Ushering in antifungal stewardship: perspectives of the haematology multidisciplinary team navigating competing demands, constraints and uncertainty

Michelle Ananda-Rajah, Samuel Fitchett, Darshini R Ayton, Anton Y. Peleg, Eliza Watson, Kelly A. Cairns, Trisha Peel

Research output: Contribution to journalArticleResearchpeer-review

Abstract

Background
The social, contextual, and behavioural determinants that influence care in patients at risk for invasive fungal diseases (IFD) are poorly understood. This knowledge gap is a barrier to the implementation of emerging antifungal stewardship (AFS) programs. We aimed to understand the barriers and enablers to AFS, opportunities for improvement, and perspectives of AFS for haematology patients at a major medical center in Australia.

Methods
Semi-structured face-to-face interviews were conducted with 35 clinicians from six specialties (haematology, infectious diseases, pharmacy, nursing, radiology, respiratory), followed by thematic analysis mapped to a behavioural change framework.

Results
Delays in fungal diagnostics including bronchoscopy was identified as the key barrier to rational prescribing. Collective decision making was the norm, aided by an embedded stewardship model with on-demand access to infectious diseases expertise. Poor self-efficacy/knowledge among prescribers was actually an enabler of AFS, as clinicians willingly deferred to infectious diseases for advice. A growing outpatient population characterized by frequent care transitions was seen as an opportunity for AFS but neglected by an inpatient focused model, as was keeping pace with emerging fungal risks. Ad hoc surveillance, audit, and feedback practices frustrated population level quality improvement for all actors. AFS was perceived as a specialized area that should be integrated within antimicrobial stewardship, but aligned with the cultural expectations of haematologists.

Conclusion
AFS is multifaceted, with fungal diagnostics a critical gap and outpatients a neglected area. Formal surveillance, audit and feedback mechanisms are essential for population level quality improvement. Resourcing is the next challenge because complex immunocompromised patients require personalised attention and audit of clinical outcomes including IFD is difficult.
Original languageEnglish
Article numberofaa168
Number of pages12
JournalOpen Forum Infectious Diseases
Volume7
Issue number6
DOIs
Publication statusPublished - Jun 2020

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