What are the challenges?

There are a number of factors that can hinder developing and establishing antifungal stewardship. One of the most common obstacles is lack of knowledge among clinical staff on fungal diseases, their clinical presentation, risk factors, diagnostics, management, and prevention. Although many principles of antibiotic stewardship can be useful, additional mycology-specific approaches are needed.

Limited expertise

The average clinician is not exposed to as many fungal diseases compared to bacterial ones. Invasive fungal infections, especially, present in specific patient groups and are often handled by specialists in this field.

Therefore, the baseline understanding is lower for the conditions, diagnostics and the drugs used to treat them. Also, the lack of knowledge on predisposing factors makes it difficult for the clinical teams to put the essential preventative measures in place (such as reducing the exposure to moulds by keeping windows closed on wards with vulnerable at-risk patients).

This can lead to inappropriate prophylactic and treatment use of antifungals, sub-optimal dosing and frequent misdiagnosis.

An important part of antifungal stewardship is to provide all members of the various clinical teams access to training on the topic. This training may need to be tailored to each service and staff group but a course like the one you are doing here is a good starting point for any clinical team regularly prescribing antifungals. Due to the rotation of staff, training should be available around the year for all new-starters.

Imperfect diagnostics

As we have seen in weeks 1 and 2, the number of sensitive and specific diagnostic methods is limited. Also, many of these tests are not run locally as they require specialist skills and setting, and delays in transportation can be a significant issue.

Overall, all currently available methods come with a list of caveats. They either lack sensitivity or specificity, or their turn-around times are too long to be helpful for guiding antifungal therapy. Also, their interpretation often requires specialist input.

This compounds the difficulty in avoiding unnecessary treatments when clinical suspicion is high. It is important that the Antifungal Stewardship Team provides clear guidance to the clinical teams: what tests should be used in different clinical scenarios and time points, and how the results of these tests should be used in decision making. Also, it is the responsibility of the Antifungal Stewardship Team to ensure that the patient-to-patient turnaround times for the tests are short enough to be useful and map against the care pathway. This often requires managerial support and input into the organisation of the logistics.

Life threatening conditions

Invasive fungal infections such as candidaemia and invasive aspergillosis have a high mortality if treatment is delayed.

This presents a conundrum for the treating clinician. Often, symptoms are non-specific and diagnosis is challenging. At the same time, empirical therapy saves lives when used appropriately. Therefore, a cautious clinician will consider fungal infection and treat empirically, in many cases, unnecessarily.

It would be inappropriate to restrict initiation of antifungal therapy in patients with possible invasive fungal infection. Therefore, the local guidelines should include tests that can be used to rule out infection and to stop treatment if negative.

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Tradition and attitudes

The specific patient groups that are at risk for these infections have long been cared for under relevant specialist teams. Over time, prescribing habits become prescribing culture.

Prescribing culture can be difficult to change. This can be even more difficult if changes are proposed from outside the department. Therefore, an individual from within the department is needed to champion antifungal stewardship. The desire to change has to come from within the team.