Antifungal stewardship in a tertiary hospital / Asesoramiento en la prescripción de antifúngicos en un hospital terciario

Background. The inappropriate use of antifungals is an important health problem related to increasing adverse effects, unnecessary cost and promotion of resistant and emerging fungal infections. Despite its relevance, many health institutions assign few resources to improve prescribing practices. Aims. To evaluate the efficiency of an antifungal stewardship programme (ASP) centered on restricted antifungal agents. Methods. The main activity during the eight-month study was to perform a programmed review of restricted antifungals (lipid formulations of amphotericin B, echinocandins and voriconazole) prescribed in hospitalized patients. In the case of amendable antifungal treatment, a recommendation was included in the electronic medical record. Results. A total of 280 antifungal prescriptions for 262 patients were revised during the study period. The indications were prophylactic in 85 cases (30.4%), pre-emptive in 10 cases (3.5%), empiric in 122 cases (43.6%), and directed in 63 cases (22.5%). A total of 70 prescriptions (25%) in 61 patients were considered to be amendable. In most of these cases, treatment could have been reduced considering the patient's clinical improvement and microbiological results. The most common advice was antifungals change (70%), antifungal withdrawal (21%), removal of one antifungal drug in cases of combined therapy (7%), and switching to oral route (1%). Proposed recommendations were addressed in 28 cases (40%). There was no significant difference in adherence with respect to the type of recommendation (p = 0.554). There was a 42% lower use of antifungals during the period of the study compared to that observed during a similar previous period. Mortality among patients who were treated according to the recommendations of the ASP was 17% and in whom treatment was not modified it was 30% (p = 0.393). Conclusions. ASPs centered on hospitalized patients may be an efficient strategy to ameliorate antifungal use in hospitals (AU)

Antecedentes. El uso inadecuado de los antifúngicos es un problema de salud relevante que puede incrementar los efectos adversos y generar costes innecesarios, además de favorecer la aparición de resistencias y de infecciones micóticas emergentes. A pesar de su importancia, muchas instituciones sanitarias destinan escasos recursos para mejorar las prácticas de prescripción. Objetivos. Evaluar la eficiencia de un programa de asesoramiento sobre antifúngicos basado en la prescripción de agentes antifúngicos restringidos. Métodos. La principal actividad durante el estudio de ocho meses de duración fue la realización de una revisión programada de antifúngicos restringidos, prescritos en los pacientes hospitalizados (formulaciones lipídicas de anfotericina B, equinocandinas y voriconazol). En el caso del tratamiento antifúngico modificable, se procedió a anotar una recomendación en la historia clínica electrónica. Resultados. Se revisó un total de 280 prescripciones de antifúngicos en 262 pacientes durante el período de estudio. Las indicaciones fueron de tipo profiláctico en 85 casos (30,4%), anticipado en 10 (3,5%), empírico en 122 (43,6%) y dirigido en 63 (22,5%). Se consideraron modificables un total de 70 prescripciones (25%) en 61 pacientes. En la mayoría de estos casos, el tratamiento podía reducirse teniendo en cuenta la mejoría clínica y los resultados microbiológicos del paciente. La indicación más frecuentemente realizada fue el cambio de antifúngico (70%), seguido por la retirada de dicho fármaco (21%), la eliminación de uno de los fármacos antifúngicos en casos de tratamiento combinado (7%) y, finalmente, la sustitución del tratamiento por la administración oral (1%). Las recomendaciones propuestas se aceptaron en 28 casos (40%). No se produjo una diferencia significativa en la adherencia con respecto al tipo de recomendación (p = 0,554). Durante el período de estudio se evidenció un descenso en el uso de antifúngicos del 42%, en comparación con el uso observado en un período previo similar. La mortalidad de los pacientes que fueron tratados de acuerdo con las recomendaciones fue del 17%, y del 30% en aquellos en los que no se modificó el tratamiento (p = 0,393). Conclusiones. El programa de asesoramiento sobre los antifúngicos prescritos en pacientes hospitalizados puede resultar una estrategia eficaz para mejorar el uso de estos fármacos (AU)

Antifungal stewardship in a tertiary hospital.

BACKGROUND: The inappropriate use of antifungals is an important health problem related to increasing adverse effects, unnecessary cost and promotion of resistant and emerging fungal infections. Despite its relevance, many health institutions assign few resources to improve prescribing practices. AIMS: To evaluate the efficiency of an antifungal stewardship programme (ASP) centered on restricted antifungal agents. METHODS: The main activity during the eight-month study was to perform a programmed review of restricted antifungals (lipid formulations of amphotericin B, echinocandins and voriconazole) prescribed in hospitalized patients. In the case of amendable antifungal treatment, a recommendation was included in the electronic medical record. RESULTS: A total of 280 antifungal prescriptions for 262 patients were revised during the study period. The indications were prophylactic in 85 cases (30.4%), pre-emptive in 10 cases (3.5%), empiric in 122 cases (43.6%), and directed in 63 cases (22.5%). A total of 70 prescriptions (25%) in 61 patients were considered to be amendable. In most of these cases, treatment could have been reduced considering the patient's clinical improvement and microbiological results. The most common advice was antifungals change (70%), antifungal withdrawal (21%), removal of one antifungal drug in cases of combined therapy (7%), and switching to oral route (1%). Proposed recommendations were addressed in 28 cases (40%). There was no significant difference in adherence with respect to the type of recommendation (p=0.554). There was a 42% lower use of antifungals during the period of the study compared to that observed during a similar previous period. Mortality among patients who were treated according to the recommendations of the ASP was 17% and in whom treatment was not modified it was 30% (p=0.393). CONCLUSIONS: ASPs centered on hospitalized patients may be an efficient strategy to ameliorate antifungal use in hospitals.