Antimicrobial stewardship has overwhelmingly focussed on antibiotics while antifungal agents have been largely neglected despite data of antifungal drug use showing clear deficiencies in prescribing behaviour. Antifungal stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antifungals by promoting the selection of the optimal antifungal drug regimen, dose, duration of therapy, and route of administration. Antifungal stewards seek to achieve optimal clinical outcomes related to antimicrobial use, minimize toxicity and other adverse events, reduce the costs of health care for infections, and limit the selection for antifungal resistant strains. The high mortality and morbidity associated with IFDs, including adverse impact on curative chemotherapy, combined with suboptimal diagnostic tools, has driven the overuse of antifungal drugs. Deescalation of empiric therapy is one of the most challenging aspects of antifungal stewardship to implement. Nonculture-based tests may enhance antifungal stewardship, but refinement of both target populations and clinical pathways incorporating their use is required. Performance indicators including structural, process and outcome measures are integral for demonstrating the value of antifungal stewardship programmes. Pharmacy costs inclusive of antifungal agents are a major determinant of IFD-attributable hospital cost. High drug costs and the toxicities of antifungal agents are the principal rationale for antifungal stewardship while antifungal resistance is an emerging but less prevalent issue. The primary goal is therefore to optimize clinical outcome while minimizing unintended consequences of antifungal drug use followed by reduction of health care costs displaying a secondary goal. New antifungals have slight differences in the spectrum of action, dose required, route of administration, and interactions with other drugs, which are difficult to manage by a non-fungal specialist. Practice guidelines adapted to the local context are the cornerstone of antifungal stewardship. Local epidemiology informs the choice of antifungal agents for the prevention and management of IFDs, underscoring the need for surveillance. Adherence to minimum standards of prescribing ensures that clinical outcomes are optimized and drug toxicities minimized, thus meeting healthcare quality and safety goals.
Lass-Flörl, C. (2014). Antifungal stewardship. International Journal of Infectious Diseases, 21, 74. https://doi.org/10.1016/j.ijid.2014.03.580