Echinocandin use in an Australian tertiary hospital: implications for antifungal stewardship

Background: Invasive candidiasis (IC) surveillance demonstrates an increasing incidence of resistance to azole-based therapy. Consequently, echinocandins are often considered first-line treatment for IC in critically ill patients. To better understand the complexities of decision-making around echinocandin initiation, an evidence-based audit tool was developed. Aim: To describe echinocandin initiation and compliance with current guidelines. Method: A retrospective audit of echinocandin initiation was conducted between 1 January 2020 and 31 December 2020 at a quaternary referral hospital. An audit tool was developed by infectious diseases physicians and antimicrobial stewardship pharmacists, capturing patient demographics, microbiological results, indication for therapy, and risk factors for invasive fungal disease (IFD). Local guideline compliance was determined. This project was determined to be a quality improvement project and was not required to undergo ethical review according to the Alfred Hospital Ethics Committee procedures. Results: One hundred sixty-seven patients were initiated on 214 courses of echinocandin therapy. Caspofungin was most commonly prescribed (n = 172, 80%). Of the 167 patients, most (n = 119, 71%) were in the intensive care unit at the time of initiation. Empiric therapy for sepsis or infection of unclear source was the most commonly documented indication (n = 117, 55%); 71% (n = 153) of all courses were deemed empiric therapy, followed by directed therapy (n = 55, 26%). The most common risk factors for IFD were recent exposure to broad-spectrum antimicrobial therapy (n = 165, 99%) and the presence of a urinary catheter (n = 141, 84%). Most first doses were compliant with local guidelines (n = 144, 67%). Conclusions: Echinocandin therapy was commonly prescribed in critically ill patients with risk factors for IFD. Although the majority of prescriptions were empiric and compliant with local guidelines, improved guidelines incorporating additional patient factors should be included in future antifungal stewardship initiatives.