Antifungal Stewardship in the Pediatric Intensive Care Unit: Time is of the Essence

Invasive fungal infections (IFIs) represent a significant cause of morbidity and mortality in critically ill children admitted to pediatric intensive care units (PICUs). Despite the variation of the incidence of candidemia and invasive candidiasis (IC) and Candida species distribution between different PICU settings, increasing rates of non-albicans Candida species and emerging antifungal resistant strains are observed. Antifungals are prescribed in PICUs mainly for empiric treatment, with limited use of diagnostic-driven strategies despite availability of fungal biomarkers in many settings. Data on antifungal prophylaxis in PICU outside traditional high-risk populations are scarce with no official guidance on administration of prophylaxis and to which patients. Diagnostic challenges, heterogeneity and complexity of PICU patients, and the absence of specific guidelines on prophylaxis contribute to increased and/or inappropriate antifungal use. Although antifungals are frequently used in PICU, antifungal stewardship (AFS) activities reported particularly in this population remain limited. Shift from empiric to pre-emptive treatment, systematic use of therapeutic drug monitoring, new diagnostic tests and fungal biomarkers and limiting the group of patients outside the high-risk groups on prophylaxis are the key targets for AFS in critically ill children. Only nine AFS interventions including PICU patients were found in the English literature; seven were part of hospital-wide stewardship programs and only three were targeted to antifungals. Audit with feedback was mainly used as a strategy, while various designs and outcomes were observed. Antifungal stewardship programs are essential to optimize antifungal use in PICUs; however, standardized frameworks tailored to these settings should be developed. This review describes the epidemiology of IFIs in PICUs, current antifungal prescribing practices, and summarizes AFS interventions implemented in PICUs up to now in order to propose recommendations for future antifungal stewardship initiatives in these patients.