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Oral step down

Antifungal stewardship helps oral step down in haematology patients

There are a number of potential problems that occur during the management of haematology patients, and which may make the use of oral antifungal switch therapy problematic

Craig Williams MD Institute of Healthcare Associated Infection, University Hospital Crosshouse, Scotland, UK

The increase in resistant bacteria and the rise of pathogens such as Clostridium difficile (C. difficile) has led to the widespread adoption of antimicrobial stewardship programmes. These are defined as programmes with coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy and route of administration.1 The stewardship programmes are delivered by providing, policies for antimicrobial use, developing local clinical prescribing leadership and organisational accountability through agreed national targets for prescribing.2 IV to oral switch therapy has long been recognised as an important part of these programs stewardship programmes, which have largely focused on antibacterials.3

More recently, the concept of antifungal stewardship (AFS) is being promoted.4–6

This may differ from

antibacterial stewardship in a number of ways. Reducing indiscriminate antimicrobial usage is key in combating the expansion of multidrug-resistant pathogenic bacteria is fundamental to clinical antibiotic stewardship. However, compared with bacteria, fungal resistance traits are not thought to be spread by mobile genetic elements, and it has been

suggested that a global explosion of resistance to medical antifungals is therefore unlikely. To date, clinical antifungal stewardship has focused mainly on reducing the drug toxicity and high costs associated with antifungal agents. However, it needs to be borne in mind that the problem of human pathogenic fungi that exhibit resistance to antimicrobials is an emergent issue and the role for example of azole agents used in agriculture remains to be fully elucidated.7 To date, AFS programmes have been delivered using interdisciplinary teams of clinicians, pharmacists, microbiologists and infection control in each large hospital/institution dealing with high-risk patients for invasive fungal

infections. The programmes8


considered various aspects, including: (i) the local fungal epidemiology, (ii) information on antifungal resistance rates,

(iii) establishing and application of therapeutic guidelines, (iv)implementation of treatment strategies for empirical, pre-emptive therapy including PK/PD data for antifungal drugs, de-escalation and ‘switch and step-down strategies’ (from intravenous to oral medication) in defined patient populations,

(v) catheter management, together with the application of routine diagnostic procedures, such as ophthalmological and cardiac evaluations, and


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