A multisite evaluation of antifungal use in critical care: implications for antifungal stewardship C. Logan 1,2 *, C. Hemsley 3 , A. Fife 4 , J. Edgeworth 3,5 , A. Mazzella 1,2 , P. Wade 3,6 , A. Goodman 3,5,7 , P. Hopkins 8 , D. Wyncoll 9 , J. Ball 10 , T. Planche 1,2 , S. Schelenz 4 and T. Bicanic 1,2 1 Clinical Infection Group, St George’s University Hospitals NHS Foundation Trust, London, UK; 2 Institute of Infection & Immunity, St George’s University of London, London, UK; 3 Department of Infectious Diseases, Guy’s & St Thomas’ NHS Foundation Trust, London, UK; 4 Infection Sciences, King’s College Hospital NHS Foundation Trust, London, UK; 5 Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, King’s College London Guy’s & St Thomas’ NHS Foundation Trust, London, UK; 6 Directorate of Pharmacy & Medicines Optimisation, Guy’s & St Thomas’s NHS Foundation Trust, London, UK; 7 MRC Clinical Trials Unit at University College London, London, UK; 8 Department of Critical Care, King’s College Hospital NHS Foundation Trust, London, UK; 9 Department of Critical Care, Guy’s & St Thomas’ NHS Foundation Trust, London, UK; 10 Department of Critical Care, St George’s University Hospitals NHS Foundation Trust, London, UK *Corresponding author. E-mail: clogan@sgul.ac.uk Received 11 January 2022; accepted 28 April 2022 Background: ICUs are settings of high antifungal consumption. There are few data on prescribing practices in ICUs to guide antifungal stewardship implementation in this setting. Methods: 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 fi- nal invasive fungal infection (IFI) diagnostic classification. Results: Overall, 6.4% of ICU admissions (305/4781) received AFT, accounting for 11.41 days of therapy/100 oc- cupied 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 con- firmed IFI; 12%, 10% and 23% were classified as possible, probable or proven IFI, respectively. Hence, in 55%, IFI was unlikely. Proven IFI (n = 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 turn- around), 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. Conclusions: Achieving a better balance between promptly treating IFI patients and avoiding inappropriate anti- fungal 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. Introduction Intensive care patients are at increased risk of invasive fungal in- fection (IFI) and consequently the ICU is a setting with high anti- fungal consumption. 1 Invasive candidiasis (IC) is the most common IFI in the ICU, with invasive pulmonary aspergillosis (IPA) increasingly recognized. Both IC and IPA are associated with high crude mortality (40%–55% 2–4 and 50%–80% 5,6 respectively), with worse outcomes if treatment is delayed. 7,8 Diagnosis is notoriously difficult; symptoms are non-specific, and conventional culture-based diagnostics have suboptimal sensitivity and prolonged turnaround time (TAT). 9,10 Thus, recog- nizing the optimal timepoints to commence antifungal therapy (AFT) and identifying when antifungals can safely be stopped or de-escalated are challenges in the ICU. © The Author(s) 2022. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/ by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. 1 of 9 JAC Antimicrob Resist https://doi.org/10.1093/jacamr/dlac055 JAC- Antimicrobial Resistance Downloaded from https://academic.oup.com/jacamr/article/4/3/dlac055/6613429 by guest on 25 June 2022