Use of antifungal therapy in hospitalized patients. I. Results prior to the marketing of fluconazole.
OBJECTIVE
To evaluate the use of antifungal agents in hospitalized patients prior to marketing of fluconazole and to assess characteristics associated with their use.


METHODS
A cohort of hospitalized patients receiving topical or systemic antifungal therapy was monitored concurrently.


METHODS
Sixty-nine hospitals ranging in size from 100 to more than 500 beds, 70.1 percent affiliated with medical schools.


METHODS
Participating clinical pharmacists each identified 15 consecutive patients receiving systemic antifungal therapy and 5 consecutive patients receiving topical antifungal therapy at their institutions. Data collection began October 1989 and ended March 1990.


METHODS
All data collected were observational in nature, and no patient intervention was required.


METHODS
Characteristics of patients receiving antifungal therapy were compared using t-tests and chi-square tests. Utilization and patterns of use of antifungal therapy were reported.


RESULTS
The most common risk factors necessitating antifungal therapy, in descending order, were: administration of broad-spectrum antibiotics and/or presence of invasive catheters, carcinoma, AIDS, leukemia or lymphoma, diabetes mellitus, solid organ or bone marrow transplantation, and chronic obstructive pulmonary disease. Five hundred seventeen patients received systemic therapy and 464 (89.7 percent) received a single systemic agent. Of these, 242 (52.2 percent) received amphotericin B, 215 (46.3 percent) received ketoconazole, 6 (1.3 percent) received flucytosine, and 1 (0.2 percent) received intravenous miconazole. Fifty-three patients received two systemic agents either concurrently or consecutively. Ketoconazole was most often used for presumed or documented oral, urogenital, or esophageal infections and amphotericin B was the preferred agent for disseminated infections and fungemia (p < 0.001). Almost half of the patients receiving amphotericin B or ketoconazole (48.3 percent) received these drugs as empiric therapy. Documented infections were more likely to be treated with amphotericin B (54.8 percent) than with ketoconazole (27.4 percent) (p < 0.001). The predominant fungal isolates were Candida albicans, Candida spp., and unspecified yeasts. Amphotericin B toxicity led to discontinuation of drug therapy in only 5.1 percent of cases. Two hundred sixty-nine patients (34.2 percent) received topical antifungal therapy only. Nystatin oral suspension was prescribed to 65.3 percent of the patients, clotrimazole troches to 23.0 percent, amphotericin B irrigation to 10.9 percent, and nystatin tablets to 0.8 percent.


CONCLUSIONS
The utilization patterns of antifungal agents in this survey follow established therapeutic guidelines. Prior to the introduction of fluconazole, amphotericin B was the agent of choice for documented systemic fungal infections. Ketoconazole was more often used for prophylaxis of fungal infections and treatment of oral and esophageal infections.
Grasela
T H
TH
Center for Pharmacoepidemiology Research, State University of New York (SUNY) at Buffalo.
Goodwin
S D
SD
Pasko
M T
MT
Walawander
C A
CA
Raebel
M A
MA
D017088:AIDS-Related Opportunistic Infections / Q000188:drug therapy; D000666:Amphotericin B / Q000627:therapeutic use; D000935:Antifungal Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D004363:Drug Utilization / Q000706:statistics & numerical data*; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007654:Ketoconazole / Q000627:therapeutic use; D009181:Mycoses / Q000188:drug therapy*; D009761:Nystatin / Q000627:therapeutic use; D011446:Prospective Studies; D012307:Risk Factors; D014481:United States
D000935:Antifungal Agents; D009761:Nystatin; D000666:Amphotericin B; D007654:Ketoconazole