Antifungal stewardship in Australian hospitals: defining the scope and future targets.

Abstract

Antimicrobial stewardship (AMS) guidelines now recommend antifungal stewardship (AFS) interventions to improve the management of invasive fungal diseases (IFDs). AFS programmes have not been reported in Australia. To determine the monitoring of antifungal use, AFS strategies and targets, and barriers to AFS implementation in Australian hospitals. An electronic quantitative cross-sectional survey was developed and distributed to public and private hospitals in Australia in February 2018. Descriptive statistics were used to summarise the findings. Eighty-three Australian hospitals completed the survey with an overall response rate of 58% (83/143). Most hospitals monitored antifungal use (62/83, 75%). Frequently used AFS metrics included costs (48/60, 80%) and yearly point prevalence surveys (45/60, 75%). Core AFS strategies were commonly in place, including preauthorisation requirements (71/80, 89%) and expert antifungal post-prescription review and feedback (PPRF) (63/80, 79%). Both these strategies were more strictly applied to high-cost, intravenous agents. Formal education (44/79, 56%) and hospital-endorsed guidelines (35/79, 44%) were modestly used. Fungal diagnostics and antifungal therapeutic drug monitoring (TDM) were utilised, largely off site. IFD surveillance was infrequently performed (9/77, 12%). Barriers to AFS identified included lack of staff time, prioritisation of AFS, and access to rapid diagnostics and TDM. AFS strategies utilised in Australian hospitals have focused on high-cost, intravenous agents. Although expert oversight of antifungals is evident, many sites omit potentially important targets for AFS, including fluconazole and oral posaconazole. Identifying these gaps and barriers to AFS will guide the development of an AFS model for hospitals.