RESUMO
Background: Invasive fungal disease (IFD) has become a serious threat to human health in China and around the world, with high mortality and morbidity. Currently, the misdiagnosis rate of IFD is extremely high, compounded with the low quality of prescription antifungals and the high incidence of adverse events associated with IFD treatment, resulting in lengthy hospitalization, low clinical response, and high disease burden, which have become serious challenges in clinical practice. Antifungal stewardship (AFS) can not only significantly increase the early diagnosis rate of IFD, reduce inappropriate utilization of antifungal drugs, improve patient prognosis, but can also improve therapeutic safety and reduce healthcare expenses. Thus, it is urgent to identify key AFS metrics suitable for China's current situation. Methods: Based on metrics recommended by international AFS consensuses, combined with the current situation of China and the clinical experience of authoritative experts in various fields, several metrics were selected, and experts in the fields of respiratory diseases, hematology, intensive care units (ICUs), dermatology, infectious diseases, microbiology laboratory and pharmacy were invited to assess AFS metrics by the Delphi method. Consensus was considered to be reached with an agreement level of ≥80% for the metric. Results: Consensus was reached for 24 metrics, including right patient metrics (n=4), right time metrics (n=3), and right use metrics (n=17). Right use metrics were further subdivided into drug choice (n=8), drug dosage (n=4), drug de-escalation (n=1), drug duration (n=2), and drug consumption (n=2) metrics. Forty-six authoritative experts assessed and reviewed the above metrics, and a consensus was reached with a final agreement level of ≥80% for 22 metrics. Conclusions: This consensus is the first to propose a set of AFS metrics suitable for China, which helps to establish AFS standards in China and is also the first AFS consensus in Asia, and may improve the standard of clinical diagnosis and treatment of IFD, and guide hospitals to implement AFS, ultimately promoting the rational use of antifungal drugs and improving patient prognosis.
RESUMO
Introduction: Voriconazole (VRCZ) is a triazole antifungal agent for which therapeutic drug monitoring (TDM) is recommended. At Juntendo University Hospital, the VRCZ TDM implementation rate was 42% between January 2011 and October 2017. Here, we report that modifications to the hospital’s drug ordering system improved the implementation rate of VRCZ TDM.Method: In August 2018, the drug ordering system was modified so that a message appeared on the screen to notify clinicians of the need to monitor VRCZ blood concentrations and to recommend a date for sample collection. In addition, the laboratory orders for VRCZ levels were digitized. We compared two one-year periods before and after implementation of the modifications (August 2017 to July 2018 and August 2018 to July 2019) to verify the effect of the changes.Result: Results showed an increase in the TDM implementation rate: 12 patients (42.8%) received TDM before modification of the system, and 26 patients (92.9%) received TDM after modification of the system. Further, the rate of blood sampling at the recommended time point for estimating blood concentration (day 5-7 after the start of administration) improved after system modification, i.e., blood samples were collected from 18 patients (64.3%) at the steady state point. In contrast, blood samples were collected from only 6 patients (21.4%) before system modification. When blood concentrations deviated from the target range in patients who received TDM, clinicians took appropriate actions, such as reducing drug doses, prescribing drug holidays, or discontinuing medications.Conclusion: A system that provides information related to VRCZ blood concentration measurements can help clinicians provide patients with optimal pharmacotherapy.