Background The incidence of invasive fungal infections in adult and paediatric patients has increased, particularly among immunocompromised patients with mortality in the setting of hematopoietic stem cell transplantation ranging from 30-40% for yeast infections and up to 70% for mould infections.1 Although many hospitals categorise antifungals as ‘restricted agents’, they are frequently used as part of haematology, oncology and cystic fibrosis protocols. This study was undertaken in an Irish, tertiary paediatric hospital and aimed to record the prevalence and pattern of antifungal prescribing and document indications for use. While there is an Antimicrobial Stewardship Policy in place in this hospital, there is no formal Antifungal Stewardship (AFS) Programme.
Method A prospective, modified single-day point prevalence study of antifungal use over 12 consecutive weeks (July 2020 and October 2020) was conducted. This data was collected as part of a submission to a European-wide study across 23 paediatric/neonatal sites. All inpatients <18 years present at 0800hours. on the day of survey who were receiving systemic antifungal agents were included. Patient data was recorded, anonymised and entered into a study-specific online portal in adherence to general data protection regulation requirements. Each patient was followed-up weekly and the outcome of each prescribing episode was recorded. Study approval was granted by the hospital’s research ethics committee.
Results 38 patients were included in the study; 60% male (n= 23), 40% female (n=15). During the 12 weeks, the overall rate of antifungal use was 6.7%. The main underlying condition recorded was cancer (63%, n= 24), 5 of which were post bone marrow transplant.
A total of 56 antifungal prescriptions were recorded; 64.3% (n= 36) recorded as prophylaxis and 35.7% (n=20) as treatment. Liposomal amphotericin B accounted for 41% of prescriptions, comprised of: fluconazole 28.6%, voriconazole 14.3%, posaconazole 8.9%, and caspofungin and itraconazole 3.6%. At the end of the study period, 86.7% of the prescriptions were ongoing for either prophylaxis or completion of treatment.
Discussion This is the first Irish paediatric study of antifungal prescribing pattern in tertiary care; the overall rate of antifungal prescribing is consistent with previously reported European data.1 The main indication for use was prophylaxis, targeted appropriately at immunocompromised patients.2 Liposomal amphotericin B is the most frequently prescribed antifungal and contributes substantially to the overall annual antifungal spend. The following limitations should be noted: although part of a wider European study, these data reflect antifungal use in a single site; data was collected during the COVID-19 pandemic which may have impacted inpatient numbers.
Conclusion Antifungal prescribing was appropriately focused on high-risk paediatric patients and was consistent with current local guidelines and aligned with European practice. Consideration should be given to substitution of liposomal amphotericin B with more cost-effective antifungals as clinically appropriate, offering significant cost savings. A formal AFS programme offers significant benefit both clinically and financially to the patients and institution, particularly in the empiric use of liposomal amphotericin B. It is anticipated that a AFS programme will be established in 2021.
Lestner JM, Versporten A, Doerholt K, Warris A, Roilides E, Sharland M, Bielicki J, Goossens H, ARPEC Project Group. Systemic antifungal prescribing in neonates and children: outcomes from the antibiotic resistance and prescribing in European children (ARPEC) study. Antimicrob Agents Chemother 2015;59:782–789.
Santiago-García B, Rincón-López EM, Ponce Salas B, et al. Effect of an intervention to improve the prescription of antifungals in pediatric hematology-oncology. Pediatr Blood Cancer 2020;67(4):e27963.
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