Is fluconazole the new azithromycin? How appropriate is our antifungal prescribing?
Reviewed by Jen Cihlar, DO, Vanderbilt University Medical Center
Khanina and colleagues aimed to evaluate the quality of antifungal prescribing across hospitals in Australia using a newly implemented (2022) antifungal stewardship audit tool into their National Antimicrobial Prescribing Survey (NAPS). This audit tool was developed by the Australian National Centre for Antimicrobial Stewardship & the National Centre for Infections Cancer (and included a validation and inter-rater reliability process) using metrics to assess guideline compliance and overall appropriateness (based on tiered scale authors created). The Antifungal NAPS comprehensively evaluates patient and disease specific risk factors, as well as the distinct phases of invasive fungal infection (IFI) management (prophylactic, empirical and directed therapy). The tool assesses both guideline compliance and overall appropriateness of antifungal prescriptions based on a variety of factors (indication, drug-pathogen mismatch, dose, duration, potential for de-escalation).
Across the 11 participating hospitals, 516 prescriptions were audited with relatively high rates of appropriateness (77.1% for any indication), with the highest being indication for prophylaxis (85.1%) and the lowest being for empiric therapy (63.4%). Looking at overall appropriate use of amphotericin (93.8%) and echinocandins (84.5%) their impressive rates could be explained by high rates of ID consultation for both (98.1% and 97.4%) as well as high rates of requiring approval if restricted. Appropriateness of fluconazole prescriptions (40.5% of all prescriptions) was lowest for empiric use (appropriate ~ 50% of the time), especially for UTI and intraabdominal infections (~ 30%) as majority reason of the time, deemed ‘indication does not require any anti- fungal. Additional, there was also opportunity for the use of prophylactic fluconazole on both ends of the spectrum – not being appropriate for use in very low risk patients for invasive fungal infection (IFI) and too narrow of spectrum for those deemed high risk IFI, which highlighted the need for likely more oversight and education in this area.
This audit tool incorporates metrics and guidance from national and international expert consensus and may be more applicable than a standard point prevalence study given intricacies of IFI definitions, complex indications, and long durations used for prophylaxis. The authors were optimistic in its uptake of its utilization across more hospitals to identify prescribing trends and areas of opportunity. Trends noted in this study certainly could differ amongst different hospital settings (most in this study were large metropolitan hospitals that volunteered). While guidelines were both international and national based, it does raise intrigue of the feasibility of a system like this applied to other nations.
Reference:
INSPIRE/SSTKhanina A, Singh N, James R, Kong DCM, Slavin MA, Thursky KA. Assessing the appropriateness of antifungal prescribing: key results from the implementation of a novel audit tool in Australian hospitals. J Antimicrob Chemother. 2025;80(4):1127-1136. doi:10.1093/jac/dkaf044