Advances in the management of fungal infections.

Abstract

The incidence of invasive fungal disease (IFD) has increased in recent years, largely due to the increasing population of patients with severe immunosuppression. Candida species are the leading cause of IFD worldwide and are one of the most common causes of hospital-acquired bloodstream infections,1 particularly in intensive care unit patients and very low birth weight infants.2 Invasive candidiasis is associated with substantial morbidity and mortality, prolonged hospital stay and increased health care costs, and, as such, is a serious public health concern.3, 4 Early diagnosis and prompt initiation of antifungal therapy is essential for the control of invasive candidiasis and three main classes of antifungal drugs are currently available: azoles (e.g. voriconazole, fluconazole, posaconazole), echinocandins (e.g. anidulafungin, caspofungin, micafungin) and polyenes (e.g. amphotericin B). However, the extensive use of some antifungal agents has led to an increased selection pressure and the development of antifungal drug resistance, which has important implications for the morbidity, mortality and health care costs associated with IFD. Antifungal stewardship is an important component of drug delivery that underpins efforts to prevent the emergence of antifungal drug resistance. Antifungal stewardship programs consist of multidisciplinary interventions led by specialists in infectious disease, microbiology and pharmacy who liaise with the major prescribing departments to optimise antifungal therapies. Here, we report on antifungal drug resistance among Candida species, with a focus on resistance mechanisms and the epidemiology and clinical consequences of resistance. In addition, we review the available evidence for the use of antifungal stewardship programs and their health economic impact.