Antifungal treatment in haematological and oncological patients: Need for quality assessment in routine care

Abstract

Invasive fungal infections in haematological and oncological patients have a major impact on morbidity, mortality and treatment costs. Therefore, rational use of antifungal agents is important for optimal patient care and resource use. The study's objective was to analyse antifungal usage in a German tertiary teaching hospital, department of haematology and oncology, to evaluate quality of antifungal treatment and to assess the need for an antifungal stewardship programme. This retrospective observational study included patients ≥18 years receiving systemic antifungals for prophylaxis or therapy of invasive fungal infection between January and June 2016. Appropriateness of antifungal prescriptions was evaluated in accordance with guidelines of the German Society of Haematology and Oncology (DGHO) and drug labelling. In total, 104/1278 (8.1%) patients received antifungals. One hundred seventy-one antifungals were prescribed: 48 for prophylaxis, 104 for empirical and 19 for targeted therapy. In 127 (74.3%) prescriptions, indication was appropriate, and in 132 (77.2%), choice of drug. Antifungals were correctly dosed in 131 prescriptions (76.6%). Thirty-four antifungals (20.0%) were co-administrated with interacting drugs (5 mild to moderate, 29 severe interactions). Results of this analysis demonstrate that use of systemic antifungals in routine care differs in a substantial number of patients from guideline and labelling recommendations. To optimise antifungal use, the implementation of antifungal stewardship programmes seems to be justified.

The current state of antifungal stewardship among pediatric antimicrobial stewardship programs

“…For example, studies have shown that up to 50% of antifungals are inadequately dosed and that certain antifungals require multiple dose adjustments to achieve therapeutic levels. 5,28,30,31 Our study revealed variability in the target therapeutic levels reported across institutions, which suggests a lack of consensus in current practices and an important opportunity for standardization. Many of the survey respondents reported a lack of confidence in making antifungal recommendations.…”

Adherence to Antifungal Guidelines in Malignant Hematology Patients: A Review of the Literature

“…Table 3 summarizes key elements of the included studies. [12][13][14][15][16][17][18][19] Five studies assessed adherence to antifungal guidelines in the inpatient setting, and 5 studies assessed the impact of an inpatient antifungal stewardship program on the appropriateness of fungal therapy. No studies of antifungal adherence in the outpatient setting were found.…”

“…Forty patients (30%) died during their hospitalization due to concomitant disease (31 cases), underlying conditions (6 cases), and fungal infection (3 cases). 12 The study by Lachenmayr et al 13 was a retrospective review of 104 patients receiving antifungal treatment and prophylaxis in the Hematology and Oncology departments of a German teaching hospital (Table 3). This included 61 patients (58.7%) with AML, 18 (17.3%) with lymphoma, 5 (4.8%) with ALL, 5 (4.8%) with multiple myeloma, and 3 (2.9%) with myelodysplastic syndrome.…”

Impact of patient education on plasma concentrations and effectiveness of posaconazole oral suspension under clinical conditions

“…Prophylaxis with the antifungal agent posaconazole reduced the rate of IFI and mortality in AML patients with neutropenia after induction chemotherapy . Although it is therefore strongly recommended by international guidelines, the use of systemic antifungal agents differs from guidelines for various reasons (eg, intolerance, drug interactions) in a substantial number of cases in clinical routine . In comparison with other established broad‐spectrum antimycotics, posaconazole is effective against mould as well as yeast infections, has a better safety profile and shows advantages concerning drug–drug interactions …”

“…3,4 Although it is therefore strongly recommended by international guidelines, 5,6 the use of systemic antifungal agents differs from guidelines for various reasons (eg, intolerance, drug interactions) in a substantial number of cases in clinical routine. 7 In comparison with other established broad-spectrum antimycotics, posaconazole is effective against mould as well as yeast infections, has a better safety profile and shows advantages concerning drug-drug interactions. 8 The oral suspension was approved for antimycotic prophylaxis in patients with AML during induction chemotherapy and stem cell transplant recipients with graft-vs-host disease (GVHD) grade II or higher in 2007.…”