Appropriateness of antifungal prescribing in Oman
Main Article Content
Keywords
Antifungal agents, Inappropriate prescribing, Guideline, Drug resistance, Anidulafungin, Fluconazole, Voriconazole
Abstract
Background: The inappropriate use of antimicrobials has substantially contributed to the development of antimicrobial drug resistance. Appropriate antibacterial prescribing has been emphasised, with minimal focus on appropriate prescribing of antifungals. Evaluation of antifungal use in the clinical setting is essential to prevent unnecessary drug exposure, development of resistance, adverse effects, and high hospitalisation costs. Objective: The purpose of this study was to assess the appropriateness of antifungal prescribing among adult patients at the Sultan Qaboos University Hospital (SQUH) in Oman. Methods: In this retrospective, observational study, the study population comprised adult patients treated with oral or intravenous antifungals between July 2018 and December 2019. The appropriateness of treatment was assessed using guidelines from the Infectious Diseases Society of America (IDSA) and the National Comprehensive Cancer Network (NCCN), as well as a set of literature-based criteria that were modified by SQUH infectious diseases team to suit local practices. These criteria included indication, dosage, and potential drug interactions. The primary outcome was the frequency of adherence to the treatment guidelines for fungal infections. Descriptive statistics were used for data analysis. Results: A total of 400 prescriptions were collected, of which 158 (39.5%) were for empirical therapy, 135 (33.8%) for targeted therapy, 69 (17.3%) for prophylactic therapy, and 38 (9.5%) for pre-emptive therapy. The overall appropriateness was 74.8%. The indication, dosage, and potential for antifungal-drug interactions were considered appropriate in 391 (97.8%), 314 (78.5%), and 381 (95.3%) prescriptions, respectively. Anidulafungin was the most prescribed antifungal agent, with 210 prescriptions (52.5%), followed by fluconazole with 102 prescriptions (25.5%), and voriconazole with 48 prescriptions (12%). Conclusion: In comparison with publised literature, our study revealed appropriate antifungal drug prescribing practices. However, studies with larger sample size in various hospital settings are necessary to confirm our findings on a national scale, and to obtain better statistical inferences and generalisability.
References
2. Minarini LADR, de Andrade LN, De Gregorio E, et al. Editorial: Antimicrobial Resistance as a Global Public Health Problem: How Can We Address It? Front Public Health. 2020;8:612844. https://doi.org/10.3389/fpubh.2020.612844
3. McEwen SA, Collignon PJ. Antimicrobial Resistance: a One Health Perspective. Microbiol Spectr. 2018;6(2). https://doi.org/10.1128/microbiolspec.ARBA-0009-2017
4. Fletcher S. Understanding the contribution of environmental factors in the spread of antimicrobial resistance. Environ Health Prev Med. 2015;20(4):243-52. https://doi.org/10.1007/s12199-015-0468-0
5. Wiederhold NP. Antifungal resistance: current trends and future strategies to combat. Infect Drug Resist. 2017;10:249-259. https://doi.org/10.2147/IDR.S124918
6. Arastehfar A, Gabaldón T, Garcia-Rubio R, et al. Drug-Resistant Fungi: An Emerging Challenge Threatening Our Limited Antifungal Armamentarium. Antibiotics (Basel). 2020;9(12):877. https://doi.org/10.3390/antibiotics9120877
7. Arnold HM, Micek ST, Shorr AF, et al. Hospital resource utilization and costs of inappropriate treatment of candidemia. Pharmacotherapy. 2010;30(4):361-8. https://doi.org/10.1592/phco.30.4.361
8. Hendrickson JA, Hu C, Aitken SL, et al. Antifungal Resistance: a Concerning Trend for the Present and Future. Curr Infect Dis Rep. 2019;21(12):47. https://doi.org/10.1007/s11908-019-0702-9
9. Perlin DS, Rautemaa-Richardson R, Alastruey-Izquierdo A. The global problem of antifungal resistance: prevalence, mechanisms, and management. Lancet Infect Dis. 2017;17(12):e383-e392. https://doi.org/10.1016/S1473-3099(17)30316-X
10. Nivoix Y, Launoy A, Lutun P, et al. Adherence to recommendations for the use of antifungal agents in a tertiary care hospital. J Antimicrob Chemother. 2012;67(10):2506-13. https://doi.org/10.1093/jac/dks256
11. Valerio M, Rodriguez-Gonzalez CG, Muñoz P, et al. Evaluation of antifungal use in a tertiary care institution: antifungal stewardship urgently needed. J Antimicrob Chemother. 2014;69(7):1993-9. https://doi.org/10.1093/jac/dku053
12. Islahudin F, Mohd SFR. Evaluation of appropriate use of antifungal therapy in a tertiary care hospital. Asian J Pharm Clin Res. 2015;8(4):195-9.
13. Lachenmayr SJ, Berking S, Horns H, et al. Antifungal treatment in haematological and oncological patients: Need for quality assessment in routine care. Mycoses. 2018;61(7):464-471. https://doi.org/10.1111/myc.12768
14. de Souza MC, Dos Santos AG, Reis AM. Drug utilization study of systemic antifungal agents in a Brazilian tertiary care hospital. Int J Clin Pharm. 2016;38(6):1398-1406. https://doi.org/10.1007/s11096-016-0382-6
15. Al Balushi KA, Alzaabi MA, Alghafri F. Prescribing Pattern of Antifungal Medications at a Tertiary Care Hospital in Oman. J Clin Diagn Res. 2016;10(12):FC27-FC30. https://doi.org/10.7860/JCDR/2016/23591.9005
16. Al-Rashdi A, Al-Maani A, Al-Wahaibi A, et al. Characteristics, Risk Factors, and Survival Analysis of Candida auris Cases: Results of One-Year National Surveillance Data from Oman. J Fungi (Basel). 2021;7(1):31. https://doi.org/10.3390/jof7010031
17. Patterson TF, Thompson GR 3rd, Denning DW, et al. Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;63(4):e1-e60. https://doi.org/10.1093/cid/ciw326
18. Pappas PG, Kauffman CA, Andes DR, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016;62(4):e1-50. https://doi.org/10.1093/cid/civ933
19. Baden LR, Swaminathan S, Angarone M, et al. Prevention and Treatment of Cancer-Related Infections, Version 2.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl ComprCancNetw. 2016;14(7):882-913. https://doi.org/10.6004/jnccn.2016.0093
20. Lone SA, Ahmad A. Candida auris-the growing menace to global health. Mycoses. 2019;62(8):620-637. https://doi.org/10.1111/myc.12904
21. Reslan Z, Lindsay J, Kerridge I, et al. Adherence to Antifungal Guidelines in Malignant Hematology Patients: A Review of the Literature. J Pharm Technol. 2019;35(6):270-280. https://doi.org/10.1177/8755122519859976
22. Poulat C, Nivoix Y, Launoy A, et al. Assessment of high-priced systemic antifungal prescriptions. Med Mal Infect. 2017;47(6):382-388. https://doi.org/10.1016/j.medmal.2017.03.004
23. Vazin A, Davarpanah MA, Ghalesoltani S. Antifungal agent utilization evaluation in hospitalized neutropenic cancer patients at a large teaching hospital. Drug Healthc Patient Saf. 2015;7:97-102. https://doi.org/10.2147/DHPS.S80762
24. Mencarini J, Mantengoli E, Tofani L, et al. Evaluation of candidemia and antifungal consumption in a large tertiary care Italian hospital over a 12-year period. Infection. 2018;46(4):469-476. https://doi.org/10.1007/s15010-018-1139-z
25. Zilberberg MD, Kollef MH, Arnold H, et al. Inappropriate empiric antifungal therapy for candidemia in the ICU and hospital resource utilization: a retrospective cohort study. BMC Infect Dis. 2010;10:150. https://doi.org/10.1186/1471-2334-10-150
26. Reboli AC, Shorr AF, Rotstein C, et al. Anidulafungin compared with fluconazole for treatment of candidemia and other forms of invasive candidiasis caused by Candida albicans: a multivariate analysis of factors associated with improved outcome. BMC Infect Dis. 2011;11:261. https://doi.org/10.1186/1471-2334-11-261
27. Ou HT, Lee TY, Chen YC, et al. Pharmacoeconomic analysis of antifungal therapy for primary treatment of invasive candidiasis caused by Candida albicans and non-albicans Candida species. BMC Infect Dis. 2017;17(1):481. https://doi.org/10.1186/s12879-017-2573-8
28. Auzinger G, Playford EG, Graham CN, et al. Cost-effectiveness analysis of anidulafungin for the treatment of candidaemia and other forms of invasive candidiasis. BMC Infect Dis. 2015;15:463. https://doi.org/10.1186/s12879-015-1143-1
29. Al-Siyabi T, Al Busaidi I, Balkhair A, et al. First report of Candida auris in Oman: Clinical and microbiological description of five candidemia cases. J Infect. 2017;75(4):373-376. https://doi.org/10.1016/j.jinf.2017.05.016
30. Alfouzan W, Dhar R, Albarrag A, et al. The emerging pathogen Candida auris: A focus on the Middle-Eastern countries. J Infect Public Health. 2019;12(4):451-459. https://doi.org/10.1016/j.jiph.2019.03.009
31. Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of America. Clin Infect Dis. 2010;50(3):291-322. https://doi.org/10.1086/649858
32. Gubbins PO. Triazole antifungal agents drug-drug interactions involving hepatic cytochrome P450. Expert Opin Drug MetabToxicol. 2011;7(11):1411-29. https://doi.org/10.1517/17425255.2011.627854
33. Gubbins PO, Heldenbrand S. Clinically relevant drug interactions of current antifungal agents. Mycoses. 2010;53(2):95-113.https://doi.org/10.1111/j.1439-0507.2009.01820.x
Article Sidebar
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Fatima Issa El-Hussain
MSc student, Department of Pharmacology and Clinical Pharmacy