Abstract
BackgroundAntimicrobial 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.MethodsA 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.ResultsFifty-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.ConclusionThe 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.
Highlights
Antimicrobial resistance is a growing public health challenge that poses a global threat [1]
Microbiology was included in all studies, it was unclear whether a clinical microbiologist was one of the core members of the antifungal stewardship (AFS) program
Even though there is limited evidence on AFS programs and the interventions are highly variable, the evidence suggests that AFS effectively improves performance measures and decreases antifungal consumption
Summary
Antimicrobial resistance is a growing public health challenge that poses a global threat [1]. In the United States, at least 2 million people acquire and at least 23,000 people die each year from an antibiotic-resistant infection [2]. Approaches to optimize antibiotic use and contain antimicrobial resistance have been recommended to preserve the benefits of antibiotics and provide the best patient care. Antimicrobial stewardship programs (ASPs) have received particular attention because of their focus on improving health outcomes and patient care. 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
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