Missed Opportunities for Antifungal Stewardship during the COVID-19 Era

Area of Science:

• Infectious Diseases
• Critical Care Medicine
• Pharmacology

Background:

• Antibacterial use surged during COVID-19, exceeding rates of bacterial coinfection.
• Critically ill COVID-19 patients face increased risk of pulmonary aspergillosis.
• Antifungal use in these high-risk populations was underreported, especially later in the pandemic.

Purpose of the Study:

• To compare mold-active antifungal drug usage in a medical intensive care unit before and during the COVID-19 pandemic.
• To assess changes in the utilization of specific antifungal agents, including liposomal amphotericin B, anidulafungin, isavuconazonium, posaconazole, and voriconazole.

Main Methods:

• Single-center, population-level cohort analysis.
• Monthly antifungal drug use rates were compared between a baseline period (April 2019-March 2020) and the pandemic period (April 2020-November 2022).
• Diagnostic modalities remained consistent between the two periods.

Main Results:

• Overall antifungal drug usage showed no significant difference from baseline, except for isavuconazonium, which saw a significant increase (p = 0.009).
• No changes in diagnostic methods were observed.
• Prescribing patterns may reflect concerns about COVID-19-associated pulmonary aspergillosis (CAPA).

Conclusions:

• Antifungal prescribing patterns for critically ill COVID-19 patients remained largely unchanged, with a notable exception for isavuconazonium.
• Increased awareness of CAPA prevalence and mortality may influence antifungal prescribing.
• Antimicrobial stewardship programs need enhanced tools for optimizing antifungal use.