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Background Aims Methods Results Conclusions Antimicrobial stewardship (AMS) guidelines now recommend antifungal stewardship (AFS) interventions to improve the management of invasive fungal diseases (IFDs). AFS programmes have not been reported in Australia.To determine the monitoring of antifungal use, AFS strategies and targets, and barriers to AFS implementation in Australian hospitals.An electronic quantitative cross‐sectional survey was developed and distributed to public and private hospitals in Australia in February 2018. Descriptive statistics were used to summarise the findings.Eighty‐three Australian hospitals completed the survey with an overall response rate of 58% (83/143). Most hospitals monitored antifungal use (62/83, 75%). Frequently used AFS metrics included costs (48/60, 80%) and yearly point prevalence surveys (45/60, 75%). Core AFS strategies were commonly in place, including preauthorisation requirements (71/80, 89%) and expert antifungal post‐prescription review and feedback (PPRF) (63/80, 79%). Both these strategies were more strictly applied to high‐cost, intravenous agents. Formal education (44/79, 56%) and hospital‐endorsed guidelines (35/79, 44%) were modestly used. Fungal diagnostics and antifungal therapeutic drug monitoring (TDM) were utilised, largely off site. IFD surveillance was infrequently performed (9/77, 12%). Barriers to AFS identified included lack of staff time, prioritisation of AFS, and access to rapid diagnostics and TDM.AFS strategies utilised in Australian hospitals have focused on high‐cost, intravenous agents. Although expert oversight of antifungals is evident, many sites omit potentially important targets for AFS, including fluconazole and oral posaconazole. Identifying these gaps and barriers to AFS will guide the development of an AFS model for hospitals. [ABSTRACT FROM AUTHOR]

Introduction: The rising prevalence of difficult-to-treat, deep-seated invasive fungal diseases (IFD) has led to high mortality. Currently available antifungal treatments, administered predominantly orally or intravenously, may not sufficiently penetrate certain body sites, and/or are associated with systemic toxicity. Little is known about how to position alternative administration approaches such as inhalational and direct drug delivery routes. Areas covered: This review provides an updated overview of unconventional drug delivery strategies for managing IFD, focusing on inhalational (to target the lungs) and direct delivery methods to the central nervous system, bone/joint, and eyes. Novel compounds (e.g. opelconazole) and existing antifungals with innovative drug delivery systems currently undergoing clinical trials and/or used off-label in the clinical setting are discussed. Expert opinion: For both inhalational agents and direct delivery approaches, there are similar challenges that include the absence of: approved formulations for specific administration routes, delivery vehicles that are simple and safe to use whilst maintaining potency and efficiency of delivery, animal models suitable for investigating pharmacokinetic/pharmacodynamic profiles of inhaled antifungals, and consensus on the composite endpoints and intervals for of follow-up in clinical trials. To meet these challenges, cooperation of all stakeholders in drug development and regulation is required. [ABSTRACT FROM AUTHOR]

Objectives: Incorrect labelling of a penicillin allergy can lead to unnecessary use of broad-spectrum, less effective, more harmful, or more costly antibiotics. Community pharmacists are well positioned to educate the public on penicillin allergies, prevent incorrect labelling persisting, and optimize prescribing of antibiotics. This study investigated community pharmacists' capacity to recognize an opportunity to directly de-label a no-risk penicillin allergy. Methods: A sequential explanatory mixed methods design using mystery shopping (quantitative) and postvisit reflections (qualitative). Mystery shoppers simulated a case of a previously dispensed prescription (involving nonimmune mediated intolerance 'thrush' as the reported allergy) that provided the opportunity for pharmacists to educate on incorrect penicillin allergy. The main outcomes were proportion of community pharmacists who ascertained the nature of the penicillin reaction, provided education on incorrect penicillin allergy labels and its consequences. Knowledge and practices regarding penicillin allergy were collected. Key findings: Across two major states in Australia, 265 community pharmacists participated. Only 44.5% (118/265) of pharmacists asked about the nature of the reaction; of those, 91.52% (108/118) indicated that 'thrush' is not an allergic reaction. No pharmacists took the opportunity to educate on how an incorrect allergy label can impact antibiotic prescribing. Postvisit reflection data revealed five probable explanations for the observations viz. outdated knowledge, lack of knowledge, prioritizing management of adverse drug reaction (thrush), variations in duty of care and assumption of true allergy without an assessment. Conclusion: Our findings underscore a concerning knowledge and practice gap among community pharmacists regarding penicillin allergy assessment which warrants more support and education in the community pharmacy sector. [ABSTRACT FROM AUTHOR]

Background Little is known about the short- and long-term healthcare costs of invasive Scedosporium/Lomentospora prolificans infections, particularly in patient groups without haematological malignancy. This study investigated excess index hospitalization costs and cumulative costs of these infections. The predictors of excess cost and length of stay (LOS) of index hospitalization were determined. These estimates serve as valuable inputs for cost-effectiveness models of novel antifungal agents. Methods A retrospective case-control study was conducted at six Australian hospitals. Cases of proven/probable invasive Scedosporium/L. prolificans infections between 2011 and 2021 (n = 34) were matched with controls (n = 66) by predefined criteria. Cost data were retrieved from activity-based costing systems and analysis was performed from the Australian public hospital perspective. All costs were presented in 2022 Australian dollars (AUD). Median regression analysis was used to adjust excess costs of index hospitalization whereas cumulative costs up to 1.5 years follow-up were estimated using interval-partitioned survival probabilities. Results Invasive Scedosporium/L. prolificans infections were independently associated with an adjusted median excess cost of AUD36 422 (P = 0.003) and LOS of 16.27 days (P < 0.001) during index hospitalization. Inpatient stay was the major cost driver (42.7%), followed by pharmacy cost, of which antifungal agents comprised 23.8% of the total cost. Allogeneic haematopoietic stem cell transplant increased the excess cost (P = 0.013) and prolonged LOS (P < 0.001) whereas inpatient death within ≤28 days reduced both cost (P = 0.001) and LOS (P < 0.001). The median cumulative cost increased substantially to AUD203 292 over 1.5 years in cases with Scedosporium/L. prolificans infections. Conclusions The economic burden associated with invasive Scedosporium/L. prolificans infections is substantial. [ABSTRACT FROM AUTHOR]

Background Management of Scedosporium/Lomentospora prolificans infections remains challenging. We described predisposing factors, clinical manifestations, and outcomes of these rare mold infections, including predictors of early (1-month) and late (18-month) all-cause mortality and treatment failure. Methods We conducted a retrospective Australian-based observational study of proven/probable Scedosporium/L prolificans infections from 2005 to 2021. Data on patient comorbidities, predisposing factors, clinical manifestations, treatment, and outcomes up to 18 months were collected. Treatment responses and death causality were adjudicated. Subgroup analyses, multivariable Cox regression, and logistic regression were performed. Results Of 61 infection episodes, 37 (60.7%) were attributable to L prolificans. Forty-five of 61 (73.8%) were proven invasive fungal diseases (IFDs), and 29 of 61 (47.5%) were disseminated. Prolonged neutropenia and receipt of immunosuppressant agents were documented in 27 of 61 (44.3%) and 49 of 61 (80.3%) episodes, respectively. Voriconazole/terbinafine was administered in 30 of 31 (96.8%) L prolificans infections, and voriconazole alone was prescribed for 15 of 24 (62.5%) Scedosporium spp infections. Adjunctive surgery was performed in 27 of 61 (44.3%) episodes. Median time to death post–IFD diagnosis was 9.0 days, and only 22 of 61 (36.1%) attained treatment success at 18 months. Those who survived beyond 28 days of antifungal therapy were less immunosuppressed with fewer disseminated infections (both P <.001). Disseminated infection and hematopoietic stem cell transplant were associated with increased early and late mortality rates. Adjunctive surgery was associated with lower early and late mortality rates by 84.0% and 72.0%, respectively, and decreased odds of 1-month treatment failure by 87.0%. Conclusions Outcomes associated with Scedosporium/L prolificans infections is poor, particularly with L prolificans infections or in the highly immunosuppressed population. [ABSTRACT FROM AUTHOR]