Variability in Antifungal and Antiviral Use in Hospitalized Children

Background: Antimicrobial stewardship programs (ASP) have primarily focused on the optimization of antibiotic therapy, while the use of antifungal therapy (AFT) and antiviral therapy (AVT) has been relatively ignored. However, AFT and AVT are costly and are associated with adverse effects. Use of these agents in hospitalized patients demands closer scrutiny to improve patient outcomes and potentially reduce hospital expenditures. We aimed to determine the extent and variability of AFT and AVT use in children.

Methods: Retrospective cohort study of AFT and AVT in patients < 18 years of age discharged from children’s hospitals contributing data to the Pediatric Health Information System database in 2015 was performed. Children at high-risk (HR) for fungal or viral infections were identified by All Patient Refined Diagnosis Related Groups (APR-DRG) codes for oncology, bone marrow transplant, and solid organ transplant. AFT included charges for fluconazole, echinocandins, voriconazole, posaconazole, itraconazole, amphotericin, and AVT included charges for acyclovir, cidofovir, famciclovir, foscarnet, ganciclovir, oseltamivir, peramivir, ribavirin, rimantadine, valacyclovir, valganciclovir, zanamivir. Days of AFT and AVT therapy (DOT) were standardized per 1,000 patient days.

Results: Of 784,240 discharges from 47 hospitals, approximately 3% received AFT or AVT. Of the 20,026 HR patients, 19% received AFT and 12% received AVT. HR patients received 10 times more DOT than non-HR patients (HR AFT DOT rate=389 and non-HR=30; HR AVT DOT=244 and in non-HR=22), and accounted for 50% of all AFT DOT and 46% of AVT DOT despite comprising only 4.5% of all discharges. Although fluconazole was the most common AFT, echinocandins had comparable total DOT rates among HR patients, and 10% of HR patients received an AFT other than fluconazole. The prevalence and total use of AFT and AVT among HR patients varied across hospitals (Figure).

Conclusion: Benchmarking AFT and AVT use reveals wide differences across hospitals, even when comparing use in similar, high risk patients, suggesting that AFT and AVT are important stewardship targets.