title: The case for antifungal stewardship.
abstract: OBJECTIVE
  Antimicrobial stewardship (AMS) has overwhelmingly focussed on antibiotics while antifungal agents have been largely neglected despite the few published audits of antifungal drug use demonstrating clear deficiencies in prescribing behaviour. In this review, we outline not only the elements of antifungal stewardship (AFS) in common with AMS but also features specific to antifungal drugs, combined with insights from our experience in AFS.
  
  
  RESULTS
  Invasive fungal diseases (IFDs) have a lower institutional incidence relative to infections caused by multiresistant bacteria, but their health and economic burden are substantial. Pharmacy costs inclusive of antifungal agents are a major determinant of IFD-attributable hospital cost. High drug costs and the toxicities of antifungal agents are the principal rationale for AFS while antifungal resistance is an emerging but less prevalent issue. The high mortality/morbidity associated with IFDs, including adverse impact on curative chemotherapy, combined with suboptimal diagnostic tools, has driven the overuse of antifungal drugs. De-escalation of empiric therapy is one of the most challenging aspects of AFS to implement. Nonculture-based tests may enhance AFS, but refinement of both target populations and clinical pathways incorporating their use is required. Performance indicators including structural, process and outcome measures are integral for demonstrating the value of AFS programmes.
  
  
  CONCLUSIONS
  Practice guidelines adapted to the local context are the cornerstone of AFS. Local epidemiology informs the choice of antifungal agents for the prevention and management of IFDs, underscoring the need for surveillance. Adherence to minimum standards of prescribing ensures that clinical outcomes are optimized and drug toxicities minimized, thus meeting healthcare quality and safety goals.
authors: Infectious Diseases Unit, Alfred Health, Infectious Diseases Department, Peter MacCallum Centre, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria, Australia. m.ananda-rajah@alfred.org.au
authors: Michelle R
authors: MR
authors: Ananda-Rajah
authors: Monica A
authors: MA
authors: Slavin
authors: Karin T
authors: KT
authors: Thursky
mesh_terms: D000935:Antifungal Agents / Q000191:economics / Q000627:therapeutic use*; D025141:Drug Resistance, Fungal; D006760:Hospitalization; D006801:Humans; D009181:Mycoses / Q000188:drug therapy* / Q000191:economics; D017410:Practice Guidelines as Topic
chemical_list: D000935:Antifungal Agents