P078 Baseline antifungal usage patterns and knowledge regarding management of invasive fungal infections as a part of a multidisciplinary antifungal stewardship (AFS) program
Authors: Sachdev Janya , Singh Gagandeep , Xess Immaculata , Soneja Manish 
Published: September 2022

Abstract

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM

Objectives
To establish a baseline of antifungal usage patterns (indication, duration, toxicity, and cost) and physician's knowledge of management of invasive fungal infections, as a basis for implementation of a multidisciplinary antifungal stewardship (AFS) program at a tertiary care center.

Methods
Data including clinical history, investigations, and antifungal therapy was collected by chart review and bedside rounds from 100 patients with laboratory-confirmed invasive fungal infections (IFIs). Requirement and adequacy of antifungal therapy were assessed in comparison with IDSA and EORTC/MSG guidelines and scored at discharge/death using the Valerio system. This system assigns points to six parameters: indication, optimal selection of antifungal agent, dosage according to individual characteristics, loading and maintenance dose, therapy adjustment after microbiological results, route of administration, and length of therapy. The maximum score (10) indicates appropriate therapy. Any score of ˂ 10 is classified as inappropriate.

Results
Out of 100 patients who met the criteria for IFI, 85 patients had a single IFI, 45 (52.9%) of whom received appropriate antifungal therapy, 17 (20%) received other than the recommended antifungal therapy and 23 (27.1%) received no antifungals. A total of 15 patients had dual IFIs, 10 (66.7%) of whom received other than the recommended antifungal therapy for one or both infections, 1 (6.7%) was treated appropriately for one infection but left untreated for the other, 2 (13.4%) patients were untreated for both infections and 2 (13.4%) were appropriately treated for both infections. The most common types of inappropriate antifungal use were inappropriate antifungal for organism (16 incidents), inadequate dosage (11 incidents), inappropriate antifungal for site (6 incidents), inadequate duration (6 incidents), and failure to adjust antifungal therapy based on microbiological test results (6 incidents). Common reasons observed for inappropriate antifungal use were delay in starting antifungal therapy or in ordering appropriate tests for establishing diagnosis, uncertainty in distinguishing fungal pathogens from colonisers, lack of rigorous antifungal charting, unavailability of first-line drug, and attempts to use a single antifungal to cover dual IFIs.

Conclusions
There are several inadequacies in Valerio scoring system, i.e., no weightage given to timely initiation of treatment, no deductions for delay in starting treatment once reports have been received, or for use of unnecessary antifungals in addition to recommended ones. Antifungals are often chosen by organism only while ignoring site-specific action and penetration of the drug. There is no comprehensive system for recording antifungal use, making it difficult to ascertain cumulative antifungal use over time. Direct association could not be made between inappropriate antifungal use and outcome as most patients had multiple comorbidities apart from fungal infection. Where fungal infection occurs along with TB, fungi are often considered commensals and left untreated. Many immunocompetent patients with IFIs are ‘unclassifiable’, ie, cannot be categorized under existing guidelines. Even for ‘classifiable’ patients, there is considerable subjectivity in antifungal treatment guidelines. There is a need for a standardized algorithm-based treatment at institutional level for these groups of patients.