title: Antifungal step-down therapy based on hospital intravenous to oral switch policy and susceptibility testing in adult patients with candidaemia: a single centre experience.
abstract: OBJECTIVE
  Echinocandins are recommended for the treatment of candidaemia in moderately severe to severely ill patients. Step-down or de-escalation from echinocandin to fluconazole is advised in patients who are clinically stable but data in relation to step-down therapy are sparse. Using our hospital intravenous to oral switch therapy (IVOST) policy to guide antifungal de-escalation in patients with candidaemia, we aimed to determine what proportion of patients are de-escalated to fluconazole, the timescale to step-down, associated reduction in consumption of echinocandins and antifungal cost savings.
  
  
  METHODS
  Patients with candidaemia were followed from April 2011 to March 2013.
  
  
  RESULTS
  A total of 37 episodes of candidaemia were documented during the study period. Twenty-seven patients were commenced on an echinocandin or voriconazole and 19 (70.3%) were de-escalated to fluconazole based on the IVOST policy. The mean and median number of days to de-escalation of therapy was 4.6 and 5 days, respectively. One patient whose therapy was de-escalated relapsed. The overall 30 day crude mortality was 37.1%. The step-down approach led to significant saving in antifungal drug cost of £1133.88 per candidaemic episode and £2208.08 per de-escalation.
  
  
  CONCLUSIONS
  Implementation of IVOST policy led to streamlining of antifungal therapy.
authors.affiliation: Department of Microbiology, University Hospital Crosshouse, Kilmarnock, UK.
authors.forename: A M
authors.initials: AM
authors.lastname: Bal
authors.forename: G S
authors.initials: GS
authors.lastname: Shankland
authors.forename: G
authors.initials: G
authors.lastname: Scott
authors.forename: T
authors.initials: T
authors.lastname: Imtiaz
authors.forename: R
authors.initials: R
authors.lastname: Macaulay
authors.forename: M
authors.initials: M
authors.lastname: McGill
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000191:economics; D000935:Antifungal Agents / Q000008:administration & dosage* / Q000191:economics; D058387:Candidemia / Q000188:drug therapy* / Q000191:economics; D004334:Drug Administration Schedule; D016527:Drug Costs; D054714:Echinocandins / Q000008:administration & dosage / Q000191:economics; D005260:Female; D015725:Fluconazole / Q000008:administration & dosage / Q000191:economics; D006760:Hospitalization; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008826:Microbial Sensitivity Tests; D016134:Organizational Policy; D012008:Recurrence; D016896:Treatment Outcome; D065819:Voriconazole / Q000008:administration & dosage / Q000191:economics
chemical_list: D000900:Anti-Bacterial Agents; D000935:Antifungal Agents; D054714:Echinocandins; D015725:Fluconazole; D065819:Voriconazole