BACKGROUND Antimicrobial resistance is a widely recognized public health threat, and stewardship interventions to combat this problem are well described. Less is known about antifungal stewardship (AFS) initiatives and their influence within the United States. The purpose of this study was to evaluate evidence on the impact of AFS interventions on clinical and performance measures. METHODS A systematic review of English language studies identified in the PubMed and EMBASE databases was performed through November 2017. The review was conducted in accordance with PRISMA. Search terms included antifungal stewardship, antimicrobial stewardship, Candida, candidemia, candiduria, and invasive fungal disease. Eligible studies were those that described an AFS program or intervention occurring in the US and evaluated clinical or performance measures. RESULTS Fifty-four articles were identified and 13 were included. Five studies evaluated AFS interventions and reported clinical outcomes (mortality and length of stay) and performance measures (appropriate antifungal choice and time to therapy). The remaining eight studies evaluated general stewardship interventions and reported data on antifungal consumption. All studies were single center, quasi-experimental with varying interventions across studies. AFS programs had no impact on mortality (3 of 3 studies), with an overall rate of 27% in the intervention group and 23% in the non-intervention group. Length of stay (5 of 5) was also similar between groups (range, 9-25 vs. 11-22). Time to antifungal therapy improved in 2 of 5 studies, and appropriate choice of antifungal increased in 2 of 2 studies. Antifungal consumption was significantly blunted or reduced following stewardship initiation (8 of 8), although a direct comparison between studies was not possible due to a lack of common units. CONCLUSION The available evidence suggests that AFS interventions can improve performance measures and decrease antifungal consumption. Although this review did not detect improvements in clinical outcomes, significant adverse outcomes were not reported.

中文翻译：

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对美国抗真菌管理干预措施影响的系统评价。

背景抗菌素耐药性是一种广泛认可的公共卫生威胁，并且很好地描述了对抗该问题的管理干预。人们对抗真菌管理 (AFS) 计划及其在美国的影响知之甚少。本研究的目的是评估 AFS 干预对临床和绩效指标影响的证据。方法 对 PubMed 和 EMBASE 数据库中确定的英语语言研究进行了系统审查，直至 2017 年 11 月。审查是按照 PRISMA 进行的。搜索词包括抗真菌管理、抗菌管理、念珠菌、念珠菌血症、念珠菌尿和侵袭性真菌病。符合条件的研究是那些描述在美国发生的 AFS 计划或干预并评估临床或性能指标的研究。结果 确定了 54 篇文章，包括 13 篇。五项研究评估了 AFS 干预措施并报告了临床结果（死亡率和住院时间）和性能指标（适当的抗真菌选择和治疗时间）。其余八项研究评估了一般管理干预措施并报告了有关抗真菌剂消费的数据。所有研究都是单中心、准实验性的，跨研究采用不同的干预措施。AFS 计划对死亡率没有影响（3 项研究中的 3 项），干预组的总体死亡率为 27%，非干预组为 23%。各组之间的住院时间（5 人中的 5 人）也相似（范围，9-25 对 11-22）。Time to antifungal therapy improved in 2 of 5 studies, and appropriate choice of antifungal increased in 2 of 2 studies. 在管理开始后，抗真菌剂的消耗量显着减少或减少（8 项中的 8 项），但由于缺乏共同单位，研究之间的直接比较是不可能的。结论 现有证据表明，AFS 干预措施可以改善性能指标并减少抗真菌药物的使用。尽管该评价未发现临床结果的改善，但未报告显着的不良结果。