Characteristics of antifungal utilization for hospitalized children in the United States

Publication summary

As the population of infants born prematurely and children affected by cancer continues to rise in the US, greater knowledge is needed on the prevention and treatment of invasive fungal infections that pose a significant risk to immunocompromised people. In this point-prevalence survey, members of the SHARPS (Sharing Antibiotic Reports for Pediatric Stewardship) Antibiotic Resistance, Prescribing, and Efficacy among Children study analyze antifungal prescribing data from 32 hospitals across 22 US states from June 2016 to December 2017.

Who this is for

• Pediatricians and pediatric pharmacists, especially those working in hematology/oncology, transplant, and intensive care settings
• Neonatologists
• Children’s hospital study coordinators

Key findings

• Over the 18-month study period, 34,927 hospitalized patients under the age of 18 were included, 6% (2,095) of whom received at least one systemic antifungal, accounting for 2,207 antifungal prescriptions.
• The antifungal prescription rate across hospitals varied widely, from 13.6 to 131.2 per 1,000 patients. Most hospitals submitted data from a neonatal intensive care unit (31 hospitals) and a hematology/oncology ward (30 hospitals), and nine hospitals submitted data from a transplant ward.
• Of patients who received an antifungal, 1,200 (57%) had an oncology or bone marrow transplant diagnosis, and 268 (13%) were born prematurely. The median age at birth for premature patients who received an antifungal was 26 weeks.
• Fluconazole, echinocandins, and other azoles were the most commonly prescribed antifungals (48%, 23%, and 20%, respectively).
• Prophylaxis was the most common reason for antifungal use (1,420 prescriptions, or 64%), and patients who received antifungal prophylaxis were more likely to be younger (median age of 4 years), and be hospitalized in a hematology/oncology ward (727 patients), a neonatal intensive care unit (208 patients), a transplant ward (187 patients), or a pediatric intensive care unit (115 patients).
• Other indications for antifungal prescribing included empirical use (429 prescriptions, or 20%) and targeted therapy (308 prescriptions, or 14%). Fifty prescriptions (2%) did not document an indication. 
• Combination antifungal therapy accounted for nearly one-third of targeted-therapy prescriptions, with the most frequently prescribed antifungals being polyene-azole (43%), echinocandin-azole (36%), and polyene-echinocandin (13%) combinations.
• The authors acknowledge that there is a lack of clear knowledge to inform prescribing practice on effectively using antifungals, especially for prophylaxis, in children with cancer and in premature infants. They recommend more research on the indications for broad-spectrum and/or combination antifungal use in hospitalized children, along with greater attention to the development of antifungal stewardship practices that meet the needs and circumstances of children at high risk of invasive fungal infections.