AFS interventions can improve performance measures and decrease antifungal consumption. Although this review did not detect improvements in clinical outcomes, significant adverse outcomes were not reported.

The current state of antifungal stewardship among pediatric antimicrobial stewardship programs

“…Although these antifungal stewardship interventions have been shown to successfully reduce antifungal consumption in hospitalized patients, the best approach to antifungal stewardship remains unknown. 5,[17][18][19][20] This lack of comparative data has likely led to the very heterogenous and hospital-specific approaches illustrated in this study. Some studies have proposed that PAF and more intensive stewardship strategies like daily PAF in combination with preauthorization and formulary restriction, may be more effective in decreasing antibiotic utilization.…”

Nationwide Cross-Sectional Study of Antimicrobial Stewardship and Antifungal Stewardship Programs in Inpatient Settings in Japan

“…21 However, the importance of AFS for both patient bene t and cost-saving was well reported in a previous study. 22,23 Based on the national database of health insurance claims and speci c health checkups in Japan, although the cost of antimicrobials decreased from 163 billion dollars in 2013 to 121 billion dollars in 2017, the cost of antifungals increased from 34 billion dollars in 2013 to 50 billion dollars in the same year. 24 A previous observational study in Japan pointed out that AFS was important to reduce the cost of antifungal use.…”

Impact of antifungal stewardship interventions on the susceptibility of Candida species in pediatric patients with malignancy

“…Even in colonized patients, susceptibility patterns might change over time, especially in immunocompromised hosts [8]. Although the AFS has known short-term effects (e.g., reduction in antifungal consumption, costs and outcomes) on the management of IFDs and patient safety [38][39][40][41], its long-term effects has been described on resistance patterns [42]. Based on stewardship program metrics, change in resistance patterns, and pathogen-speci c resistance is the most di cult target to reach [34].…”