Update on Antifungal Stewardship

Transcription

1 Update on Antifungal Stewardship Dr Jacqueline Sneddon, MRPharmS Scottish Antimicrobial Prescribing Group Antimicrobial Management Team event 7 th November 2017

2 ANTIFUNGAL STEERING GROUP CHAIR Prof Brian Jones, Consultant Microbiologist, NHS GGC GROUP MEMBERS o ID and microbiology o Antimicrobial Pharmacists o Critical care clinicians anaesthetists and clinical pharmacist o Cancer network representatives o Respiratory specialist o Paediatrics ID and clinical pharmacist

3 AIMS OF ANTIFUNGAL STEWARDSHIP PROGRAMME Development of national consensus guidance on use of systemic antifungal agents and investigations to optimise prophylaxis, empirical and targeted treatment strategies and to minimise unnecessary use and resistance development. Consultation with relevant stakeholders, including SAPG members and their associated organisations, SMVN members, ICU community, regional cancer networks and respiratory clinicians.

4 NATIONAL DATA ON ANTIFUNGAL USE NHS Scotland: use of antifungals (excluding amphotericin B) in acute hospitals, by group as percentage of all antifungal DDD/100,000/day in 2016

5 DDDs/100,000pop/day DDDs/100,000pop/day NATIONAL DATA ON ANTIFUNGAL USE Fluconazole Itraconazole Posaconazole Voriconazole Anidulafungin Caspofungin Micafungin

6 Health Board Name Azole NHS AYRSHIRE & ARRAN Fluconazole Itraconazole Posaconazole Voriconazole NHS BORDERS Fluconazole Itraconazole Posaconazole Voriconazole NHS DUMFRIES & GALLOWAY Fluconazole Itraconazole Posaconazole Voriconazole NHS FIFE Fluconazole Itraconazole Posaconazole Voriconazole NHS FORTH VALLEY Fluconazole Itraconazole Posaconazole Voriconazole NHS GRAMPIAN Fluconazole Isavuconazole Itraconazole Posaconazole Voriconazole NHS GREATER GLASGOW & CLYDE Fluconazole Isavuconazole Itraconazole Posaconazole Voriconazole NHS HIGHLAND Fluconazole Isavuconazole Itraconazole Posaconazole Voriconazole NHS LANARKSHIRE Fluconazole Itraconazole Posaconazole Voriconazole NHS LOTHIAN Fluconazole Isavuconazole Itraconazole Posaconazole Voriconazole NHS ORKNEY Fluconazole Itraconazole NHS SHETLAND Fluconazole Itraconazole Posaconazole Voriconazole NHS TAYSIDE Fluconazole Itraconazole Posaconazole Voriconazole NHS WESTERN ISLES Fluconazole Itraconazole Voriconazole BUT LARGE BOARD-LEVEL VARIATION IN VOLUME AND CHOICE Health Board Name Echinochandin NHS AYRSHIRE & ARRAN Caspofungin Micafungin NHS BORDERS Anidulafungin Caspofungin Micafungin NHS DUMFRIES & GALLOWAY Anidulafungin Caspofungin NHS FIFE Anidulafungin Caspofungin NHS FORTH VALLEY Anidulafungin Caspofungin Micafungin NHS GRAMPIAN Anidulafungin Caspofungin Micafungin NHS GREATER GLASGOW & CLYDE Anidulafungin Caspofungin Micafungin NHS HIGHLAND Anidulafungin Caspofungin Micafungin NHS LANARKSHIRE Anidulafungin Caspofungin Micafungin NHS LOTHIAN Anidulafungin Caspofungin NHS SHETLAND Caspofungin NHS TAYSIDE Anidulafungin Caspofungin NHS WESTERN ISLES Caspofungin

7 PROCUREMENT OF ANTIFUNGALS Recent large cost savings due to patent expiry and contracting by National Procurement. Caspofungin now off patent and supplies of generic product available - 86% reduction in price Anticipated many boards will now switch from anidulafungin and micafungin for some patient groups. Re-tender for micafungin is due in November and this will provide reduced price. Re-tender for anidulafungin is due in March 2018 and will also provide a 40% reduction in price. Azoles covered by the national antimicrobials framework and retender process planned for May 2018.

8 APPROACH - 3 KEY CLINICAL AREAS HAEMATOLOGY/ONCOLOGY CRITICAL CARE and SURGERY RESPIRATORY INFECTION (excluding Cystic fibrosis) Scope current practice, review evidence to support diagnostics and treatment, develop draft national consensus and consult widely.

9 HAEMATOLOGY/ONCOLOGY 3 areas prophylaxis, empirical treatment and targeted treatment. For prophylaxis and targeted treatment there are good guidelines from IDSA and ESCMID which are largely followed Empirical treatment of suspected invasive fungal infection is problematic. o Treatment often initiated if patients continue to have fever after hours of antibiotics. o CT scans can be used to direct treatment but there are issues with prompt access to radiology in some hospitals. o Diagnostics using biomarkers such as galactomannan and Aspergillus PCR may be useful particularly where there is limited/delayed access to CT and can provide reassurance to haem/onc teams in high risk patients.

10 CRITICAL CARE AND SURGERY 3 types of use - prophylaxis, empirical treatment and targeted treatment. National data shows only 250 BSI per year so invasive fungal infection is relatively rare. Use of antifungals in ICU/surgery varies dramatically across Scotland as does the use of azoles versus echinocandins. Targeted treatment well managed through direct microbiologist input and supporting lab results plus good guidelines from IDSA to support treatment choice. Key problem is identifying patients at risk of fungal infection. Many risk factors identified but most ICU patients will have several. IDSA guidelines give weak recommendation for use of prophylaxis in high risk ICU patients e.g. anastomotic leaks following repeated abdominal surgery or high oesophagectomies. Use of clinical risk algorithms and beta-d-glucan diagnostic test may help.

11 RESPIRATORY MEDICINE Antifungals used widely across a variety of rare disorders but little data available on the frequency of use or appropriateness of treatment. Key areas of use are allergic broncho-pulmonary aspergillosis (ABPA) and to lesser extent chronic pulmonary aspergillosis in COPD patients. No BTS guidelines for fungal respiratory infections and although there are ESCMID guidelines UK respiratory physicians do not use them. Overuse of azoles as a steroid-sparing strategy and patients are often managed by non-specialists. The main agent used in ABPA is itraconazole, usually a 6-month course. In invasive disease voriconazole would be used and also some use of posaconazole

12 LOCAL WORK ON ANTIFUNGALS In A&A, Abs Bal working on risk factors for azole resistance but his study has not found any that are significant. In Fife, Alan Timmins has led some national work on comparing antifungal use across several ICUs. In Tayside, Nik Rae has developed an echinocandin review service with patients being flagged by clinical pharmacists.

13 NEXT STEPS Review literature identified to answer research questions Develop audit data collection forms and surveys to gather intelligence about current practice within the 3 clinical areas

14 THANK YOU ANY QUESTIONS? Acknowledgements: Members of AF Steering Group