Compliance in two medical centers with criteria for use of caspofungin and lipid-based amphotericin B.

Abstract

Patterns of use and compliance with guidelines for use of lipid-based amphotericin B (LBA) and caspofungin at two medical institutions were studied. Charts of all adult patients receiving LBA or caspofungin or both in combination at the University of California at San Francisco Medical Center (UCSF) and the University of California at San Diego Medical Center (UCSD) between January 1 and October 22, 2001, were reviewed. A total of 140 episodes of use of LBA, caspofungin, or the combination were identified at the two institutions. The primary indication for therapy with LBA was candidiasis (34% of episodes), whereas caspofungin and the drug combination were most commonly used for aspergillosis (43% and 71% of episodes, respectively). UCSF used the antifungal agents in accordance with its guidelines in 25% of the episodes of use and UCSD in 56%. Despite a higher qualifying serum creatinine (SCr) concentration for use of LBA at UCSF than at UCSD, the mean SCr concentration upon use was lower at UCSF. Among UCSF patients who did not meet the strict SCr criteria for use of either agent, most had concomitant renal failure as defined by a creatinine clearance of <25 mL/min, known risk factors for amphotericin B-associated nephrotoxicity, or breakthrough fungal infections while receiving alternative antifungal therapy. The UCSF pharmacy and therapeutics committee recommended that these factors be included in the indications for use of these agents. Compliance with criteria for use of LBA and caspofungin at two medical centers was inconsistent, probably because the initial criteria were insufficient in defining the conditions that justified the drugs' use.