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Do we need to adopt antifungal stewardship programmes?
  1. Konstantinos Ioannidis1,
  2. Apostolos Papachristos1,
  3. Ioannis Skarlatinis1,
  4. Fevronia Kiospe2,
  5. Sotiria Sotiriou2,
  6. Eleni Papadogeorgaki3,
  7. George Plakias3,
  8. Vangelis D Karalis4,
  9. Sophia L Markantonis2
  1. 1 Department of Clinical Pharmacy, Diagnostiko kai Therapeftiko Kedro Athinas - Hygeia, Athens, Greece
  2. 2 National and Kapodistrian University of Athens Faculty of Pharmacy, Athens, Greece
  3. 3 Department of Microbiology, Diagnostiko kai Therapeftiko Kedro Athinas - Hygeia, Athens, Greece
  4. 4 Faculty of Pharmacy, Laboratory of Biopharmaceutics - Pharmacokinetics, National and Kapodistrian University of Athens, Athens, Greece
  1. Correspondence to Dr Konstantinos Ioannidis, Department of Clinical Pharmacy, Hygeia Hospital Athens, Marousi 151 23, Greece; kioannidis{at}


Background Although antimicrobial stewardship programmes are one of the highest priorities in healthcare systems and many articles have been published, few refer to the implementation of antifungal stewardship and highlight specific points on which efforts should be focused.

Objective To assess the percentage of patients with confirmed candidaemia in whom de-escalation was conducted, and the economic impact of step-down or step-up antifungal therapy. Additionally, we attempted to estimate the potential increase in drug minimum inhibitory concentrations or to detect resistant strains of Candida species.

Methods We selected, retrospectively, patients who had received systemic antifungal therapy between 2011 and 2016 for documented candidaemia. Statistical analysis and diagrams were used to assess the results.

Results Of 157 patients with confirmed candidaemia, 58 received azoles, 74 echinocandinsand 18 liposomal amphotericin B for empirical therapy. 51 patients were eligible to step-down to fluconazole but only 23 patients did so. Furthermore, in nine patients unjustified step-up from fluconazole to echinocandins or liposomal amphotericin B was carried out. The additional cost incurred bythe healthcare system due to high prices of echinocandins and liposomal amphotericin B in comparison with fluconazole was€211 837. Interestingly, it was found that one strain of C. albicans and two strains of C. glabrata were resistant to echinocandins.

Conclusion The presence of a multidisciplinary team, including an infection control specialist and a clinical pharmacist, would limit the prescription of advanced antifungal agents as empirical therapy. Moreover, this team would control the de-escalation process—where applicable—leading to a reduction in costs and, probably, a decrease in the emergence of resistant Candida species. These facts contribute to the broader discussion on the adoption of antifungal stewardship programmes.

  • echinocandins
  • candidemia
  • de-escalation
  • stewardship programs
  • financial loss

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