Original articleTraining should be the first step toward an antifungal stewardship programLa formación debe ser el primer paso en el desarrollo de un programa de optimización del uso de antifúngicos
Introduction
Invasive fungal infections (IFIs) are a major problem in tertiary care hospitals. They affect several types of patient and are cared for by several types of physician. The difficulties in confirming a diagnosis, the excellent tolerance of new drugs, and the impact of early therapy have led to extended use of empirical antifungal agents.
Previous studies, however, have shown that up to 67–74% of antifungal drugs are used inappropriately in tertiary care hospitals.1, 2, 3 A recent multicenter study performed in French intensive care units (ICU) revealed that 7% of all patients admitted on a single day were receiving antifungals, and 65% patients included had no proven IFI.4
International societies have recommended implementation of institutional antifungal stewardship programs.5 When antifungal costs surpassed €3 million and while our incidence of proven fungal infection remained stable, we decided to initiate an antifungal stewardship program that included training initiatives. We performed a knowledge survey in order to identify areas requiring specific attention.
Section snippets
Setting and participants
Our institution is a 1550-bed tertiary care hospital attending a population of 715,000 inhabitants. It is a referral center for solid organ transplantation, heart surgery, stem cell transplantation, and HIV-AIDS care.
Ours was a prospective study in which we invited 329 physicians to complete a questionnaire. Hospital areas were ordered according to spending on antifungals by the Pharmacy Department. The participating hospital departments were those that accounted for 85% of antifungal
Results
The questionnaire was completed by 200 of the 329 physicians invited to participate (60.8%; 115 staff [57.5%] and 85 residents [42.5%]). The percentage of responders was higher than 50% for all the departments involved, except for general surgery (40.8%), oncology (20.0%), and pneumology (12.5%). The distribution by departments was as follows: medical (including oncology and hematology) (60%), pediatrics (19%), intensive care unit (15.5%), and surgery (5.5%). The mean age of the responding
Discussion
Ours is the first study to evaluate knowledge of current recommendations on diagnosis and treatment of IFI in a tertiary hospital with a very high consumption of systemic antifungal drugs. We demonstrated that even frequent prescribers have a significant need for continuing medical education in this area. The most common mistakes led to overconsumption of antifungal drugs, since many physicians prescribe combinations and high doses of L-AmB, as well as inappropriate treatment for fungal
Conclusions
A simple test enabled us to assess the knowledge of prescribing physicians about important aspects of the diagnosis, prophylaxis, and treatment of IFIs. Our results revealed serious gaps that require a custom training program that could act as the first step in the implementation of an antifungal stewardship program.
Funding
This study was partially financed by PROMULGA Project (Proyecto Multidisciplinar para Optimizar la Gestión del Uso de Antifúngicos). Instituto de Salud Carlos III. PI1002868.
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2017, The Lancet Infectious DiseasesCitation Excerpt :In many centres, antimicrobial stewardship tools are not readily available because of poor access to diagnostic tests with long turn-around times. Guidelines that only cover the most common fungal infections and patient settings, combined with a generally poor understanding of fungal infections outside of specialist clinical teams, adds to the challenge of successful antimicrobial stewardship.106 Newer drugs with lower toxicities than drugs such as amphotericin B have increased empirical and prophylactic use of antifungals in many patient groups, which affects antifungal resistance and is also financially unsustainable.107
EPICO 4.0. ‘Total quality’ in the management of invasive candidiasis in critically ill patients by analysing the integrated process
2017, Revista Iberoamericana de MicologiaCitation Excerpt :The coordinators provided the following answers (Block A): Raising awareness of the problem of inadequate use of antimicrobials; Convey the need to form teams to lead the PROAs to improve the quality of care; Improve suitability of empirical antifungal treatment; Optimize dosing regimens based on the pharmacokinetic-pharmacodynamics (PK-PD) indices of antifungal drugs; and Discontinue antifungal treatment in the absence of proven fungal infection. The literature contains many studies in which the roles and responsibilities of the multidisciplinary team for antimicrobial stewardship programs in hospitals are defined.3,25,48,53,56,57 Thus, and as a guide for action, some papers describe stewardship programs for antibiotic treatment similar to PROA on antifungal treatment in invasive candidiasis.51
Antifungal stewardship in a tertiary-care institution: A bedside intervention
2015, Clinical Microbiology and InfectionCitation Excerpt :This information was used to design interactive training courses based on clinical cases. A 20-point questionnaire was administered to all participants before and after the course to evaluate the impact and effectiveness of the course [11]. We performed an audit of the use and cost of 100 antifungal prescriptions (December 2010 to January 2011) according to a quality score (scale of 0 to 10) for evaluation of the adequacy of the prescription (Table 1).
Invasive fungal disease: An entity with enough complexity to justify the existence of specialists in its manegment
2015, Enfermedades Infecciosas y Microbiologia Clinica
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See Appendix A.