Abstract Background The social, contextual, and behavioral 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 hematology patients at a major medical center in Australia. Methods Semistructured, face-to-face interviews were conducted with 35 clinicians from 6 specialties (hematology, infectious diseases, pharmacy, nursing, radiology, respiratory), followed by thematic analysis mapped to a behavioral change framework. Results Access to 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, because 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. Antifungal stewardship was perceived as a specialized area that should be integrated within antimicrobial stewardship but aligned with the cultural expectations of hematologists. Conclusions Antifungal stewardship 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 personalized attention and audit of clinical outcomes including IFD is difficult.

中文翻译：

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引入抗真菌管理：血液学多学科团队在竞争需求、约束和不确定性中的视角

摘要背景 影响有侵袭性真菌病 (IFD) 风险的患者护理的社会、背景和行为决定因素知之甚少。这种知识差距是实施新兴抗真菌管理 (AFS) 计划的障碍。我们旨在了解 AFS 的障碍和促成因素、改进的机会以及 AFS 对澳大利亚主要医疗中心血液学患者的看法。方法 对来自 6 个专业（血液学、传染病学、药学、护理学、放射学、呼吸学）的 35 名临床医生进行半结构化的面对面访谈，然后进行映射到行为改变框架的主题分析。结果 获得包括支气管镜检查在内的真菌诊断被确定为合理处方的关键障碍。集体决策是常态，在嵌入式管理模型的帮助下，可以按需访问传染病专业知识。处方者的自我效能感/知识差实际上是 AFS 的促成因素，因为临床医生愿意听从传染病的建议。以频繁的护理转换为特征的不断增长的门诊患者被视为 AFS 的机会，但被以住院患者为中心的模型所忽视，与新出现的真菌风险保持同步也是如此。临时监督、审计和反馈实践阻碍了所有参与者的总体质量改进。抗真菌管理被认为是一个专业领域，应整合到抗菌管理中，但与血液学家的文化期望保持一致。结论 抗真菌管理是多方面的，真菌诊断是一个关键的差距，而门诊是一个被忽视的领域。正式的监督、审计和反馈机制对于提高人口水平的质量至关重要。资源是下一个挑战，因为复杂的免疫功能低下的患者需要个性化的关注，并且很难对包括 IFD 在内的临床结果进行审计。