Logan C, Hemsley C, Fife A, Edgeworth J, Mazzella A, Wade P, Goodman A, Hopkins P, Wyncoll D, Ball J, Planche T, Schelenz S, Bicanic T
Clinical Infection Group, St George's University Hospitals NHS Foundation Trust, London, UK.
Department of Infectious Diseases, Guy's & St Thomas' NHS Foundation Trust, London, UK.
JAC Antimicrob Resist. 2022 Jun 23;4(3):dlac055. doi: 10.1093/jacamr/dlac055. eCollection 2022 Jun.
ICUs are settings of high antifungal consumption. There are few data on prescribing practices in ICUs to guide antifungal stewardship implementation in this setting.
An antifungal therapy (AFT) service evaluation (15 May-19 November 2019) across ICUs at three London hospitals, evaluating consumption, prescribing rationale, post-prescription review, de-escalation and final invasive fungal infection (IFI) diagnostic classification.
Overall, 6.4% of ICU admissions (305/4781) received AFT, accounting for 11.41 days of therapy/100 occupied bed days (DOT/100 OBD). The dominant prescribing mode was empirical (41% of consumption), followed by targeted (22%), prophylaxis (18%), pre-emptive (12%) and non-invasive (7%). Echinocandins were the most commonly prescribed drug class (4.59 DOT/100 OBD). In total, 217 patients received AFT for suspected or confirmed IFI; 12%, 10% and 23% were classified as possible, probable or proven IFI, respectively. Hence, in 55%, IFI was unlikely. Proven IFI (= 50) was mostly invasive candidiasis (92%), of which 48% had been initiated on AFT empirically before yeast identification. Where on-site (1 → 3)-β-d-glucan (BDG) testing was available (1 day turnaround), in those with suspected but unproven invasive candidiasis, median (IQR) AFT duration was 10 (7-15) days with a positive BDG (≥80 pg/mL) versus 8 (5-9) days with a negative BDG (<80 pg/mL). Post-prescription review occurred in 79% of prescribing episodes (median time to review 1 [0-3] day). Where suspected IFI was not confirmed, 38% episodes were stopped and 4% de-escalated within 5 days.
Achieving a better balance between promptly treating IFI patients and avoiding inappropriate antifungal prescribing in the ICU requires timely post-prescription review by specialist multidisciplinary teams and improved, evidence-based-risk prescribing strategies incorporating rapid diagnostics to guide AFT start and stop decisions.
重症监护病房（ICU）是抗真菌药物高消耗的场所。关于ICU处方实践的数据很少，难以指导该环境下抗真菌管理措施的实施。
对伦敦三家医院的ICU进行了一项抗真菌治疗（AFT）服务评估（2019年5月15日至11月19日），评估了药物消耗、处方理由、处方后审查、降阶梯治疗以及最终侵袭性真菌感染（IFI）的诊断分类。
总体而言，6.4%的ICU入院患者（305/4781）接受了AFT，占11.41天治疗时间/100个占用床日（DOT/100 OBD）。主要的处方模式是经验性用药（占药物消耗的41%），其次是靶向治疗（22%）、预防性用药（18%）、抢先治疗（12%）和非侵入性治疗（7%）。棘白菌素类是最常处方的药物类别（4.59 DOT/100 OBD）。共有217例患者因疑似或确诊IFI接受了AFT；分别有12%、10%和23%被分类为可能、很可能或确诊的IFI。因此，55%的患者不太可能患有IFI。确诊的IFI（=50例）大多为侵袭性念珠菌病（92%），其中48%在酵母菌鉴定前就已开始经验性使用AFT。在可进行现场（1→3）-β-d-葡聚糖（BDG）检测（周转时间为1天）的情况下，对于疑似但未确诊的侵袭性念珠菌病患者，BDG阳性（≥80 pg/mL）者的AFT中位（IQR）持续时间为10（7 - 15）天，而BDG阴性（<80 pg/mL）者为8（5 - 9）天。79%的处方事件进行了处方后审查（审查的中位时间为1 [0 - 3]天）。在疑似IFI未得到确认的情况下，38%的事件在5天内停药，4%的事件进行了降阶梯治疗。
要在及时治疗IFI患者和避免ICU中不适当的抗真菌处方之间取得更好的平衡，需要由多学科专业团队及时进行处方后审查，并改进基于证据的风险处方策略，纳入快速诊断以指导AFT的开始和停止决策。
