Background Antifungal (AF) stewardship programs are essential, especially in large tertiary care hospitals, where many physicians prescribe very costly drugs often on an empirical or pre-emptive basis. Purpose: To assess the quality of use of antifungal agents and to determine economic savings after 1 year of full implementation of an AF stewardship program.
Materials and methods A. Creation of the COMIC study group (Collaborative group on Mycosis) with the support and collaboration of hospital administration and medical management (02/2011) B. Development of local evidence-based guidelines and clinical pathways for the diagnosis and treatment of invasive fungal diseases (IFDs) (06/2011) C. Incorporation of IFD order sets in the CPOE system (09/2011) D. Development of educational activities (10/2011) E. Bedside intervention approach that includes pharmacists’ alerts for all adult patients receiving candins, L-AMB, voriconazole, or posaconazole and ID specialist and pharmacist visits to guide and advise attending physicians according to a custom-designed protocol. Quality of use of AF agents was evaluated with a predefined score (0–10 points). Staff attitudes to the program recommendations, daily defined doses (DDDs), and cost (US$) of AF were monitored monthly (10/2011–10/2012).
Results We evaluated 453 patients (69% men, mean age 51 [40–67] years) an average of 3 days after prescription of the AF, mostly in the haematology department (35%), medical department (23%), and ICU (20%). The reasons for prescribing AFs were prophylaxis (32%), pre-emptive therapy (13%), empirical therapy (19%), and targeted therapy (36%). The AFs prescribed were candins (47%), L-AmB (26%), voriconazole (10%), posaconazole (16%), and other (1%). Diagnostic advice to confirm or exclude the IFD was given in 308 (68%) cases. Adjustments to AF therapy were suggested with respect to indication (5%), drug selected (22%), dose (4%), microbiological results (19%), administration route (7%), and duration of treatment (29%). Of the 242 patients (54%) requiring adjustment, changes were made in 130 cases (29%). The results of the point score evaluation after intervention was 8.6 ± 1.8 points. The annual cost of AF in adult inpatients was reduced by 27% from ¤2,509,219 (2011) to ¤1,832,782 (2012). The average cost of AF DDDs was reduced from ¤104.90 to ¤80.70, mainly owing to the decrease in consumption of candins (16.8%) (from 12.1 to 10.1 DDDs/1000 patient-days) and an increase in the sequential administration of voriconazole and itraconazole (78% and 71%, respectively of oral DDDs). Taking into consideration the need to hire a part-time specialist pharmacist and expert microbiologist, the net saving generated by the project was ¤650,437.
Conclusions Implementation of multidisciplinary interventions as developed in this hospital was cost-effective.
No conflict of interest.
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