What can be done?

What is the answer to the growing problem of antifungal resistance?

The solution is multifaceted and antifungal stewardship is in its heart.

Antifungal stewardship aims to treat fungal infections effectively and, at the same time, to preserve the effectiveness of antifungal drugs for the future. Both of these outcomes are in the interests of our current and future patients.

As we have seen in the three case studies, the complexity of fungal diseases is often high. Therefore, a specialist led, multidisciplinary approach is needed. The key tools in Antifungal stewardship are diagnostic tests (see Week 1) that can guide starting and stopping antifungals and local, national and international guidelines signposting how these tests should be used, the results interpreted and patients managed.

The first task for the multidisciplinary Antifungal Stewardship Team is to develop local guidelines and/or care bundles for each patient group (ICU, haematology, GI surgery etc). These should include practical advice on the use of fungal diagnostics, their expected turn-around times, and the timing of antifungal reviews and expert support for these.

Antifungal guidelines

• Evidence based international guidelines are good tools in the development of local guidance
• Local guidelines should take into account local patient characteristics and the epidemiology of fungal infections
• International guidelines can also directly assist the non-specialist clinician in the management of less common fungal infections
• Adherence to any established guidelines needs to be audited and feedback provided to the clinical teams for action planning

Expert post prescription review and feedback

• Typically conducted by a specialist Pharmacist, Infectious Diseases specialist and/or Microbiologist
• Aims to review the appropriateness of antifungal treatment in the context of: diagnostics done, dose, administration and therapeutic drug monitoring, indication & duration
• Feedback is offered to clinicians at the bedside, and they are directed to prescribing guidelines

Restrictive prescribing

• Preventing antifungal prescribing by non-authorised clinicians (i.e. only named fungal infection specialists can issue prescriptions) is, in principle, a simple way to reduce antifungal use
• There is, however, a risk for delays in starting antifungal therapy for systemic fungal infections which would have a major impact on patient outcomes
• This approach is not commonly used as setting useful and safe prescribing restrictions for the complex patient groups at risk for fungal infections is extremely challenging

This list of strategies is not exhaustive. You may be thinking of your own ideas. Each approach arises from the core principles of antimicrobial stewardship:

• Right drug
• Right dose
• Right duration
• Right patient