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Case studies The difference AFS can make

A 2017 survey of NHS trusts in England found that only 11% (5/47) had a dedicated AFS programme, while almost all (98%) had an antibacterial stewardship programme.1,2

There is currently no national consensus on an AFS strategy in the UK or Ireland. This leaves hospitals and Trusts to follow local guidance for managing invasive fungal infections, which can be highly variable.3 While different hospitals, Trusts, and regions have employed their own strategies,3 success stories are emerging that show that AFS can be effective at achieving optimal outcomes at a significantly reduced cost.

Example and key findingsaCase 1: Royal Infirmary, Glasgow3,4

AFS programme focused on optimising antifungal stewardship: an evaluation of antifungal use in intensive care

The programme at a glance
  • AFS team: consultant microbiologist, ICU clinical team, ward pharmacist(s) and antimicrobial pharmacist(s)
  • 136 ICU patients receiving antifungal therapy (July 2017–March 2020)
    • Daily microbiology-led MDT ICU ward rounds
    • The indication, diagnosis, antifungal management and clinical advice provided were reviewed
    • pharmacist(s) and antimicrobial pharmacist(s)
    • Discussion and follow-up of any patient initiated on antifungal treatment was led by the consultant microbiologist, and included the ICU clinical team, ward pharmacist(s) and antimicrobial
  • Measures implemented: continuous surveillance and MDT approach
    • Continuous surveillance system to evaluate antifungal use and assess the impact of stewardship strategies in the ICU
    • Invasive candidiasis registry to advance understanding of the clinical characteristics and associated risk factors, epidemiology, and resistance rates 
The process
  • Every patient in the intensive care unit at Glasgow Royal Infirmary was subjected to a detailed review and risk assessment as part of the daily ward-round
    • Only those initiated on antifungal therapy were included in the retrospective analysis (n=136)
  • Retrospective analysis included assessment of: 
    • Clinical characteristics
    • Radiological, laboratory, and microbiological culture results
    • Incidence, associated risk factors, and outcomes of any recurrent episodes
    • Mortality rates (at 30 days, 90 days and all-cause)
Origin of infection

Intra-abdominal
75.8% (103/136)

Urinary/post-urological intervention
7.4% (10/136)

Line-related (intravascular catheter-related bloodstream infection)
4.4% (6/136)

Empiric treatment appropriateness based on risk assessment and/or clinical/radiological evidence (n=136)

July 2017–June 2018 (n=43/52): 82.7%

July 2018–June 2019 (n=44/49): 89.7%

July 2019–March 2020 (n=32/35): 91.4%

Overall (n=119/136): 87.5%

Culture proven invasive candidiasis was confirmed in >50% of cases (n=136). In 16.9% cases (n=23/136), a change in antifungal therapy was made based on testing results (culture proven)

Key findings
  • 90-day mortality was significantly improved in patients who received confirmed targeted therapy vs. those who were continued on empirical therapy (p=0.03)
  • However, in 87.5% of cases initiation of empirical antifungal therapy was considered appropriate based on either a risk assessment and/or clinical/radiological evidence 
  • Actions taken by the hospital during the AFS programme were used by the Scottish Antimicrobial Prescribing Group to develop ‘Good Practice Recommendations’
    • Specifically, standardisation of laboratory testing and antifungal susceptibility testing facilitated the development of recommendations, based on national surveillance data on candidaemia
       

This patient case study is just one example of how an AFS programme can make a real impact for your patients, and even inform recommendations for future practices. 

The future is in our hands. It’s time to shape it. AFS is a necessary and achievable strategy for the management of invasive fungal infections – at its core, AFS programmes seek to optimise the use of diagnostics, protect patients from unnecessary or inappropriate treatments and mitigate future antifungal resistance.3

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Further case studies
Read in-depth insight from additional successful AFS programmes for tips on implementing in your own Trust Case studiesLoading

a. This content provides an overview of different AFS programmes implemented in the UK, based on published data. This is not meant to be a comparative analysis, and the way the information is presented may differ between programmes.

ABS, antibacterial stewardship; AFS, antifungal stewardship; AMS, antimicrobial stewardship; ICU, intensive care unit;  MDT, multidisciplinary team; NHS, National Health Service.

Prescribing Information:

Click here for CRESEMBA® (isavuconazole) prescribing information

References:

Micallef C et al. J Med Microbiol 2017;66(11):1581–1589.NHS England Antifungal Stewardship Implementation Pack. Available at: https://www.england.nhs.uk/wp-content/uploads/2019/03/PSS1-meds-optimisation-trigger-5-antifungal-stewardship-implementation-pack-v7.pdf. Accessed August 2022.Talento AF et al. J Fungi 2021;7:801. https://doi.org/10.3390/jof7100801.Cottom, L.; Jones, B. Optimising antifungal stewardship: An evaluation of antifungal use in intensive care. In Proceedings of the Mycology Conference 2020, London, UK, 13–14 March 2020.
PP-CRB-GBR-1639. August 2022.

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